Focus on Depression

The Value of Effective Depression Management

The profound toll of depression on worker productivity, quality of life, the ability to function, and even survival touches nearly every sphere of public and private life. In this section, we review some of the broader costs of depression. In addition, we illustrate the impact of effective depression management, applying the NCQA Quality Dividend Calculator™ to a hypothetical company with typical rates of employee depression.

The immense impact of depression and other common behavioral disorders on productivity is illustrated in Table 1, which lists the total lost workdays and resulting costs attributable to various disorders in the United States.

The lost workdays attributable to depression may represent only the tip of the economic iceberg. A recent study has shown that over 80% of lost productivity due to depression results not from job absence (absenteeism), but from reduced performance while on the job (sometimes referred to as “presenteeism”). Emphasizing the inadequacy of current treatment patterns, the same study found that fewer than one third of depressed workers had used antidepressants within the previous 12 months.^[1]

The NCQA Quality Dividend Calculator^™ provides a useful way to compare the impact on productivity of various levels of treatment quality for disorders included in the HEDIS^® measures of health plan quality. A hypothetical company (see shaded box) was used to develop an NCQA Quality Dividend Calculator^™ assessment of productivity and cost impact resulting from various levels of depression management.^[3]

Based on the parameters entered for the hypothetical company, 551 workers are assumed to be affected by a depressive disorder. The NCQA Quality Dividend Calculator was then able to estimate the cost and productivity implications of typical care (provided by a nonaccredited plan), good care (provided by an NCQA-accredited plan), and superior care (provided by a top 10% NCQA-accredited plan). The productivity and cost gains associated with care provided by NCQA-accredited plans, relative to nonaccredited plans, are illustrated in Tables 2 and 3, respectively.

Depression also has a profound impact on patients’ quality of life, which can be best summarized by patients’ own perceptions. The results of a 2003 survey of employees and managers with depression showed that while experiencing a depressive episode^[4]:

• One in five reported “complete” or “occasional” interference with their ability to carry out work responsibilities
• 83% reported lack of motivation
• 82% reported difficulty in concentrating
• 45% reported that they come to work late or leave early
• 24% reported chronic physical pain that makes work difficult or uncomfortable
• 20% reported increased problems in dealing with coworkers

In addition, only 41% of employees felt that it was possible to acknowledge depression and still get ahead in one’s career.^[4]

The effect of depression and related disorders on workplace-related quality of life extends to income, as well. Information on annual income, based on the 1990-1992 National Comorbidity Survey, documented substantial reductions in earnings for workers with various behavioral disorders (Table 4).

Anxiety disorders also profoundly affect quality of life. A study of elderly patients showed the presence of generalized anxiety disorder (GAD) worsened quality of life measurements in a wide range of domains. The impact of GAD on quality of life was greater than that associated with acute myocardial infarction (heart attack) or type 2 diabetes and was comparable to the impact of major depressive disorder.^[5]

Quality of life is also significantly reduced by the presence of depressive symptoms in patients with other diseases. Patients with heart disease and depression reported a higher burden of symptoms, greater physical limitations, and worse quality of life than those with heart disease and no depression.^[6]

Effective treatment of depression provides substantial benefits to quality of life. An observational study of primary care patients showed that those who received appropriate evidence-based care demonstrated significant improvement in quality of life measures, as well as higher rates of employment.^[7]

