Incremental Benefit-Cost of MOMCare: Collaborative Care for Perinatal Depression Among Economically Disadvantaged Women.

OBJECTIVE: Effectiveness of collaborative care for perinatal depression has been demonstrated for MOMCare, from early pregnancy up to 15 months postpartum, for Medicaid enrollees in a public health system. MOMCare had a greater impact on reducing depression and improving functioning for women with comorbid posttraumatic stress disorder (PTSD) than for those without PTSD. This study estimated the incremental benefit and cost and the net benefit of MOMCare for women with major depression and PTSD. METHODS: A randomized trial (September 2009 to December 2014) compared the MOMCare collaborative care depression intervention (choice of brief interpersonal psychotherapy or pharmacotherapy or both) with enhanced maternity support services (MSS-Plus) in the public health system of Seattle-King County. Among pregnant women with a probable diagnosis of major depression or dysthymia (N=164), two-thirds (N=106) met criteria for probable PTSD. Blinded assessments at three, six, 12, and 18 months postbaseline included the Symptom Checklist-20 depression scale and the Cornell Services Index. Analyses of covariance estimated gain in depression free days (DFDs) by intervention and PTSD status. RESULTS: When the analysis controlled for baseline depression severity, women with probable depression and PTSD in MOMCare had 68 more depression-free days over 18 months than those in MSS-Plus (p<.05). The additional depression care cost per MOMCare participant with comorbid PTSD was $1,312. The incremental net benefit of MOMCare was positive if a DFD was valued at ≥$20. CONCLUSIONS: For women with probable major depression and PTSD, MOMCare had significant clinical benefit over MSS-Plus, with only a moderate increase in health services cost.

A randomized clinical trial of a telephone depression intervention to reduce employee presenteeism and absenteeism.

OBJECTIVES: The study tested an intervention aimed at improving work functioning among middle-aged and older adults with depression and work limitations. METHODS: A randomized clinical trial allocated an initial sample of 431 eligible employed adults (age ≥45) to a work-focused intervention (WFI) or usual care. Inclusion criteria were depression as measured by the Patient Health Questionnaire-9 (PHQ-9) and at-work limitations indicated by a productivity loss score ≥5% on the Work Limitations Questionnaire (WLQ). Study sites included 19 employers and five related organizations. Telephone-based counseling provided three integrated modalities: care coordination, cognitive-behavioral therapy strategy development, and work coaching and modification. Effectiveness (change in productivity loss scores from preintervention to four months postintervention) was tested with mixed models adjusted for confounders. Secondary outcomes included change in WLQ work performance scales, self-reported absences, and depression. RESULTS: Of 1,227 eligible employees (7% of screened), 431 (35%) enrolled and 380 completed the study (12% attrition). At-work productivity loss improved 44% in the WFI group versus 13% in usual care (difference in change, p<.001). WFI group scores on the four WLQ scales improved 44% to 47%, significantly better than in usual care (p<.001 for each scale). Absence days declined by 53% in the WFI group versus 13% in usual care (difference in change, p<.001). Mean PHQ-9 depression symptom severity scores declined 51% for WFI versus 26% for usual care (difference in change, p<.001). CONCLUSIONS: The WFI was more effective than usual care at four-month follow-up. Given increasing efforts to provide more patient-centered, value-based care, the WFI could be an important resource.

Costs of depression in Catalonia (Spain).

OBJECTIVE: To estimate the cost of depression for the adult population in Catalonia (Spain) for 2006. METHOD: The total adult population of Catalonia for the reference year was close to 6 million. A cross-design synthesis study was conducted, combining "top-down" and "bottom-up" data from secondary data sources, as well as expert opinion (nominal groups). A societal perspective was adopted. Estimates included direct health costs (hospital, primary, specialised and pharmacological care) and the indirect costs derived from the productivity lost due to morbidity and mortality. Sensitivity analyses were carried out for primary and specialised care resource utilisation. A Monte Carlo simulation model was developed to handle the uncertainty of the unit costs of primary care, specialised care and hospital visits. RESULTS: The total annual cost of depression in Catalonia for 2006 was 735.4 million Euros. Of this figure, 21.2% corresponded to direct costs, including 41 million Euros in primary care (5.6%), 8.1 million Euros in mental health specialised care (1.1%), 5.6 million Euros due to hospitalisation (0.8%) and 101.1 million Euros due to pharmacological care (13.7%); and 78.8% to indirect costs due to productivity loss. 3.7 million work days were lost to temporary disability for depression with a cost of 199.6 million Euros (27.1%), and 353.3 million Euros due to permanent disability (48%). Mortality attributed to suicide accounted for 26.9 million Euros (3.7%). The average annual cost of an adult with depression was close to 1800 Euros. LIMITATIONS: The heterogeneity of the data sources, the uncertainty in several estimates (i.e. proportion of psychotropic expenditure attributed to the treatment of depression, suicide rate attributed to depression), and the difficulty in disaggregating anxiety and depressive disorders in a number of databases are study limitations. CONCLUSIONS: The burden of depression for the Catalan public health system and society as a whole due to the consumption of resources and, more importantly, the loss of productivity is significant. Inefficiencies may be found in the overuse of pharmaceuticals and in the eligibility criteria of disability for work.

