A Closer Look At Depression

A CLOSER LOOK

AT

Depression Clinical depression is a widespread and debilitating illness that cost Americans $44 billion in 1990, making it one of the nation’s ten most costly diseases.

A C O O P E R AT I V E P R O J E C T B E T W E E N T H E N AT I O N A L A L L I A N C E F O R T H E M E N TA L LY I L L A N D T H E N AT I O N A L P H A R M AC E U T I C A L C O U N C I L

C

linical depression, or major depressive disorder, is a widespread and debilitating illness that cost Americans $44 billion in 1990, making it one of the nation’s ten most costly diseases.1 The Global Burden of Disease study determined that major depression ranked second among all diseases in disability attributable to illness.2 An estimated onefifth of all disability is caused by mental illness, primarily depression and anxiety.3 A 1990-1992 national survey found that 17.1 percent of those in the U.S. have had a major depressive episode during their lifetimes.4 Depression is a causal factor in the deaths of approximately 18,000 Americans every year, including 40 to 70 percent of all suicides.5,6 Unfortunately, fewer than half of those suffering from depression seek treatment.7 Of the almost 21 percent of patients with clinically significant symptoms who see a doctor, only 1.2 percent report depression as the reason for the visit.8 Successful treatment for depression relies on proper diagnosis. Clinical depression is often missed because sufferers mistakenly perceive the illness as a normal depression that will naturally disappear without treatment. The National Institute of Mental Health estimates that only one-third of people with major depressive episodes will ever seek treatment.9 In addition, primary care physicians frequently do not diagnose depression accurately. One study found that only 43 percent of depressed patients were recognized as such by their primary care doctors.10 Furthermore, most patients who receive treatment do not obtain an appropriate level of care.11 In the last decade, several organizations have disseminated guidelines for diagnosing and treating depression, including the American Psychiatric Association (APA)12 and the Agency for Healthcare Research and Quality (AHRQ).13 The AHRQ guidelines list ten “clinical clues” for use in screening, including female gender, age under 40, other medical conditions, substance abuse, and personal and family history of depression. According to the APA guidelines, initial treatment for depression should include antidepressant medication, psychotherapy, or a combination of the two. Severe cases may also be treated with electroconvulsive therapy. The choice of treatment may depend on severity and patient preferences.

Antidepressants are grouped into classes based on how they work. The main classes are TCAs, MAOIs, and SSRIs. Any individual antidepressant is effective in only 60 to 70 percent of patients.14 Thus, some patients will need to try another medication if the first is unsuccessful. TCAs and MAOIs were the first antidepressant drug classes. While these drugs are helpful in patients with severe depression with atypical features, they are generally not considered first-line therapy due to their potential for serious side effects.15 While all antidepressants have side effects, newer classes such as SSRIs, which first became available in the 1980s, generally produce milder side effects than TCAs and MAOIs. The most frequent side effects of SSRIs are gastrointestinal disorders and sexual dysfunction,16 but the most commonly prescribed TCAs frequently cause weight gain, sedation, and dizziness, and less often cause low blood pressure and heart problems.17 Patients taking MAOIs must severely limit their consumption of alcohol, most cheeses, and other foods rich in tyramine because when combined with MAIOs, tyramine can accumulate to dangerous levels and cause sudden high blood pressure.18 APA guidelines recommend that patients being treated with antidepressants receive an additional four to five months of drug therapy following remission of acute symptoms to allow complete resolution of the episode.12 Recent research underscores the importance of maintenance therapy beyond this time for certain patients, especially those with multiple episodes of depression, and points out a need for improved treatment of depression by primary care providers. Onequarter to more than a third of patients treated with antidepressants suffer relapse or recurrence of symptoms after achieving remission.14,19 Those who stop taking antidepressants soon after remission are most likely to experience relapse, while those who continue therapy on their initial antidepressant are least likely to relapse.20 Recent research shows that the price for treating depression according to accepted guidelines has declined over time.21 Because depressed patients, particularly those not in treatment, are high-cost users of health care, consuming two to four times more resources than other patients do, successful diagnosis and treatment of depression has the potential to reduce total health care costs and offset costs associated with lost workdays (see box on next page).22,23 Despite efforts to increase awareness and diagnosis of depression, as well as significant advances in therapy, depression remains widely untreated. The federal government’s report Healthy People 2010 sets the goal of extending treatment to 50 percent of people with major depressive disorders.11 Although this would represent a significant improvement over past treatment rates, half of severely depressed individuals would remain untreated.

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EPRESSED PATIENTS, PARTICULARLY THOSE NOT IN TREATMENT, ARE HIGH-COST USERS OF HEALTH CARE, CONSUMING TWO TO FOUR TIMES MORE RESOURCES THAN OTHER PATIENTS DO.

1990 SOCIETAL COSTS

OF

DEPRESSION

In 1990, the societal costs of depression were estimated to be $44 billion, making it one of the ten most costly diseases in the U.S.6 Absenteeism and diminished work performance are acute issues surrounding depression. A recent analysis of data from two national surveys found that workers with major depression experienced reduced productivity valued at $182-$395 over a 30-day period.24 And these costs do not encompass the full impact of depression, which also includes the pain and suffering of depressed patients and their families as well as loss in quality of life.25

SYMPTOMS

OF

Direct Treatment = $12.4 billion Premature Death = $7.5 billion

Lost Productivity = $23.8 billion

DEPRESSION

Depressed individuals suffer from a wide variety of symptoms. These may include:26 • Persistent sad, anxious, or “empty” mood • Feeling of hopelessness, pessimism • Feelings of guilt, worthlessness, helplessness • Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex • Decreased energy, fatigue, being “slowed down” • Difficulty concentrating, remembering, making decisions • Insomnia, early-morning awakening, or oversleeping • Appetite and/or weight loss or overeating and weight gain • Thoughts of death or suicide; suicide attempts • Restlessness, irritability • Persistent physical symptoms that do not respond to treatment such as headaches, digestive disorders, and chronic pain Major depression is diagnosed when a patient exhibits five or more of these symptoms most of the time, over a period of at least two weeks, and these symptoms interfere with functioning.27

T

HE NATIONAL INSTITUTE OF MENTAL HEALTH ESTIMATES THAT ONLY ONE-THIRD OF PEOPLE WITH MAJOR DEPRESSIVE EPISODES WILL EVER SEEK TREATMENT.

