Depression

A Troublesome Trend In Depression Care? Viewpoint

This is a report of service utilization data from 2 large nationally representative surveys of the US population. The authors measured rates of depression treatment, use of antidepressant medication and psychotherapy, and the number of outpatient treatment visits and expenditures.

This is a report of service utilization data from 2 large nationally representative surveys of the US population. The authors measured rates of depression treatment, use of antidepressant medication and psychotherapy, and the number of outpatient treatment visits and expenditures. The authors found that the rate of outpatient treatment for depression increased from 2.37 per 100 persons in 1998 to 2.88 per 100 persons in 2007. The percentage of treated patients who used antidepressants changed little — from 73.8% in 1998 to 75.3% in 2007 — but the percentage of those receiving psychotherapy declined from 53.6% to 43.1%. National expenditure for outpatient treatment of depression increased from $10.05 billion to $12.45 billion, primarily due to an increase in medication expenditures from $4.59 billion to $6.60 billion but also because of an increase in Medicare expenditures for depression treatment from $0.52 billion to $2.25 billion.

Viewpoint

Depression is common and can be debilitating. Fortunately, effective treatments are now available, and for the most part they are easy to prescribe and are well-tolerated. It is not a surprise that with the advent of serotonin-specific reuptake inhibitors the percentage of Americans treated for depression increased from 0.73% in 1987 to 2.33% in 1997, and that among these persons, antidepressant medication use increased from 37.3%-74.5%. The authors update these data with information about changes from 1998-2007. Antidepressant medication use has remained the same among treated persons, but psychotherapy is less commonly utilized. The rate for psychotherapy among persons treated for depression in 1987 was 71.1%; 2 decades later it was 43.1%.

Psychotherapy demands an investment of time and money and is not as easily accessible as medication treatment that can be provided by primary care clinicians. For persons with insurance, finding a “panel psychiatrist” available to see them is a challenge in itself — finding one that will also provide a combination of psychotherapy and pharmacotherapy is nearly impossible in many communities. Going “out of network” is not financially feasible for many patients. Indeed, I am surprised that the rate of psychotherapy is as high as it is.

The authors do note that the rate of outpatient treatment for depression of 2.88 per 100 persons in 2007 remains far below the estimated rate of depression in the community. More work is needed for all of us to improve recognition of major depressive disorder, lessen its stigma, and increase access to treatment.

Summary

This is a report of service utilization data from 2 large nationally representative surveys of the US population. The authors measured rates of depression treatment, use of antidepressant medication and psychotherapy, and the number of outpatient treatment visits and expenditures. The authors found that the rate of outpatient treatment for depression increased from 2.37 per 100 persons in 1998 to 2.88 per 100 persons in 2007. The percentage of treated patients who used antidepressants changed little — from 73.8% in 1998 to 75.3% in 2007 — but the percentage of those receiving psychotherapy declined from 53.6% to 43.1%. National expenditure for outpatient treatment of depression increased from $10.05 billion to $12.45 billion, primarily due to an increase in medication expenditures from $4.59 billion to $6.60 billion but also because of an increase in Medicare expenditures for depression treatment from $0.52 billion to $2.25 billion.

The authors do note that the rate of outpatient treatment for depression of 2.88 per 100 persons in 2007 remains far below the estimated rate of depression in the community. More work is needed for all of us to improve recognition of major depressive disorder, lessen its stigma, and increase access to treatment.

Psychotherapy demands an investment of time and money and is not as easily accessible as medication treatment that can be provided by primary care clinicians. For persons with insurance, finding a “panel psychiatrist” available to see them is a challenge in itself — finding one that will also provide a combination of psychotherapy and pharmacotherapy is nearly impossible in many communities. Going “out of network” is not financially feasible for many patients. Indeed, I am surprised that the rate of psychotherapy is as high as it is.

Depression is common and can be debilitating. Fortunately, effective treatments are now available, and for the most part they are easy to prescribe and are well-tolerated. It is not a surprise that with the advent of serotonin-specific reuptake inhibitors the percentage of Americans treated for depression increased from 0.73% in 1987 to 2.33% in 1997, and that among these persons, antidepressant medication use increased from 37.3%-74.5%. The authors update these data with information about changes from 1998-2007. Antidepressant medication use has remained the same among treated persons, but psychotherapy is less commonly utilized. The rate for psychotherapy among persons treated for depression in 1987 was 71.1%; 2 decades later it was 43.1%.

Source:

Marcus SC, Olfson M.
Arch Gen Psychiatry. 2010;67:1265-1273.

Leslie Citrome, MD, MPH

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