The prevalence of mental disorders in the working population over the period of global economic crisis.

OBJECTIVES: The ongoing global economic crisis may have affected people's mental health. This study aimed to, among a sample of the working population, estimate and compare the prevalence of depressive and anxiety disorders in different time intervals from January 2008 to October 2009 and to examine the demographic and socioeconomic correlates of mental disorders. METHODS: From January 2008 to October 2009, 3579 employees in Alberta were recruited using the random digit dialing method. Mental disorders were assessed using the World Health Organization's Composite International Diagnostic Interview-Auto 2.1. The lifetime and 12-month prevalence of depressive and anxiety disorders in different time intervals were estimated and compared. RESULTS: The 12-month prevalence of major depressive disorder (MDD) before September 1, 2008; between September 1, 2008, and March 1, 2009; and between March 1, 2009, and October 30, 2009, was 5.1%, 6.8%, and 7.6% (P = 0.03), respectively. The lifetime prevalence of dysthymia reported during the 3 periods was 0.4%, 0.7%, and 1.5% (P = 0.006), respectively. No changes in the 12-month prevalence of social phobia, panic disorder, and generalized anxiety disorder were found over time. CONCLUSIONS: The ongoing global economic crisis may have contributed to the increased prevalence of MDD. Future studies are needed to monitor the changes in the prevalence and to describe how the event may affect people's employment status, income, and health.

Evaluation of a system of structured, pro-active care for chronic depression in primary care: a randomised controlled trial.

BACKGROUND: People with chronic depression are frequently lost from effective care, with resulting psychological, physical and social morbidity and considerable social and financial societal costs. This randomised controlled trial will evaluate whether regular structured practice nurse reviews lead to better mental health and social outcomes for these patients and will assess the cost-effectiveness of the structured reviews compared to usual care.The hypothesis is that structured, pro-active care of patients with chronic depression in primary care will lead to a cost-effective improvement in medical and social outcomes when compared with usual general practitioner (GP) care. METHODS/DESIGN: Participants were recruited from 42 general practices throughout the United Kingdom. Eligible participants had to have a history of chronic major depression, recurrent major depression or chronic dsythymia confirmed using the Composite International Diagnostic Interview (CIDI). They also needed to score 14 or above on the Beck Depression Inventory (BDI-II) at recruitment.Once consented, participants were randomised to treatment as usual from their general practice (controls) or the practice nurse led intervention. The intervention includes a specially prepared education booklet and a comprehensive baseline assessment of participants' mood and any associated physical and psycho-social factors, followed by regular 3 monthly reviews by the nurse over the 2 year study period. At these appointments intervention participants' mood will be reviewed, together with their current pharmacological and psychological treatments and any relevant social factors, with the nurse suggesting possible amendments according to evidence based guidelines. This is a chronic disease management model, similar to that used for other long-term conditions in primary care.The primary outcome is the BDI-II, measured at baseline and 6 monthly by self-complete postal questionnaire. Secondary outcomes collected by self-complete questionnaire at baseline and 2 years include social functioning, quality of life and data for the economic analyses. Health service data will be collected from GP notes for the 24 months before recruitment and the 24 months of the study. DISCUSSION: 558 participants were recruited, 282 to the intervention and 276 to the control arm. The majority were recruited via practice database searches using relevant READ codes. TRIAL REGISTRATION: ISRCTN36610074.

Depression and the workplace: a progress report.

There has been considerable interest recently in the relationship between depression and the workplace. This interest is driven by the growing recognition that depressive disorders are highly prevalent in the workplace and have an enormously negative impact on performance, productivity, absenteeism, and disability costs. A variety of clinical research with occupational-related samples has helped to define those at risk for depression and has led to a better understanding of the overlap of the construct of clinical depression with more longstanding occupational health and organizational psychology models such as stress, burnout, and job satisfaction. From an employer perspective, depression's impact remains largely unmitigated due to stigma, uncertainty about treatment's cost effectiveness, and lack of effective interventions delivered in a workplace setting. Progress in these areas is reviewed with suggestions for future directions.

