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The Clinical and Financial Burden of Mood Disorders
Cost and Outcome
Richard C. W. Hall, M.D.
Medical Director, Psychiatric Programs
Florida Hospital
Center for Psychiatry Clinical Professor of Psychiatry University
of Florida, Gainesville
Psychosomatics - 1994
One-third of Americans suffer from some form of mental or addictive
disorder, yet most mentally ill Americans receive no active treatment.(1)
These mental and addictive disorders cost our society 273.3 billion
dollars in 1985. Of this, 43.7 billion dollars accrued from lost
earnings due to premature death. Treatment related costs of mental
illness totalled 65.6 billion, while the costs incurred by other
social agencies, such as law enforcement, courts, fire departments,
shelters etc., for the care of the mentally ill, represented an
additional 65.6 billion.
The costs to society for lost or reduced productivity totalled another
98.4 billion dollars.(2) Mood disorders in aggregate were the most
expensive mental illness. In 1992, most psychiatric hospital admissions
were due to depression, with affective disordered patients representing
45% of all admissions to private psychiatric hospitals.(3)
In spite of enormous costs, government data suggests that current
treatment is both humane and effective. A recent study by the National
Institute of Mental Health showed psychiatric treatment for affective
disorders to be highly efficacious. Six month treatment success
rates for bipolar disorder reached 80% while six month remission
rates for major depression reached 65%.(4)
If we can treat these conditions so effectively, why are our health
care costs for the treatment of mood disorders so high and what
can we learn from current research about how we can improve outcome
and reduce costs? The remainder of this article will attempt to
address these topics.
WHO DEVELOPS AFFECTIVE DISORDER?
As Klerman and Weissman(5) point out, depression is a chronic disorder
that is recurrent in nature; impairing the patient, his family and
his employer. Data from the epidemiologic catchment area survey
suggests that in 1990, 11 million Americans were clinically depressed.
Of these, 7.8 million were women and 3.2 million were men. Five
million patients suffered from a major depression, while 1.8 million
developed a bipolar disorder, and 4.1 million experienced dysthymia.(6)
WHY ARE COSTS SO HIGH? - MISDIAGNOSIS AND DELAYED OR INADEQUATE
TREATMENT Depressive disorders, when they occur are under diagnosed
and under treated. Wells et al(7) have shown that the inadequate
diagnosis and treatment of depression are responsible for most of
the costs of these disorders. Fifty to 60% of patients who present
with significant depression are inaccurately diagnosed.(8) Recent
data suggests that only one in three people with a significant depression
seeks specific treatment for their condition.(9) Most don't define
themselves as depressed when they see a health care provider. This
is in part because they feel hopeless, are unwilling to accept a
diagnosis of depressive disorder, and are fearful of stigmatization
and the loss of their job. Many physicians are also reluctant to
diagnose patients as depressed.(10) Eisenberg(11) in a recent review
correctly noted that depression is frequently unrecognized by primary
care physicians who most often focus their diagnosis and treatment
efforts on the patient's accompanying physical symptoms; most commonly
fatigue, weight loss, headache, GI disorders, pains and sleep disorders
- rather than on the depression which causes them. Reiger(9) noted
that of the 2/3 of depressed patients who did not specifically refer
themselves for depression, 80% were seen for other physical complaints,
and of these patients, only one in eight was correctly diagnosed
by their primary care provider as suffering from a depressive illness.
Significant depression often remained undiagnosed for years.(12)
Wells and colleagues have shown that depressed medically ill patients
have significantly more bodily pain and functional impairment than
do chronic suffers of medical conditions who have no depressive
symptoms. They note that depression is as physically and mentally
disabling as the most severe chronic medical disorders. Only advanced
coronary artery disease produced more bed disability days than depression,
while only arthritis caused more chronic pain. Depression is more
disabling than diabetes, hypertension, arthritis, gastrointestinal
or back disorders in terms of reducing a patient's level of physical
functioning and interfering with their ability to work, to care
for home and family and to function socially.(13)
The economic burden of depression has increased disproportionately
in the United States during the last 15 years. Stoudemire's(14)
excellent study of the economic impact of the 1980 Epidemiological
Mental Health data was the first systematic analysis of the cost
of major depressive illness. In terms of 1980 dollars, Stoudemire
showed that the annual direct cost of treating depression was two
billion dollars with an annual mortality cost of four billion dollars
and amorbidity cost due to lost productivity of 10 billion dollars.
