[Effects of Depressive Comorbidities on Revenues of Somatic Inpatients in the G-DRG-System]. / Erlösrelevanz depressiver Nebendiagnosen bei somatischen Krankenhauspatienten.

BACKGROUND: Depressive comorbidity is common with physically ill inpatients and is associated with many negative medical and economic effects (e. g., increased morbidity and mortality, increased length of stay, poorer quality of life and increased utilization of health services). The aim of this study is to clarify the question whether the additional costs caused by comorbid depressive diseases are recovered by additional G-DRG-specific revenues in order to finance necessary diagnostics and therapies of this comorbidity. METHODS: We analysed the revenues generated by depressive secondary diagnoses. Consequently, we selected patients with relevant F-diagnoses according to ICD-10 from billing data of the University Hospital Greifswald between 2010 and 2014. We recoded each case without a comorbid depression, taking into account the specifications of the relevant accounting year. Subsequently, the revenues with and without coding the comorbidity were compared (n=6,563). RESULTS: In 115 out of 6,563 patients (1.75%), mainly with unspecific recurrent depressions, the documentation and coding of a comorbid depression led to a change in the proceeds. Taking into account the applicable base rate between 2010 and 2014, the coding leads to an additional revenue of 216,737.01 Euro for the entire observation period. This corresponds to an increase of approximately 1,885 Euro per patient (n=115). In relation to the total number of patients with comorbid depressions (n=6,563) it is a surplus of 33.02 Euro. However, predominantly unspecific depressive diagnoses (e. g., F 32.8) are encoded, which do not increase the level of severity in the DRG system and, thus, have no effect on the proceeds. DISCUSSION: In very few cases, the inclusion of depressive comorbidities leads to an increase in revenue. Only some depressive diagnoses have a CCL. Due to the relatively low CCL (1 or 2), depressive comorbidities often show no effect on PCCL of multimorbid patients. Currently there is no adequate financial incentive for the hospitals to recognize and treat depressions, since the additional costs do not lead to increased revenues. In the context of a systemic treatment, depression will have to be taken into account more strongly in the financing system, especially in view of the numerous negative effects of this comorbidity.

Smoking Status and Cost of Illness in Patients with Depressive Disorder Based on the National Health Survey in Spain.

BACKGROUND: Twenty-one percent of subjects with depressive disorder (DD) smoke. This prevalence is expected to be related to healthcare resources utilization (HRU) and sick leave, thereby accounting for substantial costs to the National Health System (NHS) and to society that still need to be characterized. The objective was to estimate cost of illness in patients with DD according to their smoking status. METHODS: We used the 2011/2012 National Health Survey to document HRU and lost-workday equivalents (LWDE). Men and women 18+ years old with a DD self-reported to a physician in the past 12 months were categorized into: smokers (daily smokers), former smokers, and never smokers. HRU and LWDE were computed on an annualized basis. Multivariate general linear models adjusted for sex, age, and comorbidities were applied. RESULTS: Data from 1,816 subjects (381 smokers, 290 former smokers, and 1,145 never smokers) were analyzed. Smokers had higher total per patient annual costs (thousands, €3.14), and higher annual healthcare costs (€2.53) than former smokers (€2.35, p < .1; and €1.93, p < .05) and never smokers (€2.42, p < .05; and €2.06, p < .1): with excess costs of €0.79 and €0.72 for total annual costs and €0.60 and €0.47 for annual healthcare costs (p = .029 and p = .056, respectively). CONCLUSIONS: Smoking DD subjects were associated with higher HRU and costs from both the societal and healthcare perspectives, when compared with former and never smokers in the Spanish general population. Supporting people with DD to quit smoking might therefore be a value-for-money health policy in Spain.

Health care costs of depression in patients diagnosed with cancer.

