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January 4, 1995, Vol 273, No. 1 >
ARTICLE | January 4, 1995

How Can Care for Depression Become More Cost-effective? FREE

Roland Sturm, PhD; Kenneth B. Wells, MD, MPH
[+] Author Affiliations

Corresponding author: Roland Sturm, PhD, RAND, 1700 Main St, Santa Monica, CA 90407-2138.


JAMA. 1995;273(1):51-58. doi:10.1001/jama.1995.03520250067036
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References

Objective.  —To determine the cost and health effects of changes in the content and quality of care for depressed patients treated in prepaid general medical practices (internal and family medicine) and mental health specialty practices and shifts in the proportion of patients treated in general medicine.

Methods.  —Cost-effectiveness analysis and simulations, which are empirically based on data from the Medical Outcomes Study.

Outcome Measures.  —Change in serious functional limitations, annual treatment costs per patient, and costs per reduction in one functional limitation.

Results.  —More appropriate care for depression (increased counseling, use of appropriate antidepressant medications, or avoidance of regular minor tranquilizer use) improves functioning outcomes. Although this approach increases total costs of care, it also improves the value of care because each dollar spent on care now provides more benefits in terms of health improvements. In contrast with the effects of more appropriate care for depression, the trend away from mental health specialty care and toward general medical provider care under current treatment patterns reduces costs, worsens outcomes, and does not increase the value of health care spending in terms of health improvement per dollar.

Conclusion.  —Quality improvement measures that roughly follow practice guidelines for depression can improve outcomes and the value or cost-effectiveness of care, but at increased treatment costs; shifting patients away from mental health specialists decreases costs but worsens functioning outcomes. The best strategy for making care for depression more cost-effective is through quality improvement, not through changing specialty mix. Yet combining these strategies may achieve better outcomes, lower treatment costs, and better value of care compared with current practice patterns. To realize this potential, however, substantial quality improvement of care for depression is necessary in general medical practice.(JAMA. 1995;273:51-58)