Depression thus cost our society a total of 16 billion dollars in
1980.(14) By 1990, Greenberg et al(15) estimated the cost of depression
to be 44 billion dollars, with the direct costs of medical, psychiatric
and pharmacological care approaching 12.4 billion dollars, close
to the total amount depression cost our society in 1980. The mortality
costs of depression by 1990 had grown to 7.5 billion dollars while
morbidity costs reached 23.8 billion.(15) Noteworthy in Greenberg's
review of the literature was the relatively low cost of antidepressant
medications at 890 million dollars and the low total cost for all
pharmacological treatment for affective disorders which he estimated
at one billion one hundred and seventy five million dollars. Greenberg's
analysis considered the cost for all types of mood disorders including
major depression, bipolar disorder and dysthymia. His study did
not include the comorbid effects that depression had on medical
illness or its effect on extending med/surg hospital days. Neither
did he take into account such factors as the diminution in the quality
of a patient's life or the out of pocket costs incurred by the families
of depressed patients to pay for services such as child care.
Saravay and Lavin(16) in a review of 26 outcome studies which evaluated
the effects of psychiatric comorbidity on length of hospital stay
concluded that depression was one of three significant variables
that contributed to prolonged hospital stays and to a greater utilization
of hospitals and other health resources post discharge. Verbosky
and colleagues(17) in a retrospective study of mean length of hospital
stay for patients with a secondary diagnosis of depression who were
treated with antidepressants vs those who were not so treated showed
that the non-antidepressant treated group had an average length
of stay of 45.6 days as compared to a length of stay of 13.8 days
for those patients treated with antidepressants and 10 days for
non-depressed controls with similar medical conditions. Thus, patients
whose depression was recognized early and appropriately treated
during a hospitalization spent 31.8 fewer days in hospital. Based
on the 1988 Medicare rate average of $800 a day, early treatment
of depression could provide an expected savings of over $25,000
per admission. Broadhead et al(18) showed that during a one year
follow up period, depressed patients accumulated five times more
disability days than did non-depressed patients. Wells et al(12)
showed that depressed patients spent more days in bed than patients
with other chronic illnesses including arthritis, back pain, diabetes
and hypertension.
Several investigators(17,19-22) have shown that depression increases
medical utilization for a variety of somatic complaints, the most
common being weakness, lethargy, headaches, backaches, insomnia
and gastrointestinal disorders. These complaints often produce unnecessary:
hospitalizations, physician visits, diagnostic tests, and prescriptions
for analgesics, anxiolytics, sedatives and gastrointestinal medications.
These studies also show that patients with undiagnosed and untreated
affective disorders use HMO physical health services three times
more than non-depressed health plan enrollees. They use emergency
services three to four times as often and call about health problems
and for medication changes four to five times more often than non-depressed
enrollees. Thus untreated or inadequately treated depressed patients
increase non-psychiatric health care costs. It is most often the
chronically depressed patient, not the chronically medically ill
patient, who has the thickest HMO chart.
SUICIDE
In 1990, 15,000 men and 3,400 women who were diagnosed with an affective
disorder committed suicide. It is estimated that the number of deaths
by suicide, not so reported, is 10 times higher than that reported
suggesting that as many as 184,000 depressed patients committed
suicide in the United States in that year. Several studies have
suggested that between 40 to 70% of all suicide victims suffer from
a major depressive disorder.(23) It is estimated that total lifetime
earnings lost to the U.S. economy due to suicide in 1990 represented
7.5 billion dollars.
