Current Trends for the Management and Treatment of Depression

July 1, 2004
Hyong Un, MD

Supplements and Featured Publications, Current Trends for the Management and Treatment of Depression, Volume 10, Issue 6 Suppl

Depression is a common disorder thataffects quality of life, productivity,and healthcare outcomes and costdespite the availability of a broad range oftreatment options. Lifetime prevalencerates for depression range from 7% to 12% inmen and 20% to 25% in women.1,2 Mortalityrates are increased 6-fold by the presence ofdepression. Fifteen percent of depression-relatedmortality is by suicide. Rates ofosteoporosis, stroke, alcoholism, and cigarettesmoking are increased with depression.Conversely, rate of depression isincreased in patients with long-term medicalillnesses.3 As much as 15% to 20% ofpatients with diabetes and long-termheart failure have depression as a comorbidillness. Presence of comorbid depressioncan deteriorate the course of medical illnessand adversely affect rate of mortality andmorbidity.

The cost of depression to the economy isapproximately $44 billion.4 About half ofthis cost represents the direct cost of treatment.Indirect costs, including lost productivity,morbidity, and mortality, representthe other 50%. Depression negatively affectspatients' perception of health. Perceptionsof physical, social, and role functioning inpatients with depression are worse than anyother long-term medical illness besides cardiovasculardisease (CVD).5 Employees withdepression incur more disability days thanthose with physical symptoms caused byhypertension, CVD, or diabetes.6 Patientswho have comorbid depression and longtermmedical illness experience higher ratesof utilization and increased medical cost.Depression related to medical costs is notoften factored into overall medical cost, andit represents the hidden cost of untreateddepression. Realizing the gains in indirectcost and this hidden medical offset cost representa significant opportunity for improvingboth quality of life and health outcomesand decreasing medical costs.

Treatment of depression has advancedrapidly in the past 10 years. Antidepressantshave become safer and easier to tolerate.Efficacy has approached nearly 75%.Evidence-based psychotherapy for depressionas an effective form of treatment is wellestablished. Use of antidepressants hasincreased dramatically and is frequently thesecond or third most common prescribedclass of medications.7

Despite increased treatment efficacy andutilization, relative effectiveness of treatmentof depression has remained problematic.8 Screening and detection rates fordepression have remained low. Although50% of patients with depression are seen inthe primary care physician's office, onethird to one half are not diagnosed. Oncedepression is identified, patients receiveantidepressants that are subtherapeutic indosage and duration. Patients frequently donot continue taking antidepressants for theappropriate duration. Health EmployerData and Information Set measures havenot improved dramatically for optimal antidepressanttreatment and follow-up. Theseand other issues have led to a partial realizationof full efficacy of the treatment ofdepression.

Multiple factors contribute to low levelsof treatment effectiveness. Stigma remains apotent factor in patients acknowledging thatthey have depression and need help.Similarly, stigma may lead to reluctance onthe physician's part to openly address theissue of depression with his or her patients.The lack of systematic screening for thegeneral population and the population atrisk along with stigma contribute to a lowdetection rate. There is also a perceived lackof competency and capacity to handleissues, such as suicidality, that a patientwith depression may present with. Thisissue is compounded by lack of discretedemarcation between sadness related to situationalstress and sadness related to physiologicdepression. Providing education anddecision supports that are appropriatelytimed and relevant, culturally sensitive, andaccessible remain a significant challenge.Despite advances in evidence-based care,adherence to treatment guidelines and algorithmsremains low. Issues related to sideeffects are inadequately addressed by bothphysicians and patients.

In the context of rising health costs andhealth insurance premiums and the ever-increasingcompetitive business environment,the impact of depression in theworkplace has become an issue for employers.The impact depression has on whetheran employee is absent from work or not iswell known. It is of equal concern to employersthat depression is frequently the secondor third leading cost of disability claims. Thecost of antidepressants as a class now representsa significant portion of pharmacyspending for employers. Given the increasingawareness of both the direct and indirectcosts of depression in the workplace,employers have started to demand moreaccountability from both health plans andproviders. This awareness of rising cost oftreating depression in the face of a lack ofprogress in effectiveness of treatment willintensify the pressure on providers andhealth plans to demonstrate the value relatedto the treatment of depression. Throughcollaboration between consumers, providers,academia, health plans, and employers, thischallenge will be met.

Arch Gen Psychiatry

1. Kessler RC, McGonagle KA, Zhao S, et al. Lifetimeand 12 month prevalence of DSM III-R psychiatric disordersin the United States. Results from the NationalComorbidity Survey. . 1994;51:8-19.

JAMA

2. Kessler RC, Berglund P, Demler O, et al. The epidemiologyof major depressive disorder: results from theNational Comorbidity Survey Replication (NCS-R).. 2003;289:3095-3105.

Am FamPhysician

3. Nesse RE, Finlayson RE. Management of depressionin patient with coexisting medical illness. . 1996;53:2125-2133.

J Clin Psychiatry

4. Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER.Depression: a neglected major illness. .1993;54:419-424.

Arch Gen Psychiatry

5. Hays RD, Wells KB, Sherbourne CD, Rogers W,Spritzer K. Functioning and well-being outcomes ofpatients with depression compared with chronic generalmedical illnesses. . 1995;52:11-19.

Am J Psychiatry

6. Druss BG, Rosenheck RA, Sledge WH. Health anddisability costs of depressive illness in a major UScorporation. . 2000;157:1274-1278.

Health Aff (Millwood)

7. Huskamp H. Managing psychotropic drug costs: willformularies work? . 2003;22:84-96.

J Clin Psychiatry

8. Kobak KA, Taylor L, Katzelnick DJ, Olson N,Clagnaz P, Henk HJ. Antidepressant medication managementand Health Plan Employer Data Information Set(HEDIS) criteria: reasons for nonadherence. . 2002;63:727-732.