Cost to Treat a Depression Case Falls

Bigger Share of Sufferers Are Now Receiving Help, So Total Expenditures Rise 

SARA SCHAEFER MUÑOZ / Wall Street Journal 31dec03

WASHINGTON—The cost of treating a depressed person fell throughout the 1990s, largely because of a switch from hospitalization to medication, according to findings of a study published Tuesday. But the overall cost of treating the illness in this country rose 31% during the decade to $26 billion because of a sharp rise in the number of patients.

The study, published in the Journal of Clinical Psychiatry [Abstract below], found that the rate of treatment for depression—the share of sufferers who got help—rose 56% during the 10-year span. However, annual costs per treated case fell to $3,300 in 2000, down almost 19% from the 1990 levels.

The study was a follow-up to an assessment done in 1990. The new study concluded that the total economic cost of depression increased 7% from 1990 to 2000, in inflation-adjusted 2000 dollars. The latest study, as well as the previous one, received funding from Eli Lilly & Co., a major player in the market for antidepressants.

The cost of reduced productivity because of depression in the workplace remained nearly the same from 1990 to 2000, the study found, raising questions about the adequacy of current treatment. The study found workplace problems, such as absenteeism and lost productivity, cost about $52 billion, almost unchanged from the 1990s level.

Depression, which can be mild or severe, is a disorder that affects mood and the body. Symptoms can include persistent feelings of sadness or anxiety, decreased energy and concentration and sleep problems, as well as physical ailments such as headaches and chronic pain. According to the National Institute of Mental Health in Bethesda, Md., 9.5% of U.S. adults suffer from depression.

The study, led by Paul Greenberg of Analysis Group Inc., confirmed previous findings of the rising numbers of treated patients. A study published a year ago in the Journal of the American Medical Association found that the number of Americans treated for depression more than tripled between 1987 and 1997, rising to 6.3 million from 1.7 million. The increase reflects a growing awareness of the illness, a fading stigma attached to it, and increased treatment options.

The drop in cost per case was largely because of the shift in the way depression has been dealt with in the past decade, from hospitalization and psychotherapy to more emphasis on treatment with drugs by primary-care physicians, a less costly and time-consuming method, the study's authors said.

HIGH COST OF DEPRESSION
Economic burden of depression

			2000 Costs 
Type of Cost		(in billions)	Change From 1990  
Direct Costs  		$26.09  	 31.2  
Inpatient 		  8.88  	-33.6  
Outpatient 		  6.8  		 46.9  
Pharmaceutical  	$10.40  	452.50%
Workplace costs  	 51.54  	 -0.7  
Absenteeism  	 	 36.25  	 -8.1  
Reduced productivity  	 15.3  		 23  
Suicide-related costs  	  5.45  	 -2.4  
Total  			 83.08  	  7.4  

Yet questions remain as to why the widespread treatment for depression didn't result in lower depression-related burdens on employers, said Ronald Kessler, a professor of health-care policy at Harvard Medical School who is co-author of the study and who has consulted for Eli Lilly.

Instead, those burdens were roughly unchanged over the decade. One explanation is that the 1990s economic boom put more depressed people in the workplace, resulting in higher rates of lost productivity. Yet Dr. Kessler also believes it is because "people are getting half-treated."

This inadequate treatment, experts say, results in a phenomenon known as "presenteeism" in which people show up for work but are largely unproductive because they are depressed. This problem could stem from lack of follow-up monitoring by doctors, the high cost of continuing treatment, or the fact that many "reluctant patients" don't like to see themselves as having chronic depression and drop out of treatment too soon.

To improve the quality of care, experts said that doctors should use a standardized checklist to thoroughly evaluate a patient's progress and should increase coordination with psychiatrists, and employers should offer more coverage for the illness.

Kathryn Power, director of the federal Center for Mental Health Services, said the new study is important, partly because it could urge people to seek better treatment.

"These types of articles keep alive the question, 'Am I getting the right kind of care?' " she said.

Dr. Darrel Regier, research director for the American Psychiatric Association, said that some results of the study might be inaccurate because the researchers changed their criteria for defining depression in the 2000 data. Still, he said, the work is an important study and shows "if you want to get to an increase in productivity, it's not the number of people in treatment—it has to be effective treatment."

Abstract

The economic burden of depression in the United States: How did it change between 1990 and 2000?
Paul E. Greenberg, Ronald C. Kessler, Howard G. Birnbaum, Stephanie A. Leong, Sarah W. Lowe, Patricia A. Berglund, and Patricia K. Corey-Lisle. 
Journal of Clinical Psychiatry v.64, n.12, Dec03

From the Analysis Group, Inc. (Mr. Greenberg, Dr. Birnbaum, Mss. Leong and Lowe); Harvard University (Dr. Kessler), Boston, Mass.; the Institute for Social Research, University of Michigan, Ann Arbor (Ms. Berglund); and at Eli Lilly and Company, Indianapolis, Ind., at the time of this research (Dr. Corey-Lisle).

Background: The economic burden of depression was estimated to be $43.7 billion in 1990. A subsequent study reported a cost burden of $52.9 billion using revised prevalence data and a refined workplace cost estimation approach. The objective of the current report is to provide a 10-year update of these estimates using the same methodological framework.

METHODS: Using a human capital approach, we developed prevalence-based estimates of 3 major cost categories: (1) direct costs, (2) mortality costs arising from depression-related suicides, and (3) costs associated with depression in the workplace. Cost-of-illness estimates from 1990 were updated to reflect the experience in 2000 using current epidemiologic data and publicly available population, wage, and cost information.

RESULTS: Whereas the treatment rate of depression increased by over 50%, its economic burden rose by only 7%, going from $77.4 billion in 1990 (inflation-adjusted dollars) to $83.1 billion in 2000. Of the 2000 total, $26.1 billion (31%) were direct medical costs, $5.4 billion (7%) were suicide-related mortality costs, and $51.5 billion (62%) were workplace costs.

Conclusions: The economic burden of depression remained relatively stable between 1990 and 2000, despite a dramatic increase in the proportion of depression sufferers who received treatment. Future research will incorporate additional costs associated with depression sufferers, including the excess costs of their coexisting psychiatric and medical conditions and attention to the role of painful conditions as a driver of these costs.

Source: J Clin Psychiatry 2003; 64: 1465-1475