REFERENCES

1 +
Depression Guideline Panel. Depression in Primary Care Volume 1: Detection and Diagnosis . Rockville, Md: US Dept of Health and Human Services, US Public Health Service, Agency for Health Care Policy and Research; April 1993;. AHCPR publication No. 93-0550. Clinical Practice Guideline No. 5.
2 +
Depression Guideline Panel. Depression in Primary Care Volume 2: Treatment of Major Depression . Rockville, Md: US Dept of Health and Human Services, US Public Health Service, Agency for Health Care Policy and Research; April 1993;. AHCPR publication No. 93-0551. Clinical Practice Guideline No. 5.
3 +
Katon W, Schulberg H.  Epidemiology of depression in primary care. Gen Hosp Psychiatry . 1992;; 14:237-247.
4 +
Wells KB, Stewart A, Hays RD, et al.  The functioning and well-being of depressed patients: results of the Medical Outcomes Study. JAMA . 1989;; 262:914-919.
5 +
Broadhead WE, Blazer DG, George LK, Tse CK.  Depression, disability days, and days lost from work in a prospective epidemiologic survey. JAMA . 1990;; 264:2524-2528.
6 +
Johnson J, Weissman MM, Klerman GL.  Service utilization and social morbidity associated with depressive symptoms in the community. JAMA . 1992;; 267:1478-1483.
7 +
Rice DP, Kelman S, Miller LS, et al. The Economic Costs of Alcohol and Drug Abuse and Mental Illness . San Francisco: Institute for Health and Aging, University of California; 1990;.
8 +
Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER.  The economic burden of depression in 1990. J Clin Psychiatry . 1993;;54:405-418.
9 +
Katon W, Von Korff M, Lin E, et al.  Adequacy and duration of antidepressant treatment in primary care. Med Care . 1992;;30:67-76.
10 +
Wells KB, Hays RD, Burnam MA, Rogers WH, Greenfield S, Ware JE Jr.  Detection of depressive disorder in prepaid and fee-for-service practices: results from the Medical Outcomes Study. JAMA . 1989;;262:925-930.
11 +
Wells KB, Katon W, Rogers WH, Camp P.  Use of minor tranquilizers and antidepressant medications by depressed outpatients: results from the Medical Outcomes Study. Am J Psychiatry . 1994;; 151:694-700.
12 +
American Psychiatric Association.  Practice guideline for major depressive disorder in adults. Am J Psychiatry . 1993;;150( (suppl) ):1-26.
13 +
Schulberg HC, Block MR, Coulehan JL.  Treating depression in primary care practice: an application of decision analysis. Gen Hosp Psychiatry . 1989;;11:208-215.
14 +
Kupfer DJ.  Long-term treatment of depression. J Clin Psychiatry . 1991;;52( (suppl 5) ):28-34.
15 +
Burnam MA, Wells KB, Leake B, Landsverk J.  Development of a brief screening instrument for detecting depressive disorders. Med Care . 1988;;26: 775-789.
16 +
Robins LN, Helzer JE, Croughan J, Ratcliff KS.  National Institute of Mental Health Diagnostic Interview Schedule: its history, characteristics, and validity. Arch Gen Psychiatry . 1981;;38:381-389.
17 +
Tarlov A, Ware JE, Greenfield S, Nelson EC, Perrin E, Zubkoff M.  The Medical Outcomes Study: an application of methods for monitoring the results of medical care. JAMA . 1989;;262:925-930.
18 +
Rogers WH, McGlynn EA, Berry SH, et al.  Methods of sampling.  In: Stewart AL, Ware JE, eds. Measuring Functioning and Well-being: The Medical Outcomes Study Approach . Durham, NC: Duke University Press; 1992;.
19 +
Wells KB, Burnam MA, Rogers WH, Hays R, Camp P.  Course of depression for adult outpatients: results from the Medical Outcomes Study. Arch Gen Psychiatry . 1992;;49:788-794.
20 +
Rogers WH, Wells KB, Meredith LS, Sturm R, Burnam A.  Course of depression for adult outpatients under prepaid or fee-for-service financing. Arch Gen Psychiatry . 1993;;50:517-526.
21 +
American Medical Association. Physician Marketplace Statistics 1993 . Chicago, Ill: American Medical Association; 1994;.
22 +
Sturm R, Meredith LA, Wells KB. Provider Choice and Continuity for the Treatment of Depression . Santa Monica, Calif: RAND; 1994;. Publication DRU-692-AHCPR.
23 +
Eisenberg L.  Treating depression and anxiety in primary care. N Engl J Med . 1992;;326:1080-1084.
24 +
Hoeper EW, Kessler LG, Nycz G, et al.  The usefulness of screening for mental illness. Lancet . 1984;;1:33-35.
25 +
