Majority of People with Depression Are Not Effectively Treated, USA

(2005-05-30)

More than 85 percent of both privately insured and Medicaid patients with depression are not being effectively treated, as defined by the National Committee for Quality Assurance (NCQA), according to new data presented at the annual meeting of the American Psychiatric Association.

While both sets of patients were receiving inadequate treatment in this study, Medicaid claimants were less likely to be treated according to practice guidelines. This population was nearly twice as likely to be prescribed an antidepressant below the recommended dose (19 percent vs. 10 percent, respectively); less likely to stay on medication for more than 60 days (39 percent vs. 55 percent, respectively), the duration of time recommended for effective acute treatment; and half as likely to have their antidepressant switched or augmented (5 percent vs. 10 percent, respectively) when they did not respond or tolerate their current dose or medication.

According to practice guidelines,(1) if a patient does not feel better after two months of treatment, their physician should increase the dose, switch medications or augment with a second medication or psychotherapy to help patients achieve success. Complete resolution of all depression symptoms is the goal of treatment. When symptoms don't go away completely, patients can have difficulty getting well and staying that way.(2)

"Although patients in this study overcome the first, and very difficult, hurdle of receiving help, the treatment they received often wasn't adequate," said Rebecca Robinson, MS, health outcomes researcher, Eli Lilly and Company. "Healthcare providers need to follow through the continuum of care to ensure adequate quality care is provided to these patients by following treatment guidelines and giving patients access to medications that will increase their chances of getting well and staying well."

Additional Study Highlights

Medicaid patients scored lower than those with private insurance on all three components of the Antidepressant Medication Management (AMM) measures. Medicaid patients were more than five times less likely to attend the three recommended follow-up visits with their physician or mental health professional (5 percent vs. 29 percent, respectively) in the 12-weeks following diagnosis and prescription of antidepressant medication. They were also considerably less likely to receive effective acute treatment after a new episode of depression (39 percent vs. 61 percent, respectively) or recommended continuation care in the six months following the episode (22 percent vs. 44 percent, respectively). The one state that was similar to private insurance had greater access to antidepressant medications.

On average, Medicaid claimants were younger, sicker, and more likely to have capitated insurance plans, which includes an annual set dollar limit on payment for health care services.

Impact of Depression on Society

Major depressive disorder is the leading cause of disability in the United States and results in more days of disability than chronic medical conditions like heart disease, hypertension, diabetes and lower back pain.(3) Depression costs the United States more than $83 billion annually: more than $26 billion in direct medical costs and approximately $57 billion in indirect costs.(4) An estimated 16 percent of the costs of antidepressants are associated with patients who were never adequately treated.(5) Inadequate dose and duration of antidepressant treatment has been reported to directly hinder treatment outcomes.(6)

More than 200 million days of work are lost each year due to depressive disorders and, on average, 55 percent of costs are absorbed by employers because of absenteeism and lost work productivity.(7) The annual cost of lost productive work time, excluding short- and long-term disability costs, time among US workers with depression was $44 billion. Individuals with major depression consistently reported the most lost productive work time when it co-occurred with pain, weakness, or fatigue; gastrointestinal complaints, and sensory or nerve impairment.

Most of the costs were for reduced performance while at work rather than absenteeism -- less than one third of these workers reported use of antidepressants in the previous 12 months and treatment effectiveness was reported to be moderate.(8)

Methods

The study included people with depression starting antidepressant therapy including privately insured (n= 9,933) and Medicaid claimants (n= 20,170) -- and were followed for 12 months using MarketScan Commercial Claims and Encounter (Commercial) and Medicaid data from the same three states. Those with prior antidepressant use or diagnosis of schizophrenia, bipolar, and psychoses were excluded.

Treatment quality was monitored using NCQA Antidepressant Medication Management measures (AMM) and antidepressant utilization patterns. The three components of AMM include optimal practitioner contact, effective acute phase treatment and effective continuation phase treatment. Antidepressant use patterns measured were early discontinuation, late discontinuation, switch/augment and titration.

About Eli Lilly and Company

Lilly, a leading innovation-driven corporation, is developing a growing portfolio of first-in-class and best-in-class pharmaceutical products by applying the latest research from its own worldwide laboratories and from collaborations with eminent scientific organizations. Headquartered in Indianapolis, Ind., Lilly provides answers -- through medicines and information -- for some of the world's most urgent medical needs. Additional information about Lilly is available at http://www.lilly.com.

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(1) Practice Guideline for the Treatment of Patients With Major Depression, 2nd edition. (April, 2000): http://www.psych.org/psych_pract/treatg/pg/Depression2e.book-7.cfm - figure3

(2) Paykel ES, et al. Psychol Med. 1995;25(6):1171-1180.

(3) Druss, BG, Rosenheck RA, Sledge WH. Health and Disability Costs of Depressive Illness in a Major US Corporation. American Journal of Psychiatry, 157:8, 1274-1278.

(4) The Numbers Count: Mental Disorders in America.

(5) Weilburg JB, Stafford RS, O'Leary KM, Meigs JB, Finkelstein SN. Costs of antidepressant medications associated with inadequate treatment. American Journal of Managed Care, 2004. 10(6): p. 357-65.

(6) Selecting an SSRI: Dosing and compliance. J Clin Psychiatry Monograph 1999; 17: 34-36.

(7) Greenberg P, et al. The Economic Burden of Depressive Disorders in the United States: How Did it Change Between 1990 and 2000? Journal of Clinical Psychiatry 2003; 64:1465-1475.

(8) Stewart WF, Ricci JA, Chee E, Hahn SR, Morganstein D. Cost of Lost Productive Work time among US workers with depression. JAMA 2003; 289:3135- 3144.

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