Spending on pharmaceuticals was analyzed for individuals who received health benefit coverage from large employers in 1994 and 1997. The sample included individuals who received drug treatment for depression and those who were diagnosed with a condition other than depression for which these drugs are often indicated. A similar analysis was conducted using data from 1998 and 2000.

FACTORS INFLUENCING DRUG SPENDING FOR DEPRESSION 1994-1997 Spending for antidepressants rose 86 percent from 1994 to 1997. Volume factors (increased numbers of people with depression receiving prescriptions for antidepressants, and increased intensity and duration of drug therapy) contributed much more to spending growth than did price factors.

METHODOLOGY This study separately analyzed prescription drug spending growth for two large national claims databases, one representing managed care plan enrollees and the other representing those covered by large employer-provided health benefit plans. The study defined and assessed several factors affecting the price per day of therapy and the volume of therapy — the number of days of therapy received and the number of patients receiving drug therapy. The analysis also examined the effects of price and volume changes for established drugs on the market during the entire period of analysis and for new drugs that were first marketed during this period.

Price Factors

Volume Factors

Factors Influencing Growth in Rx Expenditures: Total Growth in Expenditures Growth Due to Volume Factors

Fifty-four percentage points of the overall 86 percent spending growth came from an increase in the percentage of patients who filled prescriptions for antidepressants. The size of this effect is consistent with increasing awareness among consumers and health care providers of the benefits of treatment for depression.

% Positive Impact +86 +66

Changes in the Number of Prescriptions per Person for Established Drugs Changes in the Number of Prescriptions per Person for New Entrants

-14 +17

Changes in Days of Therapy for Established Drugs

+9

Changes in Days of Therapy for New Entrants

+0

Patients per 1000 Health Plan Enrollees Growth Due to Price Factors

+54 +20

Inflation

+7

Changes in Mix of Established Drugs

+11

Price of New Entrants

+2

Source: MEDSTAT’s Marketscan database

% Negative Impact

SPENDING PER CAPITA FOR ANTIDEPRESSANT MEDICATIONS Average $ Spent Per Capita

350 300 250 200

1994

150

1997

100 50

In both 1994 and 1997, per capita spending was highest for the SSRI class of antidepressants. Per capita spending on SSRIs rose 47 percent from 1994 ($212) to 1997 ($311). But per capita spending on TCAs was much lower in 1997 ($34) than in 1994 ($49). Source: MEDSTAT’s Marketscan database

0

All

TCAs

SSRIs

All Other

FACTORS INFLUENCING DRUG SPENDING FOR DEPRESSION 1998-2000

Price Factors

Volume Factors

Spending on drugs for treating depression was 33 percent higher in 2000 than in 1998. Again, volume factors contributed more to growth than did price factors. Likewise, the greatest impact was again from the increase in the percentage of people treated with antidepressants

Factors Influencing Growth in Rx Expenditures: Total Growth in Expenditures Growth Due to Volume Factors

% Positive Impact +33 +22

Changes in the Number of Prescriptions per Person for Established Drugs

-4

Changes in the Number of Prescriptions per Person for New Entrants

+3

Changes in Days of Therapy for Established Drugs

+3

Changes in Days of Therapy for New Entrants Patients per 1000 Health Plan Enrollees Growth Due to Price Factors

0 +20 +11

Inflation

+10

Changes in Mix of Established Drugs

+0.5

Price of New Entrants Source: MEDSTAT’s Marketscan database

% Negative Impact

+1

ABOUT

THIS PUBLICATION: The National Alliance for the Mentally Ill (NAMI) was established in 1979 with the aim of eradicating mental illness and improving the quality of life of all those affected by these illnesses. NAMI is a nonprofit, grassroots self-help and advocacy organization of over 220,000 consumers, families, professionals, sponsors, and friends of people with mental illnesses such as major depression, bipolar disorder, schizophrenia, obsessivecompulsive and anxiety disorders, most of whom work through more than 1,000 local and state affiliates. Since 1953, the National Pharmaceutical Council (NPC) has sponsored and conducted scientific, evidence-based analyses of the appropriate use of pharmaceuticals and the clinical and economic value of pharmaceutical innovation. NPC provides educational resources to a variety of health care stakeholders, including patients, clinicians, payers and policy makers. More than 20 research-based pharmaceutical companies are members of the NPC.

For more information or for additional resources, please contact:

National Alliance for the Mentally Ill Colonial Place Three 2107 Wilson Boulevard Suite 300 Arlington, VA 22201 Phone: 703-524-7600 www.nami.org

The National Pharmaceutical Council 1894 Preston White Drive Reston, VA 20191-5433 Phone: 703-620-6390 Fax: 703-476-0904 www.npcnow.org

FOR MORE INFORMATION ABOUT DEPRESSION, PLEASE CONTACT: National Alliance for the Mentally Ill www.nami.org 1-888-999-6264

National Institute of Mental Health (NIMH) www.nimh.nih.gov/ (301) 443-4513

American Psychiatric Association www.psych.org 1-888-357-7924

American Psychological Association www.apa.org 1-800-374-2721

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