Reducing the Burden of Depression: Title and subTitle BreakBuilding Villages for Coordinated Care

In this issue of JAMA, Wang et al¹ provide evidence that implementing depression care programs through employer-sponsored managed behavioral health can improve clinical outcomes, job retention, and effective hours worked compared with usual care. The programs encouraged depressed workers to learn about and use evidence-based depression treatments, supported clinicians in following practice guidelines, and offered telephone counseling and self-help workbooks. The monetary value of the increased work time under the program exceeded the direct intervention costs and likely exceeded or was within the range of cost increases due to greater mental health specialty use under the intervention. While formal estimates of cost-effectiveness and employer return on investment are pending, it appears to be in the business interests of many employers to implement such programs to protect their investments in the retention and productivity of workers they have hired and trained.

These findings should be evaluated within the context of the simple but startling facts about depression. Clinical depressive disorders are among the most prevalent of major medical conditions, affecting about 16% of adults in their lifetime.² Owing to high prevalence, early age at onset (unlike other debilitating disorders that occur past the age of parenting and work responsibilities), and strong impact on functional status, depressive disorders are leading contributors to disability worldwide.³ Depressive disorders are highly treatable yet often remain unrecognized and untreated.^{4 - 5} While a number of effective programs promote higher use of treatments in service delivery settings, particularly primary care practices, these programs are not yet widely implemented.^{6 - 13} Thus, technology is available to treat this disabling condition, but US health care systems have failed to take full advantage of the technology to reduce personal or societal consequences of depression.

The intervention approach in the study by Wang et al¹ can be characterized as “building a village” of health plans, clinicians, and resources that “surround” depressed persons with opportunities to learn about and engage in evidence-based care, attending to a careful fit of intervention requirements and context-specific implementation options. This approach has generally proven effective in primary care,¹⁴ and the substantial outreach efforts mirror those in the WE Care study¹⁵ demonstrating that depression treatments are effective for low-income and minority women. In the study by Wang et al, telephone managers from the behavioral health company offered counseling and communicated recommendations to clinicians, an extension of their usual role.¹ In the Partners in Care study,^{14 ,16} primary care nurses expanded their disease management skills to include assessment, education, and follow-up concerning depression. In both studies, patients and clinicians were free to use or not use study resources according to their preferences.^{1 ,14} Such interventions have the advantage of preserving the naturalistic context of the delivery systems, potentially facilitating the translation of findings into change by example. Interventions in both studies achieved roughly similar outcomes: a 10 percentage-point gain in use of appropriate treatment and in recovery from depression over a year, as well as roughly 2 more weeks of days worked in a year in the study by Wang et al and a month more of days worked over 2 years in Partners in Care.^{1 ,14 ,17}

Depression interventions have many advantages for individuals, their family and friends, employers and society, over and above relief of individual symptoms. As mothers' depression improves following care, for example, their children also enjoy improvements in mental health.¹⁸ The study by Wang et al¹ demonstrates that treatment of depression increases productivity and may reduce economic losses due to depression for employees and employers. If such gains exceed costs of providing the interventions and treatments, there is “money on the table” across stakeholders that could be used to pay for interventions. Why then do many individuals with depression endure their illness without care?

One barrier to care is that depression affects motivation and cognition, making it difficult for many individuals with depression to realize they have a need and obtain care without the outreach provided by nurse/care managers. Family members also may fail to identify depression or have knowledge about appropriate care. This suggests that opportunities to improve access to depression care should be embedded within an infrastructure available to potentially depressed persons, such as primary care settings. However, an awareness of the effects of treatment on social costs such as productivity may not provide a strong incentive for clinicians and health plans to improve care, as they do not necessarily face immediate financial consequences from patients' changes in productivity or may not track this outcome. Yet most private health care in the United States is financed through employer-sponsored insurance. Direct contributions to the bottom line of employers offers them an incentive to promote depression care, independent of policy mandates or other motives such as responding to employee demand.

Other stakeholders, including policy makers and the public, may benefit from improved depression care through an increased tax base from employees who work more or an overall improved economy. Yet it is challenging in the US policy environment to use economic gains from one policy sector such as the labor market as leverage to support improved health care. However some policy changes could be implemented to better align the incentives to implement depression care programs across diverse stakeholders and to avoid undermining the goals of such programs, for example by excluding depression treatment from health insurance coverage when changing jobs or insurance based on a recent history of depression treatment in an employer-based depression program. Under such an ill-advised policy, the risk of losing coverage would serve as a major deterrent to seeking care.

The need to coordinate program implementation and policy suggests an expanded concept of “a village,” that includes not only wrap-around interventions but coordinated efforts across affected stakeholders. It may be true that the stakeholder with the most power to influence services delivery for most Americans is the employer, but broader and deeper change in access to depression care may yet require a concerted effort among affected parties to yield programs that address public and self-stigma and to provide access to depression treatments under policies that facilitate use of such programs and do not penalize individuals for using them. Studies such as that by Wang et al¹ strongly support such integrated solutions.

Exactly how programs to improve depression care are implemented may affect the distribution of benefits—an important issue given evidence of disparities in quality of depression care and the potential for practice-based programs to overcome disparities in depression outcomes.^{15 ,19} Developers of interventions and policies should consider implications of their design for inclusion of underserved groups who may not seek behavioral health care. Despite the extensive efforts by Wang et al¹ to reach general employees, the majority of persons had already inquired about outpatient care. Learning how to optimize personal and societal gains by improving access to quality depression care across diverse communities through employer, practice, and community-based programs and policy changes is a next agenda for evidence-based action. As a community participant in the Witness for Wellness program recently stated: “Depression is everybody's business.”²⁰