Collaboration Is Key A unique nonprofit partnership was formed among 3 large integrated health care systems (one of which is solely dedicated to children) to address health issues affecting children and adults. The partnership first developed an initiative to work directly through the partnering organizations’ affiliated obstetricians, hospital postpartum staff and pediatricians using office-based systems to systematically identify and treat tobacco use. This program was then used as a model to address depression associated with pregnancy and childbirth. The partnership piloted the Partnership for Women’s Health program, screening and addressing maternal depression in the postpartum period in both obstetric and pediatric settings. The model for the initiative was based on several key components: 1) Assess: early and routine screening for depression at every 6-week postpartum and 2-month well child visit; 2) Advise: proactively contact mothers who have screened positive for depression and educate them on depression and resources; 3) Assist: link the mothers to resources and services that are available within the community and assist them in accessing services; and 4) Arrange for follow-up care and assess outcomes. The program uses the Edinburgh Postnatal Depression Scale (EPDS), a standardized screening tool, to screen all mothers at routine visits. The office staff administers the measure and physicians are encouraged to review the scores and discuss the results with the mothers. The surveys are also scored by a centralized hub, and mothers screening positive are proactively contacted by an outsourced Health Advisor, who is a licensed clinical social workers. At the time of screening, patients are provided with a 1-page information sheet on depression encouraging them to discuss their symptoms, if present, with a physician, and a list of local resources. Physicians are provided educational materials, a list of resources, as well as a crisis protocol for responding to urgent issues to assist them in the process of referring patients to an appropriate community program for immediate care as necessary. A key component of this model is to proactively contact women with positive screens and connect them with existing appropriate treatment resources. All physician offices participating in the initiative faxed the EPDS forms to the project’s central location on a daily basis. The EPDS forms were then reviewed by the Health Advisor, and proactive calls were made to women with a score of 10 or above and/or a positive response on item number 10, suicidal ideation. A summary of the case was sent to the referring physician, which included patient-specific feedback. For women who scored less than 10, there was no direct contact made, and a copy of the EPDS was put into their record. The initiative focused on the delivery of consistent messages and resources by health care professionals to their patients, as well as a seamless system integrating an outsourced centralized Health Advisor with each individual physician’s office. During the outbound telephonic triage call, the Health Advisor spent time talking to the patient to normalize the disorder and to de-stigmatize the condition, educating the mother on the condition, providing support, and encouraging her to obtain treatment services. For women who screened positive for depression, the Health Advisor would assess the patient’s access to resources, connect the patient to the insurance carrier and/or treatment provider via a 3-way call, and follow-up to assure service linkage. The Health Advisor conducted a follow-up to determine whether the patient had utilized the resources and to provide additional resources and information as needed. Additionally, mothers were contacted by a research assistant at 2 weeks following the last Health Advisor contact to collect data on program evaluation. During this follow-up, the patient’s experience with the initiative was assessed, clinical information and services use was obtained, and satisfaction with the screening tool, clinician office involvement, physician involvement, Health Advisor involvement, and overall program was gathered. The success of this pilot initiative was attributed to many factors including: the dedicated program staff; the development of clear, concise roles for clinicians and office staff members; the use of a quick, accurate assessment tool; and the involvement of a centralized Health Advisor to reduce the burden on individual offices. It also appears to be clear that mothers at risk for depression need to be contacted proactively to assist them with accessing services. An advisory committee and management team, comprised of a core team of staff and physician representative from each of the 3 partners in the initiative, provided guidance to the partnership.

Targeting the Primary Care Physician and Members A large health plan sought to increase adherence to antidepressant medication among its enrolled members. As part of a large corporate-wide effort, an internal work group was formed on a national multidepartmental level, and the goals for the initiative were driven by HEDIS® measures. Barriers to adherence were identified using a fishbone diagram. In addition to the fishbone diagram (see Figure 1), the assessment included an analysis grid focusing on barriers identified through a literature search, strategies to address those barriers, and documentation from the medical literature supporting the recommended strategies. In an effort to address the barriers members identified regarding their lack of understanding of the biologic nature of depression and side effects of medication, the health plan mailed an educational brochure to members diagnosed with depression. Through additional analysis of the HEDIS® data, the health plan found that members treated by a psychiatrist had higher rates of adherence than members treated by a PCP. The health plan developed an antidepressant profile report of members who had the potential to be nonadherent to their antidepressant medication and mailed these reports to the treating PCPs. In addition to the physician mailing, CME seminars on medication compliance were held across the country targeting the high-volume PCP offices, and CME programs on depression were made available online. The health plan is in the process of assessing the impact of these initiatives on adherence to antidepressant medication. The health plan also continues to revise existing strategies and implement new strategies for the future. Plans for the future include mailings to members newly diagnosed with depression introducing them to the resources available on depression using a similar educational brochure as that sent earlier to existing members. Physicians also will be provided with a depression resource kit. The resource kit will contain patient screening and educational materials, a list of frequently asked questions, a resource sheet of internal and external contacts, information about the health plan’s Web site on depression, and a member action plan. Through these efforts, the health plan hopes to demonstrate that providing educational materials to members and targeting PCPs can have a substantial beneficial impact on increasing adherence rates to antidepressant medication among patients with depression.

Figure 1. Antidepressant Medication Management Barrier Analysis

In a randomized controlled trial, effective treatment of depression using both psychotherapy and antidepressants increased the quality of life (measured with respect to role functioning and social functioning) among low-income minority women.^[8] In another study of older adults with arthritis and depressive symptoms, effective depression treatment produced significant reductions in pain and disease interference with daily activities, as well as significant increases in quality of life measures.^[9]

The impact of depression on severe illnesses, such as cancer, cardiovascular disease, and diabetes, was discussed previously in the Overview of Depression section. Depression is associated with poor outcomes, recovery, and disease management across a range of diseases.