A randomized trial of self-management and psychoeducational group therapies for comorbid chronic posttraumatic stress disorder and depressive disorder.

The authors randomized 101 male veterans with chronic combat-related posttraumatic stress disorder (PTSD) and depressive disorder to an evidence-based depression treatment (self-management therapy; n = 51) or active-control therapy (n = 50). Main outcome measures for efficacy, using intention-to-treat analyses, were subjective and objective PTSD and depression scales at pretest, posttest, and 3-, 6-, and 12-month follow-up. Other measures included treatment compliance, satisfaction, treatment-targeted constructs, functioning, service utilization, and costs. Self-management therapy's modestly greater improvement on depression symptoms at treatment completion disappeared on follow-up. No other differences on symptoms or functioning appeared, although psychiatric outpatient utilization and overall outpatient costs were lower with self-management therapy. Despite success in other depressed populations, self-management therapy produced no clinically significant effect in depression with chronic PTSD.

Health status, resource consumption, and costs of dysthymia. A multi-center two-year longitudinal study.

BACKGROUND: In this study we estimated the health status, resource consumption and costs of a large cohort of patients with early and late-onset dysthymia. METHODS: The DYSCO (DYSthymia COsts) project is a multi-center observational study which prospectively followed for two years a randomly chosen sample of patients with dysthymia in the Italian primary health care system. RESULTS: A total of 501 patients were followed for two years; 81% had early-onset dysthymic disorder. During the study, improvement was seen in most domains of the 36-Item Short Form Health Survey (SF-36) questionnaire. Comparison of the SF-36 scores for the two groups showed that only the physical health index significantly differed during the two years. The use of outpatient consultations, laboratory tests and diagnostic procedures was similar in the two groups, but patients with early-onset dysthymia were admitted significantly more than late-onset cases. Hospital admissions were almost entirely responsible for the higher total cost per patient per year of early-onset dysthymia. LIMITATIONS: A first limitation of this study is that general practitioners were selected on the basis of their willingness to participate, not at random; secondly, no information was collected on concomitant psychiatric comorbidities. CONCLUSIONS: The present study provides the first prospective, long-term data on service use and costs in patients with dysthymia. Differently from patients with early-onset dysthymia, patients with late-onset dysthymia were admitted less and cost less.

Health status, resource consumption, and costs of dysthymic patients in Italian primary care.

AIMS: To describe the health status, resource consumption and costs of patients with dysthymic disorder in the Italian primary care setting. METHODS: A total of 79 general practitioners (GPs) participated the study. Diagnosis was based on each GP's clinical assessment. At entry the Mini-International Neuropsychiatric Interview (MINI) was used as a supporting diagnostic aid. Health status was measured with the SF-36 questionnaire. Resource consumption and costs regarded the six months before enrolment. RESULTS: Out of 598 patients enrolled by GPs according to their clinical assessment, 503 fulfilled the MINI criteria and 95 did not. The latter had a better perception of their health than the former. Resource consumption was similar in the two groups; and the total per patient six-month costs did not differ significantly. CONCLUSIONS: The study confirms there may be a gap between standardised criteria for defining dysthymia and everyday clinical practice. All dysthymic patients diagnosed by GPs might be considered together from a health policy perspective.

[Disability payments due to unipolar depressive and bipolar affective disorders]. / Die vorzeitige Berentung von unipolar depressiv und bipolar affektiv Erkrankten.

OBJECTIVE: Little is known concerning the frequency of disability payments due to depressive and bipolar affective disorders in Germany. METHOD: 177 consecutive psychiatric in-patients were assessed with standardized interviews concerning diagnosis (SCID-I, DSM-IV) and illness history. To compare unipolar depressive and bipolar affective patients, a survival analysis was calculated. RESULTS: 116 patients suffered from unipolar depression, 61 from bipolar affective disorder. Highly significantly, patients with bipolar affective disorders were granted disability payments more frequently and at an earlier age. Half of the bipolar affective patients received disability payments by the age of 46 years, half of the unipolar depressive patients by the age of 58 years. CONCLUSIONS: In this sample, bipolar affective patients received disability payments frequently and at an early age, which stresses that the prognosis of bipolar affective disorders is not as good as has been assumed for a long time. Early disability payments may lead to poverty and may obstruct access to social rehabilitation.

Community-integrated home-based depression treatment in older adults: a randomized controlled trial.