DEPRESSION IN THE WORKPLACE
7.8 Million of the 11 million Americans who suffer from depression
are found in the work force.(24) In 1990, 200 million days were
lost from productive work due to depression. Of these, 70% were
lost by women. Reduced productivity and days lost to work cost employers
11.7 billion dollars in 1990.(15) In addition, patients who experience
clinical depression have an average reduction in total earnings
of 25%.(25) Recent EAP studies have shown that during any calendaryear,
13% of employees will experience a clinically significant depression
which necessitates time off work.
The effects of depression on workers include a devastating loss
of self esteem and confidence and an inability to make decisions
which often leads to unsatisfactory performance evaluations that
may result in either dismissal and/or adversarial relations between
employer and employee.
Depressed patients experience costly declines in productivity, an
increased accident rate both on and off the job, and an increased
rate of disability claims. Job loss may precipitate suicide or homicide.
TREATMENT IMPLICATIONS
Managed care has altered the way one conceptualizes treating mental
illness. Increasingly, there is pressure to refer patients with
psychiatric disorders to the lowest level of provider who can address
their needs and to treat them in the least restrictive, most cost
sensitive environment. Multiple barriers, which often make no clinical
sense, have been created to limit access to psychiatrists and psychiatric
inpatient care. For example, the State of Florida PRO criteria for
hospital admission for a patient with major affective disorder requires
that a patient have a specific suicide plan. If a patient presents
with a serious depression with vegetative symptoms, intermittent
panic attacks, suicidal ideation, a history of past suicide attempts
and a concurrent medical illness about which he/she is ruminating,
that patients' admission would in all likelihood be disallowed by
the PRO because the patient wasn't sure exactly how and when they
would commit suicide! If the patient were admitted and had not shown
a dramatic improvement within 14 days, the PRO might deny any further
payment and suggest that the patient be discharged from the hospital
as a "failure to respond." The uncoupling of admission and discharge
criteria from scientific data in an attempt to constrain cost, places
patients and clinicians at significant risk. Several recent studies
have shed considerable new light on how we might appropriately approach
depressive illness and still constrain cost.
Keller et al(26) in a five year, five university, prospective follow
up study of 431 depressed patients showed that these patients had
a high rate of chronicity, with 12% not recovering by the end of
five years. Most of the patients who did recover did so in the first
six months of the study. These investigators showed that the severity
of the patient's initial symptoms predicted recovery, with less
impaired patients recovering sooner. They also noted that many of
the patients who did not recover continued in a state of chronic
dysthymia. They also suggested that dysthymia is a significant predictor
for recurrence of major depression.
Fawcett(27) has shown that patients with major affective disorder
and concurrent panic attacks are at high risk for suicide. These
patients must have access to their physicians and cannot be locked
out of stabilizing hospital treatment by arbitrary admission criteria.
Kupfer et al(28) in reviewing the NIMH depression study commented
on the chronic course of major depressive illnesses and noted that
these conditions hadboth a high relapse and a high recurrence rate.
They felt that the 16 week treatment paradigm for treatment of acute
major depression is insufficient to maintain long term recovery
and suggested that these patients required skillful, long term,
ongoing follow up and active pharmacological treatment. They showed
that the average time from the onset of a major depression to recovery
was between 25 to 37 weeks, not the two to 14 weeks defined by many
PRO and managed care protocols.(29)
TREATMENT REDUCES COST
Baldessarini(30) has shown that successful treatment of affective
disorders significantly reduces the cost of these conditions. He
documents that adequate antidepressive treatment is effective in
at least 65 to 80% of patients and that the return of these patients
to normal functioning saves the considerable costs associated with
untreated depression. The early and proper diagnosis and treatment
of depression produces considerable savings to the health care delivery
system by reducing unnecessary physician's visits, diagnostic tests,
prescriptions, psychiatric hospitalization and extended medical/surgical
hospitalizations.
EARLY DIAGNOSIS AND TREATMENT REDUCES MORBIDITY
Kupfer et al(28) studied a group of 45 patients with recurrent major
depression who were treated with combined pharmacotherapy and psychotherapy
in a similar fashion for two consecutive episodes. These patients
showed a comparable mean time to initial stabilization of between
11 to 12 weeks with the episode continuing for seven to eight months.