Badger LW, Rand EH.  Unlearning psychiatry: a cohort effect in the training environment. Int J Psychiatry Med . 1988;;18:123-135.
26 +
Brody DS, Lerman CE, Wolfson H, et al.  Improvement in physicians' counseling of patients with mental health problems. Arch Intern Med . 1990;; 150:993-998.
27 +
Linn L, Yager J.  The effect of screening, sensitization, and feedback on notation of depression. J Med Educ . 1982;;20:1233-1240.
28 +
Linn LS, Yager J.  Screening for depression in relationship to subsequent patient and physician behavior. Med Care . 1982;;20:1233-1240.
29 +
Magruder-Habib K, Zung WK, Feussner JR.  Improving physicians' recognition and treatment of depression in general medical care: results from a randomized clinical trial. Med Care . 1990;;28:239-250.
30 +
Shapiro S, German PS, Skinner EA, et al.  An experiment to change detection and management of mental morbidity in primary care. Med Care . 1987;;25:327-339.
31 +
Ormel J, Koeter MWJ, van den Brink W, van de Willige G.  Recognition, management, and the course of anxiety and depression in general practice. Arch Gen Psychiatry . 1991;;48:700-706.
32 +
Ellis RP, McGuire TG.  Supply-side and demandside cost sharing in health care. J Econ Perspectives . 1993;;257:135-151.
33 +
Mumford E, Schlesinger HJ, Glass GV, et al.  A new look at evidence about reduced cost of medical utilization following mental health treatment. Am J Psychiatry . 1984;;141:1145-1158.
34 +
Mintz J, Mintz LI, Arruda MJ, Hwang SS.  Treatment of depression and the functional capacity to work. Arch Gen Psychiatry . 1992;;49:761-776.
35 +
Kamlet MS, Wade M, Kupfer DJ, et al.  Costutility analysis of maintenance treatment for recurrent depression: a theoretical framework and numerical illustration.  In: Frank RG, Manning WG, eds. Economics and Mental Health . Baltimore, Md: Johns Hopkins University Press; 1992;.
36 +
Sturm R, McGlynn EA, Meredith LS, Wells KB, Manning WG, Rogers WH.  Switches between prepaid and fee-for-service health systems among depressed outpatients. Med Care . 1994;;32:917-929.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Depression Guideline Panel. Depression in Primary Care Volume 1: Detection and Diagnosis . Rockville, Md: US Dept of Health and Human Services, US Public Health Service, Agency for Health Care Policy and Research; April 1993;. AHCPR publication No. 93-0550. Clinical Practice Guideline No. 5.
2 +
Depression Guideline Panel. Depression in Primary Care Volume 2: Treatment of Major Depression . Rockville, Md: US Dept of Health and Human Services, US Public Health Service, Agency for Health Care Policy and Research; April 1993;. AHCPR publication No. 93-0551. Clinical Practice Guideline No. 5.
3 +
Katon W, Schulberg H.  Epidemiology of depression in primary care. Gen Hosp Psychiatry . 1992;; 14:237-247.
4 +
Wells KB, Stewart A, Hays RD, et al.  The functioning and well-being of depressed patients: results of the Medical Outcomes Study. JAMA . 1989;; 262:914-919.
5 +
Broadhead WE, Blazer DG, George LK, Tse CK.  Depression, disability days, and days lost from work in a prospective epidemiologic survey. JAMA . 1990;; 264:2524-2528.
6 +
Johnson J, Weissman MM, Klerman GL.  Service utilization and social morbidity associated with depressive symptoms in the community. JAMA . 1992;; 267:1478-1483.
7 +
Rice DP, Kelman S, Miller LS, et al. The Economic Costs of Alcohol and Drug Abuse and Mental Illness . San Francisco: Institute for Health and Aging, University of California; 1990;.
8 +
Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER.  The economic burden of depression in 1990. J Clin Psychiatry . 1993;;54:405-418.
9 +
Katon W, Von Korff M, Lin E, et al.  Adequacy and duration of antidepressant treatment in primary care. Med Care . 1992;;30:67-76.
10 +
Wells KB, Hays RD, Burnam MA, Rogers WH, Greenfield S, Ware JE Jr.  Detection of depressive disorder in prepaid and fee-for-service practices: results from the Medical Outcomes Study. JAMA . 1989;;262:925-930.
11 +
Wells KB, Katon W, Rogers WH, Camp P.  Use of minor tranquilizers and antidepressant medications by depressed outpatients: results from the Medical Outcomes Study. Am J Psychiatry . 1994;; 151:694-700.