OBJECTIVE: Depression is common among patients diagnosed with cancer. Patients with cancer and depression use more health care services compared with nondepressed cancer patients. The current study seeks to estimate the added cost of depression in cancer patients in the first year after cancer diagnosis. METHODS: Health care charges were obtained for 2051 depressed and 11 182 nondepressed patients with an International Classification of Diseases, Ninth Revision, diagnosis of cancer in the 2014 calendar year from the University of California San Diego Healthcare System. The annual health care charges for cancer patients with and without depression were analyzed using generalized linear models with a log-link function and gamma distribution, covarying for age, sex, race/ethnicity, comorbid diseases, and presence of metastatic disease. Total cost data were broken down into several categories including ambulatory care, emergency department visits, and hospital visits. RESULTS: Depressed cancer patients had total annual health care charges that were 113% higher than nondepressed cancer patients (B = 0.76; P < .001). The estimated mean charges for depressed patients were $235 337 compared with $110 650 for nondepressed patients. Depressed cancer patients incurred greater charges than nondepressed patients in ambulatory care (B = 0.70; P < .001), emergency department charges (B = 0.31; P < .001), and hospital charges (B = 0.39; P < .001). CONCLUSIONS: Depressed cancer patients incur significantly higher health care charges across multiple cost categories including ambulatory care, emergency department visits, and hospital visits. Future research should investigate if interventions for detecting and treating depression are effective for reducing health care use and costs in cancer patients.

Effects of symptom clusters and depression on the quality of life in patients with advanced lung cancer.

People with advanced lung cancer experience later symptoms after treatment that is related to poorer psychosocial and quality of life (QOL) outcomes. The purpose of this study was to identify the effect of symptom clusters and depression on the QOL of patients with advanced lung cancer. A sample of 178 patients with advanced lung cancer at the National Cancer Center in Korea completed a demographic questionnaire, the M.D. Anderson Symptom Inventory-Lung Cancer, the Center for Epidemiological Studies Depression Scale, and the Functional Assessment of Cancer Therapy-General scale. The most frequently experienced symptom was fatigue, anguish was the most severe symptom-associated distress, and 28.9% of participants were clinically depressed. Factor analysis was used to identify symptom clusters based on the severity of patients' symptom experiences. Three symptom clusters were identified: treatment-associated, lung cancer and psychological symptom clusters. The regression model found a significant negative impact on QOL for depression and lung cancer symptom cluster. Age as the control variable was found to be significant impact on QOL. Therefore, psychological screening and appropriate intervention is an essential part of advanced cancer care. Both pharmacological and non-pharmacological approaches for alleviating depression may help to improve the QOL of lung cancer patients.

Long-term consequences of landmine injury: A survey of civilian survivors in Bosnia-Herzegovina 20 years after the war.

INTRODUCTION: Bosnia-Herzegovina is one of the most landmine-contaminated countries in Europe. Since the beginning of the war in 1992, there have been 7968 recorded landmine victims, with 1665 victims since the end of the war in 1995. While many of these explosions result in death, a high proportion of these injuries result in amputation, leading to a large number of disabled individuals. OBJECTIVE: The purpose of this study is to conduct a survey of civilian landmine victims in Bosnia-Herzegovina in order to assess the effect of landmine injuries on physical, mental, and social well-being. METHODS: Civilian survivors of landmine injuries were contacted while obtaining care through local non-governmental organizations (NGOs) throughout Bosnia-Herzegovina to inquire about their current level of independence, details of their injuries, and access to healthcare and public space. The survey was based upon Physicians for Human Rights handbook, "Measuring Landmine Incidents & Injuries and the Capacity to Provide Care." RESULTS: 42 survivors of landmines completed the survey, with an average follow up period of 22.0 years (±1.7). Of civilians with either upper or lower limb injuries, 83.3% underwent amputations. All respondents had undergone at least one surgery related to their injury: 42.8% had at least three total operations and 23.8% underwent four or more surgeries related to their injury. 26.2% of survivors had been hospitalized four or more times relating to their injury. 57.1% of participants reported they commonly experienced anxiety and 47.6% reported depression within the last year. On average, approximately 3% of household income each year goes towards paying medical bills, even given governmental and non-governmental assistance. Most survivors relied upon others to take care of them: only 41.5% responded they were capable of caring for themselves. 63.4% of respondents reported their injury had limited their ability to gain training, attend school, and go to work. CONCLUSION: The majority of civilian landmine survivors report adverse health effects due to their injuries, including anxiety, depression, multiple surgeries, and hospitalizations. The majority also experience loss of independence, either requiring care of family members for activities of daily living, disability, and inability to be employed. Further research is required to determine effective interventions for landmine survivors worldwide.