CONTEXT: Older adults with social isolation, medical comorbidity, and physical impairment are more likely to be depressed but may be less able to seek appropriate care for depression compared with older adults without these characteristics. OBJECTIVE: To determine the effectiveness of a home-based program of detecting and managing minor depression or dysthymia among older adults. DESIGN AND SETTING: Randomized controlled trial with recruitment through community senior service agencies in metropolitan Seattle, Wash, from January 2000 to May 2003. PATIENTS: One hundred thirty-eight patients aged 60 years or older with minor depression (51.4%) or dysthymia (48.6%). Patients had a mean of 4.6 (SD, 2.1) chronic medical conditions; 42% of the sample belonged to a racial/ethnic minority, 72% lived alone, 58% had an annual income of less than 10 000 dollars, and 69% received a form of home assistance. INTERVENTIONS: Patients were randomly assigned to the Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) intervention (n = 72) or usual care (n = 66). The PEARLS intervention consisted of problem-solving treatment, social and physical activation, and potential recommendations to patients' physicians regarding antidepressant medications. MAIN OUTCOME MEASURES: Assessments of depression and quality of life at 12 months compared with baseline. RESULTS: At 12 months, compared with the usual care group, patients receiving the PEARLS intervention were more likely to have at least a 50% reduction in depressive symptoms (43% vs 15%; odds ratio [OR], 5.21; 95% confidence interval [CI], 2.01-13.49), to achieve complete remission from depression (36% vs 12%; OR, 4.96; 95% CI, 1.79-13.72), and to have greater health-related quality-of-life improvements in functional well-being (P =.001) and emotional well-being (P =.048). CONCLUSIONS: The PEARLS program, a community-integrated, home-based treatment for depression, significantly reduced depressive symptoms and improved health status in chronically medically ill older adults with minor depression and dysthymia.

Estimating earnings losses due to mental illness: a quantile regression approach.

BACKGROUND: The ability of workers to remain productive and sustain earnings when afflicted with mental illness depends importantly on access to appropriate treatment and on flexibility and support from employers. In the United States there is substantial variation in access to health care and sick leave and other employment flexibilities across the earnings distribution. Consequently, a worker's ability to work and how much his/her earnings are impeded likely depend upon his/her position in the earnings distribution. Because of this, focusing on average earnings losses may provide insufficient information on the impact of mental illness in the labor market. AIMS: In this paper, we examine the effects of mental illness on earnings by recognizing that effects could vary across the distribution of earnings. METHODS: Using data from the National Comorbidity Survey, we employ a quantile regression estimator to identify the effects at key points in the earnings distribution. RESULTS: We find that earnings effects vary importantly across the distribution. While average effects are often not large, mental illness more commonly imposes earnings losses at the lower tail of the distribution, especially for women. In only one case do we find an illness to have negative effects across the distribution. IMPLICATIONS: Mental illness can have larger negative impacts on economic outcomes than previously estimated, even if those effects are not uniform. Consequently, researchers and policy makers alike should not be placated by findings that mean earnings effects are relatively small. Such estimates miss important features of how and where mental illness is associated with real economic losses for the ill.

Increased medical costs of a population-based sample of depressed elderly patients.

BACKGROUND: We examined whether older adults with depressive symptoms below the diagnostic threshold and those with DSM-IV major depression and/or dysthymia have higher medical costs than those without depression. METHODS: We mailed the PRIME-MD 2-item depression screen to the patients of 2 large primary care clinics of a staff-model health maintenance organization in Seattle, Wash. All 11 679 patients 60 years and older with primary care providers at the participating clinics were included, and 8894 (76.2%) were successfully enrolled. An additional 107 patients were referred to the study by their primary care physician. Nonrespondents were slightly younger and had higher inpatient medical costs in the previous 6 months. Patients with positive findings on at least 1 item or referred by their family physician were offered an interview with the Structured Clinical Interview for DSM-IV. The total cost of medical services for the 6 months before the study was obtained from the cost accounting system of the health maintenance organization. RESULTS: Total ambulatory costs were 43% to 52% higher and total ambulatory and inpatient costs were 47% to 51% higher in depressed compared with nondepressed elderly patients after adjustment for chronic medical illness. This increase was seen in every component of health care costs, with only a small percentage due to mental health treatment. In mean costs, depressed elderly patients averaged an increase of 763 US dollars to 979 US dollars in ambulatory costs and 1045 US dollars to 1700 US dollars in ambulatory and inpatient costs. No differences in costs were noted between patients with subthreshold depressive syndromes and those with DSM-IV depressive disorders. CONCLUSION: Depressive symptoms and DSM-IV depressive disorders in elderly patients are associated with significantly higher health care costs, even after adjustment for chronic medical illness.

Effectiveness of psychotherapy and combination treatment for chronic depression.

