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The National Depressive and Manic-Depressive Association Consensus Statement on the Undertreatment of Depression

Robert M. A. Hirschfeld, MD; Martin B. Keller, MD; Susan Panico; Bernard S. Arons, MD; David Barlow, PhD; Frank Davidoff, MD; Jean Endicott, PhD; Jack Froom, MD; Michael Goldstein, MD; Jack M. Gorman, MD; Don Guthrie, PhD; Richard G. Marek, MD; Theodore A. Maurer; Roger Meyer, MD; Katharine Phillips, MD; Jerilyn Ross, MA, LCSW; Thomas L. Schwenk, MD; Steven S. Sharfstein, MD; Michael E. Thase, MD; Richard J. Wyatt, MD
JAMA. 1997;277(4):333-340. doi:10.1001/jama.1997.03540280071036.
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Objective.  —A consensus conference on the reasons for the undertreatment of depression was organized by the National Depressive and Manic Depressive Association (NDMDA) on January 17-18, 1996. The target audience included health policymakers, clinicians, patients and their families, and the public at large. Six key questions were addressed: (1) Is depression undertreated in the community and in the clinic? (2) What is the economic cost to society of depression? (3) What have been the efforts in the past to redress undertreatment and how successful have they been? (4) What are the reasons for the gap between our knowledge of the diagnosis and treatment of depression and actual treatment received in this country? (5) What can we do to narrow this gap? (6) What can we do immediately to narrow this gap?

Participants.  —Consensus panel members were drawn from psychiatry, psychology, family practice, internal medicine, managed care and public health, consumers, and the general public. The panelists listened to a set of presentations with background papers from experts on diagnosis, epidemiology, treatment, and cost of treatment.

Evidence.  —Experts summarized relevant data from the world scientific literature on the 6 questions posed for the conference.

Consensus Process.  —Panel members discussed openly all material presented to them in executive session. Selected panelists prepared first drafts of the consensus statements for each question. All of these drafts were read by all panelists and were edited and reedited until consensus was achieved.

Conclusions.  —There is overwhelming evidence that individuals with depression are being seriously undertreated. Safe, effective, and economical treatments are available. The cost to individuals and society of this undertreatment is substantial. Long suffering, suicide, occupational impairment, and impairment in interpersonal and family relationships exist. Efforts to redress this gap have included provider educational programs and public educational programs. Reasons for the continuing gap include patient, provider, and health care system factors. Patient-based reasons include failure to recognize the symptoms, underestimating the severity, limited access, reluctance to see a mental health care specialist due to stigma, noncompliance with treatment, and lack of health insurance. Provider factors include poor professional school education about depression, limited training in interpersonal skills, stigma, inadequate time to evaluate and treat depression, failure to consider psychotherapeutic approaches, and prescription of inadequate doses of antidepressant medication for inadequate durations. Mental health care systems create barriers to receiving optimal treatment. Strategies to narrow the gap include enhancing the role of patients and families as participants in care and advocates; developing performance standards for behavioral health care systems, including incentives for positive identification, assessment, and treatment of depression; enhancing educational programs for providers and the public; enhancing collaboration among provider subtypes (eg, primary care providers and mental health professionals); and conducting research on development and testing of new treatments for depression.


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