Assessing the Costs and Benefits of Insuring Psychological Services as Part of Medicare for Depression in Canada.

OBJECTIVE: The study estimated costs and effects associated with increasing access to publicly funded psychological services for depression in a public health care system. METHODS: Discrete event simulation modeled clinical events (relapse, recovery, hospitalizations, suicide attempts, and suicide), health service use, and cost outcomes over 40 years in a population with incident depression. Parameters included epidemiologic and economic data from the literature and data from a secondary analysis of the 2012 Canadian Community Health Survey on mental health. Societal costs were measured with the human capital approach. Analyses estimated the incremental cost-effectiveness ratio associated with improved access to psychological services among individuals not receiving adequate mental health care and reporting an unmet need for such care compared with present use of health services for mental health reasons. RESULTS: Over 40 years, increased access to mental health services in a simulated population of adults with incident depression would lead to significantly lower lifetime prevalence of hospitalizations (27.9% versus 30.2% base case) and suicide attempts (14.1% versus 14.6%); fewer suicides (184 versus 250); a per-person gain of .17 quality-adjusted life years; and average societal cost savings of $2,590 CAD per person (range $1,266-$6,320). Publicly funding psychological services would translate to additional costs of $123,212,872 CAD ($67,709,860-$190,922,732) over 40 years. Savings to society would reach, on average, $246,997,940 CAD ($120,733,356-$602,713,120). CONCLUSIONS: In Canada, every $1 invested in covering psychological services would yield $2.00 ($1.78 to $3.15) in savings to society. Covering psychological services as part of Medicare for individuals with an unmet need for mental health care would pay for itself.

[Telephone coaching for depression]. / Telefoncoaching bei Depression.

BACKGROUND: Depression is associated with a substantial utilization of resources in the German healthcare system. A typical symptom in depression is loss of drive, which possibly contributes to non-adherence and increased costs. OBJECTIVE: The study is based on routine healthcare data and tested the hypothesis that telephone coaching in cases of depression leads to a reduction in total healthcare costs. MATERIAL AND METHODS: Based on approximately 80 covariates and using propensity score matching, a total of 1586 persons who had received telephone coaching for depression and covered by a German statutory health insurance fund were matched to a comparable cohort of patients with depression to whom telephone coaching had not been provided. RESULTS: Within the study period of 12 months (3rd quarter 2012-4th quarter 2013) a positive program effect was observed for the intervention group by a significant reduction of total healthcare costs (2332 € vs. 2626 €, p = 0.0015) resulting in total savings to the statutory health insurance fund of 415,532 €. Investment costs amounted to 256,683.42 € leading to a return on investment of 1.62 € (total savings/total investment). The coaching program was well accepted by patients. CONCLUSION: Telephone coaching for depression was able to significantly reduce total healthcare expenditure and the intervention was well accepted by patients.

Depression treatment and healthcare expenditures among elderly Medicare beneficiaries with newly diagnosed depression and incident breast, colorectal, or prostate cancer.

OBJECTIVES: Depression is associated with high healthcare expenditures, and depression treatment may reduce healthcare expenditures. However, to date, there have not been any studies on the effect of depression treatment on healthcare expenditures among cancer survivors. Therefore, this study examined the association between depression treatment and healthcare expenditures among elderly with depression and incident cancer. METHODS: The current study used a retrospective longitudinal study design, the linked Surveillance, Epidemiology, and End Results-Medicare database. Elderly (≥66 years) fee-for-service Medicare beneficiaries with newly diagnosed depression and incident breast, colorectal, or prostate cancer (N = 1502) were followed for a period of 12 months after depression diagnosis. Healthcare expenditures were measured every month for a period of 12-month follow-up period. Depression treatment was identified during the 6-month follow-up period. The adjusted associations between depression treatment and healthcare expenditures were analyzed with generalized linear mixed model regressions with gamma distribution and log link after controlling for other factors. RESULTS: The average 1-year total healthcare expenditures after depression diagnosis were $38 219 for those who did not receive depression treatment; $42 090 for those treated with antidepressants only; $46 913 for those treated with psychotherapy only; and $51 008 for those treated with a combination of antidepressants and psychotherapy. As compared to no depression treatment, those who received antidepressants only, psychotherapy only, or a combination of antidepressants and psychotherapy had higher healthcare expenditures. However, second-year expenditures did not significantly differ among depression treatment categories. CONCLUSIONS: Among cancer survivors with newly diagnosed depression, depression treatment did not have a significant effect on expenditures in the long term.

