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Depression - Trends In Treatment

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Published On: January 09, 2001          Updated On: January 09, 2002
© Terence T. Gorski, 2001

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Depression -  Trends in Treatment
By Terence T. Gorski
January 9, 2001

1.    The number of Americans treated for depression soared from 1.7 million to 6.3 million between 1987 and 1997.  There are strong indicators that the number of people seeking treatment for depression continued to increase from 1997 to 2000.

2.    About 5 percent of the U.S. population — roughly 14 million people — could benefit from treatment for depression.

3.    About 2.5% of Americans, approximately 7 million people, are treated for depression each year.  This is only about half the number of people who could benefit from treatment.

4.    There is strong evidence suggesting that :  

A.   Cognitive Behavioral Therapy (CBT) for Depression is just as effective as medication management in the treatment of depression, but the two types of treatment tend to work best with with different types of depression.  In other words CBT for Depression is effective with some patients who are not helped by antidepressant medication and antidepressant medication is effective with some patients who are not helped by CBT for Depression; and 

B.   The most effective treatment for depression involves the combination of CBT for Depression and antidepressant medication.    

5.    Between 1987 and 1997 the proportion of patients who used antidepressant medication climbed from 37 percent to nearly 75 percent. 

6.    Between 1987 and 1997 the proportion who received psychotherapy declined from 71 percent to 60 percent.  

7.    These trends in the treatment of depression can be attributed to the following factors:

Factor #1:  Development of the SSRI's:  The development of Selective Serotonin Reuptake Inhibitors (SSRI's), a new generation of antidepressant medications with  fewer side effects than the previous generation of tricyclic antidepressants.

Factor #2:  The Aggressive Marketing of the SSRI's:  The aggressive marketing of the SSRI's to managed care organizations, primary care physicians, and consumers.  The general media advertising for the SSRI's has been designed to educate the general population about the symptoms of depression, describe depression as a medical illness, explain that the SSRI's can be used as an effective treatment,  and encourage people to discuss problems of depression with their primary care physician and request medication.  

Factor #3:  The Easing of Stigma:  The stigma associated with depression is easing which makes more people willing to admit to themselves that they are depressed and seek treatment.

Factor #4:  The Ineffective Marketing of Psychotherapy for Depression:  Psychotherapy has not been recognized as a preferred treatment for depression by managed care organizations, primary care physicians, or the general population of consumers even thought strong evidence shows that the most effective treatment for depression combines Cognitive Behavioral Therapy (CBT) for Depression with antidepressant medication and that Cognitive Behavioral Therapy (CBT) for Depression can be effective for some depressed patients who do not benefit from antidepressant medication.  This is because psychotherapy has not been aggressively or effectively marketed.  

Factor #5:  The Influence of Managed Care Organizations:  Managed Care organizations have had a large impact upon the identification and treatment of depression.  Most managed Care Organizations (MCO's) encourage the early identification and treatment of depression using appropriate medications.  Most MCO's prefer medication management as a more cost-effective alternative to either hospitalization or outpatient psychotherapy.  As a result, they are more likely to refer to primary-care physicians who use medication to treat depression than to refer to psychotherapists who specialize in depression treatment.

Factor #6:  The Increased Involvement of Primary Care Physicians:  More primary care physicians are getting involved in the treatment of depression.  The aggressive marketing of antidepressant medications is convincing more people that depression is a legitimate medical problem that can be effectively treated.  As a result, more people are asking their primary care physicians to treat their depression with medication.  Primary care physicians have a financial incentive to identify and treat depression in their patients because most managed care organizations are willing to pay for medication management .

References

Olfson, Mark; Marcus, Steven C.; Druss, Benjamin; Elinson, Lynn ; Tanielian, Terri MA; and Pincus, Harold Alan; National Trends in the Outpatient Treatment of Depression, JAMA. January 9, 2002; 287:203-209

Tanner, Lindsey, Treatment for Depression Soars, Associated Press (AP), January 9, 2002 <Read The Article>

Treatment For Depression Soars

By Lindsey Tanner
Associated Press (AP) Medical Writer

January 09,2002

CHICAGO (AP) — The number of Americans treated for depression soared from 1.7 million to 6.3 million between 1987 and 1997, and the proportion of those receiving antidepressants doubled, researchers say.

The researchers attributed the sharp increases to the emergence of aggressively marketed new drugs like Prozac, the rise in managed care and an easing of the stigma attached to the disease.

