Focus on Depression

Addressing the Quality Gap in Care of Depression

As discussed in the Overview of Depression, performance measures suggest that management of depression has stagnated, and one measure has recently regressed despite efforts to improve.^[1]To overcome the multilevel barriers to more effective management, health plans might employ a variety of tools. Some examples include:

• Educational program for primary care providers and the covered population highlighting the prevalence and cost of depression, its clinical presentation, the effectiveness of current therapies, and the consequences of untreated depression
• Compliance improvement programs that involve pharmacists as educators
• Performance measures that address continuity of treatment, combined with feedback and benchmarking comparisons

Despite the overall lack of improvement in care of behavioral disorders, a number of health plans are making progress in the management of depression. The Quality Improvement Activities and Quality Options described throughout this publication highlight the programmatic approaches employed by several health care organizations to improve depression management. They underscore the need to implement programs that address all stakeholders in the management of behavioral disorders and to solicit ongoing feedback as part of the improvement process.

Each plan included in this publication has a different mix of barriers, and each plan represents a distinct set of member and provider needs. We present these case studies to suggest the range of possible interventions and to provide the basis for creativity in the development of plan-specific programs.

The case for more effective depression management is clear. Depressive disorders cost employers in the United States an estimated $44 billion per year in lost productivity, diminish the quality of life for millions of patients and families, and contribute significantly to poor disease outcomes and premature death.

The effectiveness of current treatments for depression has been documented in numerous studies. Newer pharmacotherapies like SSRIs, as well as more traditional drugs, have demonstrated significant benefit in treated depressed patients.^[2] Although conclusions from studies of psychosocial interventions are less clear-cut, there is strong evidence for efficacy of behavioral, cognitive-behavioral, and interpersonal therapy in the treatment of depression.^[3]

Moreover, the cost-effectiveness of depression screening and treatment using outpatient strategies has also been amply documented. The US Preventive Services Task Force (USPSTF), a group of health care experts convened under the AHRQ, has concluded that one-time screening for depressive disorders in adults, when combined with effective follow-up, reduces the risk for persistent depression. In addition, when evaluated using standard yardsticks such as cost per quality-adjusted life-year gained, such programs are as cost-effective as mammography screening of women over age 50 or treatment of mild-to-moderate hypertension.^[4] Psychotherapy has been shown to reduce overall treatment costs, especially for severe behavioral disorders, primarily by reducing hospitalization costs.^[5]

A study by the RAND Corporation has shown that increasing the intensity of depression treatment may be an important key to improvements in outcomes and cost-effectiveness. Because restoring patients to full functioning is a central goal of treatment, one important measure of cost-effectiveness is in terms of the resources required to remove a functional limitation, such as the inability to work at a paying job, do housework, or engage in moderate to strenuous physical activity. The RAND study showed that the cost of adding treatment elements (antidepressant therapy or counseling) according to practice guidelines was relatively modest, but produced a disproportionate increase in the number of functional limitations removed. As a result, the average cost per functional limitation removed was less for intensive treatment ($3,000-$4,000) than for minimal treatment (over $5,000), as illustrated in Figure 1.^[6]

Each of the stakeholders involved in the management of depression has an important role to play in improving the treatment of behavioral disorders.

Employers can translate their understanding of the impact of depression on productivity into funding for employee education programs to:

• Increase awareness of depression prevalence, symptoms, and impact; as well as its effect on other comorbid conditions such as cardiovascular disease (CVD), diabetes, and cancer
• Reduce the stigma associated with diagnosis and treatment seeking
• Encourage employee compliance with treatment programs
• Consider only health plans that report HEDIS performance measures for behavioral health care, and use performance comparisons as a basis for plan selection
• Encourage (and be willing to pay for) coverage parity for behavioral disorders

Health plans can facilitate public understanding and awareness of depression and its impact through member education campaigns similar to those used for CVD and cancer. They can also work to:

• Evaluate behavioral care “carve-out” program on the basis of treatment quality and outcomes in addition to cost containment. One recent study has shown that implementation of a carve out reduced the quality of treatment (shorter duration and poorer continuation of therapy) compared to pervious in-house management of behavioral disorders^[7]
• Incentive network physician groups, using pay for performance models to improve the quality of care and outcomes for patients with depression
• Position model depression quality improvement activities as a competitive advantage in order to attract purchasers
• Incorporate depression screenings into disease management programs for CVD, diabetes, cancer, and other disorders associated with elevated depression risk
• Equalize the approach to reimbursement for treatment of physical and behavioral disorders, including both medical and psychosocial therapies; access restrictions may reduce utilization most among those who need care the most - those with actual disorders^[8]

Providers and medical groups can work toward:

• Development and implementation of more up-to-date assessment and treatment guidelines, especially at the primary care level
• Improved coordination between different professional stakeholders (PCPs, psychiatrists, psychologists, others) both globally and in individual patient care
• Endorsement of educational opportunities for providers at the primary care level to increase awareness and use of current therapies and referral guidelines
• Establish practice protocols that include standard screening for patients with CVD, diabetes, cancer, and other disorders associated with high rates of depression

Advocacy groups and other patient-representative organizations can help by:

• Encouraging government agencies, employees, and health care plans to strive for coverage and research funding for behavioral disorders
• Supporting employers, health plans, and practitioners in implementing desired reforms by providing educational materials and legislative assistance
• Facilitating community involvement in promoting awareness of behavioral disorders and treatment options
• Reinforcing the importance of encouraging treatment adherence on the part of patients

The improved clinical understanding of depression and related disorders, and the development and refinement of effective intervention strategies, provide great encouragement that depression can be more effectively managed in the near term. In addition, the growing awareness among all stakeholders about the impact of depression on productivity and on patient outcomes from physical and behavioral comorbidities imparts the needed motivation to improve detection and treatment. Indeed, the suggestions above relate primarily to systemic problems with the identification of need and delivery of care, rather than gaps in basic knowledge or understanding. It is incumbent on all involved parties to continue to work toward better management of behavioral health.

[1] - National Committee for Quality Assurance. The State of Health Care Quality: 2003. Washington, DC: National Committee for Quality Assurance; 2003.

[2] - Williams JW Jr, Mulrow CD, Chiquette E, Noel PH, Aguilar C, Cornell J. A systemic review of newer pharmacotherapies for depression in adults: evidence report summary. Ann Intern Med. 2000;132:743-756.

[3] - American Psychiatric Association. Practice guideline for the treatment of patients with major depression. Available at: http://www.psych.org/psych_pract/treatg/pg/Depression2e.book.cfm. Accessed January 7, 2004.

[4] - Pignone MP, Gaynes BN, Rushton JL, et al. Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;136:765-776.

[5] - Gabbard GO, Lazar SG, Hornberger J, Spiegel D. The economic impact of psychotherapy: a review. Am J Psychiatry. 1997;154:147-155.

[6] - Sturm R, Wells KB. How can care for depression become more cost-effective? JAMA. 1995;273:51-58.

[7] - Ray WA, Daugherty JR, Meador KG. Effect of a mental health “carve-out” program on the continuity of antipsychotic therapy. N Engl J Med. 2003;348:1885-1894.

[8] - Landerman LR, Burns BJ, Swartz MS, Wagner HR, George LK. The relationship between insurance coverage and psychiatric disorder in predicting use of mental health services. Am J Psychiatry. 1994;151:1785-1790.

Return to top