Burden of illness in fibromyalgia patients with comorbid depression.

OBJECTIVES: To assess the burden of fibromyalgia (FM) in patients with FM taking antidepressant medication for comorbid depression. METHODS: Symptom burden, impact on work and activity, and healthcare resource utilisation (HCRU) was examined at randomisation in patients enrolled in a clinical trial. Symptom burden was estimated based on self-reported health status measures. The Work Productivity and Activity Impairment: Specific Health Problem scale adapted to FM and a separate HCRU questionnaire were completed. The relationship between FM severity and burden was evaluated. RESULTS: The total population analysed comprised 193 patients; 71 (36.8%) had moderate FM and 119 (61.7%) severe FM. Patients had moderate pain, severe impairment in functioning due to FM, sleep disruption, mild anxiety, and mild depression. In the 7 days preceding randomisation, an average of 58.0% overall work impairment was reported, with 15.2% of working hours missed and 54.0% productivity while at work. In the 3 months preceding randomisation, on average, 5.0 visits per patient were made to healthcare professionals. Physical treatments were used by 34.7% and supplements by 31.6% of patients. Prescription and non-prescription medications, as well as professional services providing help with activities of daily living (ADL) that are impacted by FM, were used by >75% of patients. In addition, 50.4 hours of unpaid help was provided for ADL assistance. Total out-of-pocket expenditures were US$307.1, €410.4, or C$211.3, depending on location. FM burden worsened with increasing FM severity. CONCLUSIONS: This study demonstrates the significant burden of FM in patients with comorbid depression treated with an antidepressant.

[Cost-Effectiveness of the Treatment of Depression in Old Age]. / Kosteneffektivität der Depressionsbehandlung im Alter.

OBJECTIVE: To conduct a systematic literature review of cost-effectiveness studies evaluating the treatment of depression in old age. METHODS: Systematic literature search in electronic databases in March 2014. RESULTS: Nine studies were included in the review. They were conducted in the Netherlands, the United Kingdom and the United States. The studies investigated psychological interventions (N = 3), pharmacotherapy (N = 1), and integrated care models (N = 5). The results varied greatly. CONCLUSION: The variation of the results in the included studies does not permit generalized conclusions, especially not for the widespread and recommended pharmacotherapy. Cost-effectiveness of psychological interventions and integrated care programs differed depending on the details of the program designs.

Clinical usefulness and economic implications of continuation/maintenance electroconvulsive therapy in a Spanish National Health System public hospital: A case series.

