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The American Journal of Managed Care August 2014
Personalized Preventive Care Reduces Healthcare Expenditures Among Medicare Advantage Beneficiaries
Shirley Musich, PhD; Andrea Klemes, DO, FACE; Michael A. Kubica, MBA, MS; Sara Wang, PhD; and Kevin Hawkins, PhD
Impact of Hypertension on Healthcare Costs Among Children
Todd P. Gilmer, PhD; Patrick J. O'Connor, MD, MPH; Alan R. Sinaiko, MD; Elyse O. Kharbanda, MD, MPH; David J. Magid, MD, MPH; Nancy E. Sherwood, PhD; Kenneth F. Adams, PhD; Emily D. Parker, MD, PhD; and Karen L. Margolis, MD, MPH
Tracking Spending Among Commercially Insured Beneficiaries Using a Distributed Data Model
Carrie H. Colla, PhD; William L. Schpero, MPH; Daniel J. Gottlieb, MS; Asha B. McClurg, BA; Peter G. Albert, MS; Nancy Baum, PhD; Karl Finison, MA; Luisa Franzini, PhD; Gary Kitching, BS; Sue Knudson, MA; Rohan Parikh, MS; Rebecca Symes, BS; and Elliott S. Fisher, MD
Potential Role of Network Meta-Analysis in Value-Based Insurance Design
James D. Chambers, PhD, MPharm, MSc; Aaron Winn, MPP; Yue Zhong, MD, PhD; Natalia Olchanski, MS; and Michael J. Cangelosi, MA, MPH
Massachusetts Health Reform and Veterans Affairs Health System Enrollment
Edwin S. Wong, PhD; Matthew L. Maciejewski, PhD; Paul L. Hebert, PhD; Christopher L. Bryson, MD, MS; and Chuan-Fen Liu, PhD, MPH
Contemporary Use of Dual Antiplatelet Therapy for Preventing Cardiovascular Events
Andrew M. Goldsweig, MD; Kimberly J. Reid, MS; Kensey Gosch, MS; Fengming Tang, MS; Margaret C. Fang, MD, MPH; Thomas M. Maddox, MD, MSc; Paul S. Chan, MD, MSc; David J. Cohen, MD, MSc; and Jersey Chen, MD, MPH
Potential Benefits of Increased Access to Doula Support During Childbirth
Katy B. Kozhimannil, PhD, MPA; Laura B. Attanasio, BA; Judy Jou, MPH; Lauren K. Joarnt; Pamela J. Johnson, PhD; and Dwenda K. Gjerdingen, MD
Synchronization of Coverage, Benefits, and Payment to Drive Innovation
Annemarie V. Wouters, PhD; and Nancy McGee, JD, DrPH
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The Effect of Depression Treatment on Work Productivity
Arne Beck, PhD; A. Lauren Crain, PhD; Leif I. Solberg, MD; Jürgen Unützer, MD, MPH; Michael V. Maciosek, PhD; Robin R. Whitebird, PhD, MSW; and Rebecca C. Rossom, MD, MSCR
Optimizing Enrollment in Employer Health Programs: A Comparison of Enrollment Strategies in the Diabetes Health Plan
Lindsay B. Kimbro, MPP; Jinnan Li, MPH; Norman Turk, MS; Susan L. Ettner, PhD; Tannaz Moin, MD, MBA, MSHS; Carol M. Mangione, MD; and O. Kenrik Duru, MD, MSHS
Does CAC Testing Alter Downstream Treatment Patterns for Cardiovascular Disease?
Winnie Chia-hsuan Chi, MS; Gosia Sylwestrzak, MA; John Barron, PharmD; Barsam Kasravi, MD, MPH; Thomas Power, MD; and Rita Redberg MD, MSc
Effects of Multidisciplinary Team Care on Utilization of Emergency Care for Patients With Lung Cancer
Shun-Mu Wang, MHA; Pei-Tseng Kung, ScD; Yueh-Hsin Wang, MHA; Kuang-Hua Huang, PhD; and Wen-Chen Tsai, DrPH
Health Economic Analysis of Breast Cancer Index in Patients With ER+, LN- Breast Cancer
Gary Gustavsen, MS; Brock Schroeder, PhD; Patrick Kennedy, BE; Kristin Ciriello Pothier, MS; Mark G. Erlander, PhD; Catherine A. Schnabel, PhD; and Haythem Ali, MD