12 +
American Psychiatric Association.  Practice guideline for major depressive disorder in adults. Am J Psychiatry . 1993;;150( (suppl) ):1-26.
13 +
Schulberg HC, Block MR, Coulehan JL.  Treating depression in primary care practice: an application of decision analysis. Gen Hosp Psychiatry . 1989;;11:208-215.
14 +
Kupfer DJ.  Long-term treatment of depression. J Clin Psychiatry . 1991;;52( (suppl 5) ):28-34.
15 +
Burnam MA, Wells KB, Leake B, Landsverk J.  Development of a brief screening instrument for detecting depressive disorders. Med Care . 1988;;26: 775-789.
16 +
Robins LN, Helzer JE, Croughan J, Ratcliff KS.  National Institute of Mental Health Diagnostic Interview Schedule: its history, characteristics, and validity. Arch Gen Psychiatry . 1981;;38:381-389.
17 +
Tarlov A, Ware JE, Greenfield S, Nelson EC, Perrin E, Zubkoff M.  The Medical Outcomes Study: an application of methods for monitoring the results of medical care. JAMA . 1989;;262:925-930.
18 +
Rogers WH, McGlynn EA, Berry SH, et al.  Methods of sampling.  In: Stewart AL, Ware JE, eds. Measuring Functioning and Well-being: The Medical Outcomes Study Approach . Durham, NC: Duke University Press; 1992;.
19 +
Wells KB, Burnam MA, Rogers WH, Hays R, Camp P.  Course of depression for adult outpatients: results from the Medical Outcomes Study. Arch Gen Psychiatry . 1992;;49:788-794.
20 +
Rogers WH, Wells KB, Meredith LS, Sturm R, Burnam A.  Course of depression for adult outpatients under prepaid or fee-for-service financing. Arch Gen Psychiatry . 1993;;50:517-526.
21 +
American Medical Association. Physician Marketplace Statistics 1993 . Chicago, Ill: American Medical Association; 1994;.
22 +
Sturm R, Meredith LA, Wells KB. Provider Choice and Continuity for the Treatment of Depression . Santa Monica, Calif: RAND; 1994;. Publication DRU-692-AHCPR.
23 +
Eisenberg L.  Treating depression and anxiety in primary care. N Engl J Med . 1992;;326:1080-1084.
24 +
Hoeper EW, Kessler LG, Nycz G, et al.  The usefulness of screening for mental illness. Lancet . 1984;;1:33-35.
25 +
Badger LW, Rand EH.  Unlearning psychiatry: a cohort effect in the training environment. Int J Psychiatry Med . 1988;;18:123-135.
26 +
Brody DS, Lerman CE, Wolfson H, et al.  Improvement in physicians' counseling of patients with mental health problems. Arch Intern Med . 1990;; 150:993-998.
27 +
Linn L, Yager J.  The effect of screening, sensitization, and feedback on notation of depression. J Med Educ . 1982;;20:1233-1240.
28 +
Linn LS, Yager J.  Screening for depression in relationship to subsequent patient and physician behavior. Med Care . 1982;;20:1233-1240.
29 +
Magruder-Habib K, Zung WK, Feussner JR.  Improving physicians' recognition and treatment of depression in general medical care: results from a randomized clinical trial. Med Care . 1990;;28:239-250.
30 +
Shapiro S, German PS, Skinner EA, et al.  An experiment to change detection and management of mental morbidity in primary care. Med Care . 1987;;25:327-339.
31 +
Ormel J, Koeter MWJ, van den Brink W, van de Willige G.  Recognition, management, and the course of anxiety and depression in general practice. Arch Gen Psychiatry . 1991;;48:700-706.
32 +
Ellis RP, McGuire TG.  Supply-side and demandside cost sharing in health care. J Econ Perspectives . 1993;;257:135-151.
33 +
Mumford E, Schlesinger HJ, Glass GV, et al.  A new look at evidence about reduced cost of medical utilization following mental health treatment. Am J Psychiatry . 1984;;141:1145-1158.
34 +
Mintz J, Mintz LI, Arruda MJ, Hwang SS.  Treatment of depression and the functional capacity to work. Arch Gen Psychiatry . 1992;;49:761-776.
35 +
Kamlet MS, Wade M, Kupfer DJ, et al.  Costutility analysis of maintenance treatment for recurrent depression: a theoretical framework and numerical illustration.  In: Frank RG, Manning WG, eds. Economics and Mental Health . Baltimore, Md: Johns Hopkins University Press; 1992;.
36 +
Sturm R, McGlynn EA, Meredith LS, Wells KB, Manning WG, Rogers WH.  Switches between prepaid and fee-for-service health systems among depressed outpatients. Med Care . 1994;;32:917-929.

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