INTRODUCTION: Continuation/maintenance electroconvulsive therapy has been shown to be effective for prevention of relapse in affective and psychotic disorders. However, there is a limited nubber of studies that investigate clinical management, associated costs, and perceived quality variables. MATERIAL AND METHODS: A series of 8 cases included during the first 18 months of the Continuation/Maintenance Electroconvulsive Therapy Program of the Psychiatry Department at 12 de Octubre University Hospital is presented. Clinical variables (Clinical Global Impression-Improvement Scale, length of hospitalization, number of Emergency Department visits, number of urgent admissions) before and after inclusion in the continuation/maintenance electroconvulsive therapy program were compared for each patient, as well as associated costs and perceived quality. RESULTS: After inclusion in the program, 50.0% of patients reported feeling « much better ¼ and 37.5% « moderately better ¼ in the Clinical Global Impression-Improvement Scale. In addition, after inclusion in the continuation/maintenance electroconvulsive therapy program, patients were hospitalized for a total of 349 days, visited the Emergency Department on 3 occasions, and had 2 urgent admissions, compared to 690 days of hospitalization (P = .012), 26 Emergency Department visits (P = .011) and 22 urgent admissions (P = .010) during the same period before inclusion in the program. Associated direct costs per day of admission were reduced to 50.6% of the previous costs, and costs associated with Emergency Department visits were reduced to 11.5% of the previous costs. As regards perceived quality, 87.5% of patients assessed the care and treatment received as being « very satisfactory ¼, and 12.5% as « satisfactory ¼. CONCLUSIONS: This continuation/maintenance electroconvulsive therapy program has shown to be clinically useful and to have a favourable economic impact, as well as high perceived quality.

Out-of-pocket expenditure by Australian seniors with chronic disease: the effect of specific diseases and morbidity clusters.

BACKGROUND: Out of pocket expenditure (OOPE) on healthcare is related to the burden of illness and the number of chronic conditions a patient experiences, but the relationship of these costs to particular conditions and groups of conditions is less studied. This study examines the effect on OOPE of various morbidity groupings, and explores the factors associated with a 'heavy financial burden of OOPE' defined by an expenditure of over 10% of equivalised household income on healthcare. METHODS: Data were collected from 4,574 senior Australians using a stratified sampling procedure by age, rurality and state of residence. Natural clusters of chronic conditions were identified using cluster analysis and clinically relevant clusters based on expert opinion. We undertook logistic regression to model the probability of incurring OOPE, and a heavy financial burden; linear regression to explore the significant factors of OOPE; and two-part models to estimate the marginal effect of factors on OOPE. RESULTS: The mean OOPE in the previous three months was AU$353; and 14% of respondents experienced a heavy financial burden. Medication and medical service expenses were the major costs. Those who experienced cancer, high blood pressure, diabetes or depression were likely to report higher OOPE. Patients with cancer or diabetes were more likely than others to face a heavy burden of OOPE relative to income. Total number of conditions and some specific conditions predict OOPE but neither the clusters nor pairs of conditions were good predictors of OOPE. CONCLUSIONS: Total number of conditions and some specific conditions predict both OOPE and heavy financial burden but particular comorbid groupings are not useful in predicting OOPE. Low-income patients pay a higher proportion of income than the well-off as OOPE for healthcare. Interventions targeting those who are likely to face severe financial burdens due to their health could address some of these differences.

Cost effectiveness of telecare management for pain and depression in patients with cancer: results from a randomized trial.

OBJECTIVE: Pain and depression are prevalent and treatable symptoms among patients with cancer, yet they are often undetected and undertreated. The Indiana Cancer Pain and Depression (INCPAD) trial demonstrated that telecare management can improve pain and depression outcomes. This article investigates the incremental cost effectiveness of the INCPAD intervention. METHODS: The INCPAD trial was conducted in 16 community-based urban and rural oncology practices in Indiana. Of the 405 participants, 202 were randomized to the intervention group and 203 to the usual-care group. Intervention costs were determined, and effectiveness outcomes were depression-free days and quality-adjusted life years. RESULTS: The intervention group was associated with a yearly increase of 60.3 depression-free days (S.E. = 15.4; P < 0.01) and an increase of between 0.033 and 0.066 quality-adjusted life years compared to the usual care group. Total cost of the intervention per patient was US$1189, which included physician, nurse care manager and automated monitoring set-up and maintenance costs. Incremental cost per depression-free day was US$19.72, which yields a range of US$18,018 to US$36,035 per quality-adjusted life year when converted to that metric. When measured directly, the incremental cost per quality-adjusted life year ranged from US$10,826 based on the modified EQ-5D to US$73,286.92 based on the SF-12. CONCLUSION: Centralized telecare management, coupled with automated symptom monitoring, appears to be a cost effective intervention for managing pain and depression in cancer patients.