The Effect of Depression Treatment on Work Productivity

Arne Beck, PhD; A. Lauren Crain, PhD; Leif I. Solberg, MD; Jürgen Unützer, MD, MPH; Michael V. Maciosek, PhD; Robin R. Whitebird, PhD, MSW; and Rebecca C. Rossom, MD, MSCR
This study demonstrated that reduction of depression symptoms following routine treatment in primary care is significantly associated with improvements in productivity at work.
We analyzed data on the relationship between depression and work impairment for all 432 participants (37% of the consented and enrolled patients) who reported that they were working for wages either full- or part-time both at the baseline interview and at 6 months, and who provided 6-month data on the PHQ-9 and WPAI measures, and were receiving usual care in their clinic setting prior to DIAMOND program implementation. Demographic characteristics and treatment received at baseline and 6 months for these patients are described in Table 2. Table 2 shows that the majority of patients were female, middleaged, white, married, with at least some college education, and reporting good, very good, or excellent health status. At baseline, 65% of patients reported being treated for depression 1 or more times in the past (40% reported 2 or more times). Patients reported receiving relatively few treatment modalities other than antidepressants during the 6-month study period. These included individual counseling (27%), psychiatrist visit (4%), group therapy (2%), and other depression treatment (2%).

Table 3 shows weighted baseline and 6-month data on productivity loss and depression symptoms. At baseline, productivity loss represented an average of 38.2% of employees’ usual work hours, or 14.4 hours of work missed or work time impaired due to health in the last 7 days. At 6 months, productivity loss decreased to 26.9%, or 10.0 hours (P <.001). At both points in time, productivity loss was more attributable to employees’ underperformance while at work, or presenteeism, than to missing work, or absenteeism. Patients with more productivity loss (e.g., higher WPAI scores) at baseline tended to report more improvement (reduction in WPAI scores) in productivity from baseline to 6 months (reduction = –.61, P <.001), and this improvement was greater for those who achieved response (n = 51, M = – 14.1, SD = 30.8) or remission (n = 182, N = –19.0, SD = 32.7) as measured by PHQ-9 scores at 6 months (neither response nor remission, n = 199, M = – 3.4, SD = 29.6).

Mean PHQ-9 scores also decreased from 12.0 at baseline to 7.1 at 6 months, (P <.001). At baseline, 64.7% of patients had PHQ-9 scores in the moderate to severe range, whereas at 6 months, this percentage had decreased to 26.9%.

Similar to the finding for productivity loss, patients with more severe depression symptoms (higher PHQ-9 scores) at baseline tended to report greater reduction in PHQ-9 scores from baseline to 6 months (reduction = –0.41, P <.001).

The model that was of most interest was the weighted general linear model that predicted change from baseline to 6 months in productivity from change in depression symptoms, baseline productivity loss, and depression symptoms, adjusting for self-reported health status and several demographic variables (see Table 4). The overall model containing all covariates was significant, F = 38.57, P <.0001 (model R2 = .48). 

Specifically, we found that for every 1-point decrease in PHQ-9 scores from baseline to 6 months, there was a 1.87 point increase in productivity. Patients’ PHQ-9 scores decreased an average of 5 points over 6 months of usual care for depression, and this symptom improvement was associated with an average improvement of 9.35 points (11%) in productivity during the same period, translating into an approximate gain of 4.4 hours per week in productivity. The productivity gain observed corresponds to an effect size of 0.34 (WPAI change score divided by SD of WPAI at baseline, or 9.35/27.8). Individual variables significantly associated with productivity change were baseline productivity loss (P <.0001), baseline depression symptoms (P <.0001), and change in depression symptoms from baseline to 6 months (P <.0001). Lower productivity and greater depression symptoms at baseline, as well as greater depression symptom reduction from baseline to 6 months, were all associated with greater improvements in productivity (P <.0001) from baseline to 6 months.


The results from this study suggest that improvement in depression symptoms is associated with improvement in productivity for primary care patients receiving usual care for depression. Patients’ average PHQ-9 score decrease of 5 points is clinically significant and was associated with a productivity gain of approximatelf 4.4 hours per week, after adjusting for loss to follow-up at 6 months, baseline scores, demographic variables, and self-reported health status.