The presence of depression also increases health care utilization and overall per-patient costs. Among elderly patients hospitalized for medical conditions, depression significantly increased the length of hospitalization and the need for subsequent inpatient care.^[10] In a survey of primary care practices, depressed patients had more primary care visits, higher rates of specialist referrals, and higher total costs and outpatient costs than nondepressed patients^[11].

The effects of depression in these illnesses may be in part related to the inability of patients to adhere to treatment recommendations. For example, depression has been associated with poor adherence to medication regimens in patients with human immunodeficiency virus, hypertension, and diabetes.^[12]-[14] Effective management of depression could be expected to improve adherence and lead to better overall outcomes for comorbid conditions.

One of the most comprehensive studies of the effect of depression treatment in patients with comorbid conditions was the Sertraline AntiDepressant Heart Attack Randomized Trial (SADHART) study, a double-blind evaluation of 369 patients with major depressive disorder and a history of either myocardial infarction or unstable angina.^[15] Antidepressant therapy was effective in reducing depressive symptoms among patients with heart disease and proved to be safe with regard to cardiac symptoms. The benefit of antidepressant therapy also extended to a wide range of quality of life measures. In addition, antidepressant treatment significantly reduced the levels of markers associated with increased blood clotting tendency compared with placebo. This reduction occurred even through patients were taking antiplatelet drugs, which suggests that antidepressant treatment may reduce the likelihood of future cardiac events.^[15]-[17]

The most important benefit of improved management is in terms of lives saved and lives extended. People with depression are at increased risk for committing suicide. The lifetime risk for suicide among patients who have been hospitalized for depression is 10% to 15%, and major depressive disorders are believed to account for 20% to 35% of the 30,000 suicides in the United States annually. The odds of depressed patients committing suicide are heightened by the presence of specific risk factors (Table 5).

There is evidence that depression treatment can help reduce the risk of suicide as measured by rates of suicidal ideation, a precursor to an actual suicide attempt. A recent study showed the intervention for depression at the primary care level, based on the application of current treatment guidelines, reduced the proportion of suicidal ideation among elderly patients from nearly 30% to 16.5%.^[18]

In addition to the risk for suicide, depression is also associated with an increased risk of premature death from other causes (not self-inflicted), especially when depression occurs in combination with serious medical conditions, such as cardiovascular disease.^[19],[20] A study of poststroke depression demonstrated the effectiveness of treatment (ie, antidepressants) in reducing the risk of death from stroke within a year from 64% to 32%.^[21]

Even when the effects of comorbid conditions are excluded, the presence of severe depression symptoms can lead to increased mortality, and the more severe the depression, the higher the risk of death. In one study of 3,056 elderly patients, the presence of depression was linked to nearly twice the risk of death over a four-year period, even after adjustment for health status, demographics, and health behaviors. In a six-year study of 5,201 men and women over age 65, patients with high depressive scores had a 41% greater risk of death than those with low scores.^[23]-[25]

In summary, the impact of depression and related disorders includes poor quality of life, reduced income, reduced productivity, and increased workplace costs, in addition to the most severe consequences, suicide and premature mortality. Effective management of depression can reduce the impact of workplace absenteeism and presenteeism, overall employee costs, and mortality, while improving quality of life and treatment adherence and disease status for comorbid conditions.

[1] - 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.

[2] - Data on file. The Impact of Mental Disorders on Work. [data analyzed from the National Comorbidity Survey]. Pfizer Inc, New York, NY.

[3] - The NCQA Quality Dividend Calculator™ 2.0. Available at: http://www.ncqacalculator.com/Index.asp Accessed March 15, 2004.

[4] - Is Depression a Roadblock to Career Success? Media symposium sponsored by the University of Michigan Depression Center and National Mental Health Association. March 22, 2004. Available at: http://www.med.umich.edu/opm/newspage/2004/FINAL%20Caril%20Presentation%20-%203-19.pdf Accessed April 6, 2004.

[5] - . Loebach Wetherell J, Throp SR, Patterson TL, Golshan S, Jeste DV, Gatz M. Quality of ife in geriatric generalized anxiety disorder: a preliminary investigation. J Psychiatr Res. 2004;38:305-312.