Early intervention at the onset offirst symptoms during the second
episode significantly shortened the overall length of the depressive
episode by approximately four to five months. These investigators
clearly demonstrated that early aggressive treatment can alter the
natural course of a particular episode of major depression. With
early intervention, they were able to stabilize patients in between
three to three and one half months as compared to eight to 10 months
once a patient's depression had become established.
Keller(26) showed that 50% of depressed patients recovered in less
than 12 weeks with adequate treatment. Eighty five percent of the
patients who recovered by 12 months after entry into treatment did
so in the first four months.
Kupfer(29) showed a total cumulative recovery for patients with
major depression at four months of 63%. He also demonstrated that
immediate treatment at the time of first symptom recurrence significantly
shortened the overall length of the second depressive episode by
an average of 16 weeks.
The implications of this work are profound, suggesting that physicians
need to follow their patients closely and at the first sign of relapse
again begin an aggressive treatment regimen. Depressed patients
need to have immediate and open access to their treating physicians
without having to go through intermediary gate keepers or councilors.
Early intervention shortens recurrent bouts of major depression
by four to five months and significantly reduces both cost and human
suffering. Isacsson, et al(31) studied 283 patients who committed
suicide. Of that number they were able to obtain blood for toxicology
in 247 cases (87%). Only 8% of the total sample (19 patients) had
antidepressants in their blood. Only 12% of suicide victims diagnosed
as suffering from major or atypical depression had antidepressants
identified in their blood. Lethal blood levels of antidepressants
were found in 4% of all the suicide victims. In most of these incidences,
multiple other substances were also present. Most patients who suicided
by multiple drug overdose were diagnosed as having comorbid depression
and substance abuse. More than 50% of the patients who committed
suicide were seen by a physician within 90 days prior to the time
of their suicide and had clear symptoms of major affective disorder.
Of these, only half received any treatment with antidepressants.
Of the patients who were treated with antidepressants at the point
of their last contact, only one-third had antidepressants in their
blood at the time of their suicide.
This study suggests that when a diagnosis of major depression is
made, that patients should be treated more aggressively with antidepressants
rather than having these medications withheld for fear of suicide.
It demonstrates that immediate intervention, frequent appointments
and careful blood level monitoring are essential and that patients
should continue in intensive therapy until their depression has
stabilized.
Frank et al(32) in a three year study found that patients who had
serious recurrent depression required long term maintenance treatment.
These patients did best when prescribed medications in higher than
usual maintenance dosages. They benefited most from medication treatment
and a lower than expected number of interpersonal psychotherapy
visits. Optimal improvement occurred when patients were treated
with 200mg/day of imipramine and were seen once monthly by their
treating psychiatrist. All of the above studies force reconsideration
of:
(1) our current practice of decreasing medication dosage over
the long term for seriously depressed patients, particularly those
who have a history of recurrence or relapse;
(2) reliance on time limited follow up and brief non-medical psychotherapy
for these patients and
(3) reliance on gate keepers who restrict access to the patient's
psychiatrist for medical and psychotherapeutic management of these
chronically depressed patients.
CONCLUSION
Depression is a major national public health concern costing our
society more than 44 billion dollars a year. It represents one of
America's 10 most costly diseases. Major affective disorder must
be regarded as an episodic, recurring, relapsing chronic disease
that requires access to a physician for ongoing psychotherapy and
medication maintenance. Recent studies have shown that treatment
is cost efficient, humane and highly effective when planned for
the long term. Short term treatment strategies which restrict access
to physicians andprovide low level, short duration (i.e., six months
or less) pharmacologic maintenance are not our most effective treatment
strategies. Brief treatment strategies directed only at acute episodes
are insufficient and often ineffective, resulting in chronic impairment,
decreased work and social performance, increased costs, lost productivity
and increased human suffering. Adequate early treatment has been
shown to save lives, reduce suffering, enhance work performance
and reduce the long term sequelae of these illnesses. Brief, repetitive
interventions in the mildly ill are effective in preventing progression
to severe incapacitation and alter the duration and severity of
the patients' symptoms.
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