Although considerable research has been conducted on the efficacy of psychotherapy for depression, with and without medication, relatively few studies have focused on chronic forms of depression. Approximately 20% of individuals with depression experience episodes that last for two years or longer. We review the controlled research on the effectiveness of treatments separately for dysthymia and chronic major depression, focusing on the practical implications of the research for clinicians. In trials conducted with dysthymics, medication has been superior to psychotherapy, with limited evidence that combined treatment has advantages over medication or psychotherapy alone. In chronic major depression, combined treatment has demonstrated significant superiority over medication or psychotherapy alone. Possible explanations for the discrepant findings among dysthymics and those with chronic major depression are discussed.

Sertraline and/or interpersonal psychotherapy for patients with dysthymic disorder in primary care: 6-month comparison with longitudinal 2-year follow-up of effectiveness and costs.

BACKGROUND: There is little information on the long-term effects and costs of a combination of Sertraline and interpersonal psychotherapy (IPT) for the treatment of dysthymia in primary care. METHODS: In a single-blind, randomized clinical trial, 707 adults (18-74 years of age inclusive) with DSM-IV dysthymic disorder, with or without past and/or current major depression, as an acute or chronic episode, in a community-based primary care practice in Ontario, Canada, were randomized to treatment with either Sertraline alone (50-200 mg), or IPT alone (10 sessions), or Sertraline plus IPT combined. In the acute treatment phase (first 6 months) all groups received full active treatment. This was followed by an additional 18-month naturalistic follow-up phase. Subjects were assessed for effectiveness of treatment in reducing depressive symptoms using the Montgomery Asberg Depression Rating Scale (MADRS) at 6 months and twice again during the 18-month follow-up by blind independent observers. Treatment costs and subjects' use of other health and social services were also investigated. RESULTS: At 6 months, 586 subjects completed the MADRS questionnaire. There was a significant difference (P=0.025) in mean MADRS scores: 14.3 (Group I); 14.9 (Group II); 16.8 (Group III), using analysis of covariance. Response (40% improvement) rates were 60.2% for Sertraline alone, 46.6% for IPT alone, and 57.5% for Sertraline augmented by IPT (P=0.02). At 2 years, 525 subjects were retained for follow-up. There was no statistically significant difference between Sertraline alone and Sertraline plus IPT in symptom reduction. However, both were more effective than IPT alone in reducing depressive symptoms (P=0.03). There was a statistically significant difference between groups in costs for use of health and social services. The IPT treatment groups had the lower costs for use of health and social services. CONCLUSIONS: Sertraline or Sertraline plus IPT was more effective than IPT alone after 6 months. Over the long term (2 years), all three treatments provide reasonably effective treatment for reducing symptoms of dysthymia, but Sertraline or combining Sertraline with IPT is more effective than IPT alone. Of these two more effective treatments, subjects in the Sertraline plus IPT group had less health and social service costs by $480 per person over 2 years. These findings underscore the effects of combining pharmacotherapy and psychotherapy and the economic value of this more comprehensive treatment of dysthymia in primary care.

Comorbid dysthymia and substance disorder: treatment history and cost.

OBJECTIVE: The purpose of this study was to determine the treatment history and cost of previous treatment among patients with comorbid substance-related disorder and dysthymia, as compared to patients with substance-related disorder only. METHOD: Retrospective data were obtained regarding past treatment. Treatment cost was calculated on the basis of the 1996 cost of various treatment modalities. The setting was alcohol-drug programs located within departments of psychiatry in two centers. A total of 642 patients were assessed, of whom 39 had substance-related disorder and dysthymia and 308 had substance-related disorder only (the remaining patients had other comorbid conditions). Data collection instruments included an interview-based questionnaire regarding previous psychiatric and substance abuse treatment. Current cost of treatment in various settings was assessed on the basis of a survey of facilities used by patients in this area. RESULTS: Patients with substance-related disorder and dysthymia had received more substance-related disorder treatment in 18 of 20 measures. Patients with substance-related disorder and dysthymia used 4.7 times more substance-related disorder treatment dollars than patients with substance-related disorder only, although their demographic characteristics were similar. Past self-help activities and pharmacotherapy were remarkably similar for both groups. Although substance-related disorder treatment differed considerably between the two groups of patients, other types of psychiatric treatment (i.e., non-substance-related treatment) did not differ between the two groups. CONCLUSIONS: Patients with substance-related disorder and dysthymia are referred to (or seek) substance-related disorder treatment more often than patients with substance-related disorder only but are referred to (or seek) non-substance-related psychiatric treatment no more often than patients with substance-related disorder only. The cost of previous substance-related disorder treatment was several times higher for the patients with substance-related disorder and dysthymia.