[Optimized quality of care for affective disorders by health insurance-based case-management: a controlled cost-study]. / Krankenkassengestütztes Case-Management verbessert kostenneutral die Behandlungsqualität bei affektiven Störungen.

OBJECTIVE: Improvement of depression treatment by health insurance based case-management. Criteria of improvement were a higher treatment rate of patients suffering from affective disorders or depression by psychiatrists or psychotherapists than by general practitioners or family doctors and sickness fund payments. METHODS: Training of health insurance account managers (characteristics of depression, counselling and, case management techniques). Evaluation of outcomes during 12-months against a control group of account managers without training. RESULTS: Intervention group: 87.8 % patients with in average 13.5 contacts to psychiatrists or psychotherapists; control group: 82.6 % patients with 11.8 contacts. The difference was statistically significant. Health insurance payments did not differ. CONCLUSIONS: A higher treatment rate by psychiatrists and psychotherapists can be achieved by health insurance-based case-management without a cost-increase.

Debt and depression among the Dibao population in northwestern China.

BACKGROUND: With the rapid development of economy, depression disorder is not only a public health issue but also a socioeconomic problem and attracting more and more attention in China. AIMS: The target of this study is to examine the prevalence of depression and the related risk factors in the Dibao population in northwestern China. METHOD: A cross-sectional analysis in a random sample survey conducted in three northwestern Chinese cities in 2007. The data from 4459 respondents with completed Center for Epidemiological Studies-Depression (CES-D) scales were evaluated to explore the key risk factors for depression. Using depression as a binary variable according to the cutoff of the CES-D score and then as a continuous variable, multiple logistic and line regression analysis were performed to compare the odds ratio and the weight of different risk factors for depression. RESULTS: The prevalence of depression in non-Dibao population was 34.7% but that in the Dibao population was 50.0% (p < .001). After adjusting for important confounders, Dibao population had an odds ratio (OR) of 1.38 (95% confidence interval (CI): 1.16-1.63) to have possible depression compared to those non-Dibao people. Furthermore, depression was associated with a higher OR of indebtedness (OR: 1.59, 95% CI: 1.31-1.93), and a small amount of debt would increase the possibility of depression for Dibao people (OR: 1.69, 95% CI: 1.28-2.23). In addition, gender, body mass index (BMI), tobacco use and social network were also important risk factors for depression in the Dibao population. Using depression as a continuous variable, being a member of the Dibao population and being indebted will add 2.06 and 1.83 to the CES-D score, respectively, compared with the non-Dibao population and not being indebted. A comparison of the odds ratios of depression between the Dibao and the non-Dibao population showed that factors such as gender, BMI, tobacco use, social network and indebtedness were statistically significant in the Dibao population but were not statistically significant in the non-Dibao population. Additionally, having a savings account was statistically significant in the non-Dibao population but not in the Dibao population. CONCLUSIONS: It was not surprising, as proved by other studies, that gender, obesity and social network were risk factors associated with depression in the Dibao population. Our findings indicated that a small amount of indebtedness was also closely related to depression in the Dibao population.

Prevention of common mental disorders: what can we learn from those who have gone before and where do we go next?

OBJECTIVE: Prevention strategies have made a major contribution to the considerable successes in reductions in cardiovascular disease and cancer mortality seen in recent decades. However, in the field of psychiatry, similar population-level initiatives in the prevention of common mental disorders, depression and anxiety, are noticeably lacking. This paper aims to provide a brief overview of the existing literature on the topic of the prevention of common mental disorders and a commentary regarding the way forward for prevention research and implementation. METHODS: This commentary considers what we currently know, what we might learn from the successes and failures of those working in prevention of other high prevalence health conditions, and where we might go from here. Taking cognisance of previous preventive models, this commentary additionally explores new opportunities for preventive approaches to the common mental disorders. RESULTS: The consensus from a large body of evidence supports the contention that interventions to prevent mental disorders across the lifespan can be both effective and cost-effective. However, funding for research in the area of prevention of common mental disorders is considerably lower than that for research in the areas of treatment, epidemiology and neurobiology. Thus, there is a clear imperative to direct funding towards prevention research to redress this imbalance. Future prevention interventions need to be methodologically rigorous, scalable to the population level and include economic evaluation. Evidence-based knowledge translation strategies should be developed to ensure that all stakeholders recognise preventing mental disorders as an imperative, with appropriate resources directed to this objective. CONCLUSION: There has been a recent expansion of research into potentially modifiable risk factors for depression, and it is now timely to make a concerted effort to advance the field of prevention of common mental disorders.