The study found that the share of patients who used antidepressant medication climbed from 37 percent to nearly 75 percent. At the same time, the proportion who received psychotherapy declined from 71 percent to 60 percent.

While an increase in treatment for depression was not surprising, ``the size of the increase was larger than I think most people in the field expected,'' said Dr. Mark Olfson, a psychiatrist at Columbia University and the New York State Psychiatric Institute who led the study. Studies since 1997 suggest the trend continues, he said. 

The study was an analysis of two national surveys. The findings appear in Wednesday's Journal of the American Medical Association.  The publicizing of newer antidepressants that have fewer side effects — such as Prozac, which was introduced in late 1987 — has helped make patients more willing to seek treatment, the researchers said. This publicity has included pharmaceutical industry efforts to market the drugs directly to consumers and public-awareness campaigns about depression.

The rise in managed care also has contributed to the increase in use of medication, which may be less costly and time-consuming than psychotherapy, the researchers said.

Managed care also has placed more emphasis on primary-care physicians, who may be more likely to prescribe medication than to refer patients to specialists for psychotherapy, said Ronald Kessler, a professor of health care policy at Harvard University who was not involved in the study. 

Kessler said evidence shows that combining medication with psychotherapy is the most effective treatment for depression. While many of the patients studied received both, some clearly did not, and Kessler said the findings do not indicate whether patients received adequate treatment.

The analysis is based on data from 34,459 people who participated in a 1987 medical expenditures survey by the U.S. Department of Health and Human Services. The researchers compared those findings with data from 32,636 participants in a similar 1997 survey by the Agency for Healthcare Research and Quality.

While the study shows ``that the acceptance of a medical intervention for depression is clearly increasing, it still is significantly below what the potential need for care is,'' said Dr. Darrel Regier, research director for the American Psychiatric Association.

Other surveys have suggested that about 5 percent of the U.S. population — roughly 14 million people — could benefit from treatment for depression, but the study suggests that only about half that number are actually receiving care, Regier said. 

On the Net:
JAMA: http://jama.ama-assn.org
National Institute of Mental Health: http://www.nimh.nih.gov/publicat/depression.cfm 
National Mental Health Association: http://www.nmha.org
American Psychiatric Association: http://www.psych.org

National Trends in 
The Outpatient Treatment of Depression
January 9, 2002
JAMA. 2002;287:203-209

Authors
Mark Olfson, MD, MPH; Steven C. Marcus, PhD; 
Benjamin Druss, MD; Lynn Elinson, PhD; Terri Tanielian, MA;
Harold Alan Pincus, MD

Context  Recent advances in pharmacotherapy and changing health care environments have focused increased attention on trends in outpatient treatment of depression.

Objective  To compare trends in outpatient treatment of depressive disorders in the United States in 1987 and 1997.

Design and Setting  Analysis of service utilization data from 2 nationally representative surveys of the US general population, the 1987 National Medical Expenditure Survey (N = 34 459) and the 1997 Medical Expenditure Panel Survey (N = 32 636).

Participants  Respondents who reported making 1 or more outpatient visits for treatment of depression during that calendar year.

Main Outcome Measures  Rate of treatment, psychotropic medication use, psychotherapy, number of outpatient treatment visits, type of health care professional, and source of payment.

Results  The rate of outpatient treatment for depression increased from 0.73 per 100 persons in 1987 to 2.33 in 1997 (P<.001). The proportion of treated individuals who used antidepressant medications increased from 37.3% to 74.5% (P<.001), whereas the proportion who received psychotherapy declined (71.1% vs 60.2%, P = .006). The mean number of depression treatment visits per user declined from 12.6 to 8.7 per year (P = .05). An increasingly large proportion of patients were treated by physicians for their condition (68.9% vs 87.3%, P<.001), and treatment costs were more often covered by third-party payers (39.3% to 55.2%, P<.001).

Conclusions  Between 1987 and 1997, there was a marked increase in the proportion of the population who received outpatient treatment for depression. Treatment became characterized by greater involvement of physicians, greater use of psychotropic medications, and expanding availability of third-party payment, but fewer outpatient visits and less use of psychotherapy. These changes coincided with the advent of better-tolerated antidepressants, increased penetration of managed care, and the development of rapid and efficient procedures for diagnosing depression in clinical practice.

JAMA. 2002;287:203-209

 

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