[6] - Ruo B, Rumsfeld JS, Hlatky MA, Liu H, Browner WS, Whooley MA. Depressive symptoms and health-related quality of life: the Heart and Soul Study. JAMA. 2003;290:215-221.

[7] - Schoenbaum M, Unutzer J, McCaffrey D, Duan N, Sherbourne C, Wells KB. The effects of primary care depression treatment on patients’ clinical status and employment. Health Serv Res. 2002;37:1145-1158.

[8] - Miranda J, Chung JY, Green BL, et al. Treating depression in predominantly low-income young minority women: a randomized controlled trial. JAMA. 2003;290:57-65

[9] - Lin EH, Katon W, Von Korff M, et al, for the IMPACT Investigators. Effect of improving depression care on pain and functional outcomes among older adults with arthritis: a randomized controlled trial. JAMA. 2003;290:2428-2429.

[10] - Koenig HG, Shelp F, Goli V, Cohen HJ, Blazer DG. Survival and health care utilization in elderly medical inpatients with major depression. J Am Geriatr Soc. 1989;37:599-606.

[11] - Luber MP, Hollenberg JP, Williams-Russo P, et al. Diagnosis, treatment, comorbidity, and resource utilization of depressed patients in a general medical practice. Int J Psychiatry Med. 2000;30:1-13.

[12] - Tucker JS, Burnam MA, Sherbourne CD, Kung FY, Gifford AL. Substance use and mental health correlates of nonadherence to antiretroviral medications in a sample of patients with human immunodeficiency virus infection. Am J Med. 2003;114:573-580.

[13] - Wan PS, Bohn RL, Knight E, Glynn RJ, Mogun J, Avorn J. Noncompliance with antihypertensive medications: the impact of depressive symptoms and psychosocial factors. J Gen Intern Med. 2002;17:504-511.

[14] - Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes: impact of depressive symptoms on adherence, function, and costs. Arch Intern Med. 2000;160:3278-3285.

[15] - Glassman AH, O’Connor CM, Califf RM, et al, for the Sertraline AntiDepressant Heart Attack Randomized Trial (SADHART) Group. Sertraline treatment of major depression in patients with acute MI or unstable angina. JAMA. 2002;288:701-709.

[16] - Swenson JR, O’Connor CM, Barton D, et al, for the Sertraline AntiDepressant Heart Attack Randomized Trial (SADHART) Group. Influence of depression and effect of treatment with sertraline on quality of life after hospitalization for acute coronary syndrome. Am J Cardiol. 2003;92:1271-1276.

[17] - Serebruany VL, Glassman AH, Malinin Al, et al, for the Sertraline AntiDepressant Heart Attack Randomized Trial Group. Platelet/endothelial biomarkers in depressed patients treated with the selective serotonin reuptake inhibitor sertraline after acute coronary events: the Sertraline AntiDepressant Heart Attack Randomized Trial (SADHART) Platelet Substudy. Circulation. 2003;108:939-944.

[18] - Brue ML, Ten Have TR, Reynolds CF 3rd, et al. Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial. JAMA. 2004;291:1081-1091.

[19] - Penninx BW, Beekman AT, Honig A, et al. Depression and cardiac mortality: results from a community-based longitudinal study. Arch Gen Psychiatry. 2001;58:221-227.

[20] - Ramasubbu R, Patten SB. Effect of depression on stroke morbidity and mortality. Can J Psychiatry. 2003;48:250-257.

[21] - Jorge RE, Robinson RG, Arndt S, Starkstein S. Mortality and poststroke depression: a placebo-controlled trial of antidepressants. Am J Psychiatry. 2003;160:1823-1829.

[22] - Agency for Health Care Policy and Research (AHCPR). Depression: Quick Reference Guide - Detection, Diagnosis and Treatment. Clinical Practice Guideline. 1993. Available at: http://www.mentalhealth.com/bookah/p44-dq.html. Accessed March 17, 2004.

[23] - Penninx BW, Geerlings SW, Deeg DJ, van Eijk JT, van Tilburg W, Beekman AT. Minor and major depression and the risk of death in older persons. Arch Gen Psychiatry. 1999;56:889-895.

[24] - Unutzer J, Patrick DL, Marmon T, Simon GE, Katon WJ. Depressive symptoms and mortality in a prospective study of 2,558 older adults. Am J Geriatr Psychiatry. 2002;10:521-530.

[25] - . Schulz R, Beach SR, Ives DG, Martire LM, Ariyo AA, Kop WJ. Association between depression and mortality in older adults: the Cardiovascular Health Study. Arch Intern Med. 2000;160:1761-1768.