The costs associated with antidepressant use in depression and anxiety in community-living older adults.

OBJECTIVE: To determine the costs associated with antidepressant (AD) use by depression and anxiety status in a public-managed health care system. METHODS: Data were obtained from a population-based health survey of 1869 older adults. Depression and anxiety were based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria and measured at 2 time points 1 year apart. AD and health service use and costs were identified from provincial administrative databases and included hospitalizations, physician fees, outpatient medications, and ambulatory visits. Patient costs considered were related to drug copayments, transportation, and time spent seeking medical care. Annual costs associated with AD use were studied as a function of mental health status at baseline and follow-up interviews (persistence, incidence, remission, or no illness). Generalized linear models with a gamma distribution were used to control for individual factors. RESULTS: The costs incurred by participants using ADs as a whole (17.8%) reached $6678 (95% CI $5449 to $8182), significantly more than in participants not using ADs ($4698; 95% CI $3710 to $5949). AD use was associated with greater total adjusted costs among respondents with no depression (adjusted difference = $1769; 95% CI $236 to $3702) and no anxiety (adjusted difference = $1845; 95% CI $203 to $3486). CONCLUSION: The results showed that AD use was not associated with cost savings in any group, and indeed with greater costs among participants who were neither depressed nor anxious at any time point. Future cost studies may consider the analyses of different AD classes regarding the different clinical mental health profiles in older adults.

The impact of the type of insurance plan on adherence and persistence with antidepressants: a matched cohort study.

OBJECTIVE: To compare adherence to, and persistence with, antidepressants (AD) in Quebec patients who are covered by private and public drug insurance. METHOD: A matched cohort study was conducted using prescription claims databases: reMed, a medication data registry for Quebec residents covered by private drug insurance, and Régie de l'assurance maladie du Québec database for Quebec residents with public drug insurance. Patients were aged 18 to 64 years and filled at least 1 prescription for an AD in monotherapy between December 2007 and September 2009 (194 privately and 2055 publicly insured patients). Adherence over 1 year was estimated using the proportion of prescribed days covered (PPDC). The difference in mean PPDC between patients with private and public drug insurance was estimated with linear regression. Persistence was compared between the groups with a Cox regression model. RESULTS: The PPDC was 86.4% (95% CI 83.3% to 89.5%) in privately insured and 82.2% (95% CI 78.5% to 85.9%) in publicly insured patients and the adjusted mean difference was 5.1% (95% CI 1.6% to 8.6%). Persistence was 51.0% in the private group and 19.7% in the public group at 1 year (P < 0.001); the adjusted hazard ratio was 0.49 (95% CI 0.30 to 0.79). CONCLUSION: Better adherence and persistence were observed in privately insured patients. Adherence difference may be due to lower copayment among privately insured patients.

Cost-effectiveness of preventive interventions for depressive disorders: an overview.

The last 7 years have seen a growing number of cost-effectiveness studies demonstrating that screening people for signs of depression and the subsequent provision of psychological therapy to prevent the onset of depressive disorder is a cost-effective intervention. Many of the studies have expressed outcomes generically, either as quality-adjusted life-years or disability-adjusted life-years, and reported results well below conventional thresholds of 'value for money.' However, such interventions are still not routinely delivered in many healthcare systems, suggesting a 'translational' gap between evidence and practice. Future research needs to better integrate comprehensive economic evaluation indices into study designs, such as broad assessment of costs and impacts, including non-health impacts, to gain an accurate insight into the broader economic benefits of such interventions. Furthermore, a focus on interventions aimed at children and adolescents, which can demonstrate impact into adulthood, are likely to be highly favourable, both clinically and economically.