Our findings of reduced productivity loss following usual care for depression are consistent with findings from randomized trials of enhanced depression care interventions as well as some cross sectional and modeling studies.16,17 The approximate gain of 4 hours per week in productivity among patients we observed at 6 months compares favorably to the estimate of an annualized gain of 2 hours of work per week in the randomized trial of a telephonic depression-care program for employed individuals (Wang et al).8 Notably, participants in the latter trial were more likely to have minor depression and were recruited from their work sites, not from primary care clinics where patients in the current study may have been seeking care specifically for depression. A randomized trial evaluating enhanced depression care for primary care patients conducted by Rost et al found 8% increases in productivity among consistently employed workers over a 2-year period.10 The study by Woo et al of Korean workers with major depression showed that after 8 weeks of treatment, absenteeism and clinical symptoms of depression were significantly reduced and associated wit significant improvement in self-rated job performance.19

Although our study combined the outcomes of absenteeism and presenteeism, trajectories of improvement following treatment may differ for each, as shown in Table 3. Birnbaum et al linked employee health survey data to medical and drug claims data and found that increased compliance with antidepressants was associated with reduced absenteeism but not presenteeism, noting that the process of recovery from depression may continue at work, hindering productivity.15 The findings of Buist-Bouwman et al underscore this phenomenon, suggesting that concentration and attention problems are significant mediators of the association between depression and role functioning, and therefore should be a focus of treatment.29 Other studies have shown that even minor depression symptom severity is associated with work impairment, and although work performance improves in proportion to depression symptom remission following treatment, it remains consistently lower among individuals showing clinical improvement in depression compared with non-depressed controls, suggesting the importance of treating patients to full remission in order to restore psychosocial function.7,30,31 Our findings support this assertion. After 6 months of antidepressant treatment, productivity loss decreased to 26.9%, a level associated with minor depression (PHQ- 9 scores in the 5-9 range), but still well above the 8% reported as normative data from the WPAI for-nondepressed individuals with no other chronic medical condition. Steve Schwartz, director of research, (Health Media, e-mail, August 25, 2010). 

Several studies also have measured or estimated reductions in indirect costs following depression treatment using different costing methods and yielding varying but mostly favorable results.9,11,32-34 These include findings of annualized absenteeism cost reductions of $50 for depressed employees who were compliant with antitdepressant medications, $1800 annualized value of higher mean hours worked among depression intervention participants, $1982 savings per depressed full-time employee over 2 years for patients receiving collaborative care for depression, and cost savings of $7508 per employee per year resulting from improvements in self-rated job performance following treatment. Moreover, a cost-benefit modeling study by Lo Sasso et al suggested that every 1 dollar invested in enhanced depression care yields approximately 3 dollars to employers in the form of productivity gains by employees.35

The reductions in productivity loss we found in this study would potentially yield cost savings to employers, especially in light of the fact that the participating primary care clinics did not increase treatment costs that might have occurred in trials of enhanced depression care. On the other hand, the incremental benefit of enhanced depression care on labor outcomes may exceed the additional costs associated with these enhancedcare management programs, whether they focused on pharmacotherapy, psychotherapy, or both.36 In either case, findings from this and other studies underscore the benefit to employers of investing in treatment for depression.

The results reported in this paper have both strengths and limitations. Unlike typical clinical trials of depression care, usual primary care for depression prior to implementation of the DIAMOND initiative involved minimal patient exclusion criteria, no implementation or monitoring of treatment protocols, the allowance for variation in how depression care was implemented at the numerous participating clinics, and no special training provision to participating primary care providers. The relatively large sample of primary care patients participating in DIAMOND was obtained from members of a majority of health plans (including individuals utilizing Medicaid products) across the state of Minnesota who received usual care for depression. Because the data were collected before these clinics participated in enhanced depression care as part of the DIAMOND Initiative, the results reflect real-world care patterns in the absence of additional depression care management support. Therefore, the results should be generalizable to primary care patients receiving usual care for depression, notwithstanding the limited racial and ethnic diversity of individuals in this geographic region. In addition, we examined depression symptoms and productivity loss longitudinally, enabling us to model predictors of improvement in productivity loss over 6 months following initiation of antidepressants.

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