A recent paper in the Archives of General Psychiatry by Steven Marcus and Mark Olfson provides interesting data about recent trends in the treatment of depression. We thought it would be useful to review some of their findings.
Marcus and Olfson analyzed and compared information from two large surveys: one conducted in 2007, and another in 1997 (along with additional data from 1987). In 2007, slightly less than 3 out of every 100 people in the U.S. were treated for depression. This compares to about 2 per 100 in 1997 and less than 1 per 100 in 1987. The data indicate that the percentage of people treated for depression tripled in the early 1990s with a more modest increase in the early 2000 era. Overall, about 8.7 million people in this country received treatment for depression in 2007 compared to about 6.5 million in 1997. This increase resulted from a growing U.S. population as well as from the modest increase in the percent of the population receiving treatment.
Three groups of people accounted for much of this increase: older Americans, African Americans, and males. Ostensibly, this is good news given that African Americans and men have been under-treated for depression in the past. In terms of older Americans, it is likely that the prescription drug coverage provided by Part D of Medicare has allowed a greater number of older persons to afford treatment. The costs of depression treatment paid by Medicare increased from $0.52 billion in 1997 to $2.25 billion in 2007. Over half of this increase was related to the cost of antidepressants.
Overall costs of outpatient treatment of depression increased from about $10 billion in 1997 to $12.5 billion in 2007. This 24% increase is substantially smaller than the 64% increase in total healthcare costs during this same period.
In both surveys, about 75% of the patients who were treated for depression received antidepressant medications. In the most recent survey, less than half of those who received antidepressants also received psychotherapy. Fewer people were treated with psychotherapy at the time of the 2007 survey than at the time of the earlier survey. Of those treated with psychotherapy, the large majority were also treated with antidepressants.
In another recent paper, the authors report that reimbursement for psychotherapy has decreased. They also comment that many primary care physicians are unable to locate appropriate therapists to provide this form of treatment.
Several psychotherapies, including cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT), have been shown to be effective in treating depression. It is unfortunate that many therapists (psychologists and others) are not trained in these therapies and that primary care physicians are having a difficult time finding therapists able to treat patients with effective evidenced-based treatments. It is interesting to note that some therapists seek to obtain prescription drug privileges in spite of the fact that there is substantial need for these professionals to provide evidenced-based psychotherapies. Reimbursement for psychotherapies tends to be lower than reimbursement for briefer visits associated with medication management. Would increasing the reimbursement rates for psychotherapies lead non-physician mental health professionals to become more interested in providing these forms of treatment and less concerned about obtaining prescription privileges?
Data from the Marcus & Olfson paper indicate that about 85% of depressed individuals receiving care were treated by physicians; half of these physicians were psychiatrists. Less than 20% of patients were treated by psychologists and about 7% were treated by social workers. Some patients were treated by both physicians and non-physician mental health professionals.
The number of hospitalizations for depression decreased by over 40% during the 10-year interval between surveys. There are likely many reasons for this decrease. Possibly, outpatient treatments have improved. Also, there may be stricter criteria for being admitted to the hospital for depression.
Quality-of-care information was not studied in this recent paper. In our book Demystifying Psychiatry and in earlier postings, we discuss ways to improve the quality and efficiency of care by utilizing collaborative care models. Collaborative care models would encourage ongoing communication between healthcare teams and patients as well as the use of group therapies, internet therapies, or individual therapies as evidence provides support for the effectiveness of these various approaches.
There is also the potential to curb costs if physicians were to consider prescribing less expensive, generic antidepressants more often. In general, older, generic medications are as effective as newer drugs that are not yet available in generic formulations. Why do physicians prescribe a drug that may cost $100 per month when a $4 per month medication might be equal in terms of effectiveness and safety? Part of the answer may have to do with the marketing of drugs to both patients and physicians. Hopefully, data will increasingly influence prescription practices, and costs of medications will become part of the decision making process.
In summary, the percentage of people treated for depression has increased modestly over the last ten years. Certain demographic groups, including older persons, African Americans, and males, are now receiving more treatment than in the past. Medications are the major treatment modality even though evidenced-based psychotherapies would likely be effective and safe. Costs of treatment have increased at a much slower rate than the general increase in healthcare costs. Inpatient hospitalizations for depressions have decreased.
These trends indicate that some progress has been made in recognizing and treating a very disabling illness - depression. There is much room for improvement, however. From a public health perspective, effective treatment of depression will save lives, diminish disabilities, and save money.
This column was co-written by Eugene Rubin MD, PhD and Charles Zorumski MD