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Depression: Implications for State and Local Healthcare Programs

Options & Strategies


Harold Pincus, M.D., Executive Vice Chair, Department of Psychiatry, University of Pittsburgh School of Medicine, and Senior Scientist, RAND Corporation and Director, RAND Pittsburgh Health Institute, University of Pittsburgh, Pittsburgh, Pennsylvania

Depression, the second-leading cause of disease burden in the United States, is a chronic illness that affects 17 million people. The risk for depression ignores race, ethnicity, educational level, and socioeconomic status. Up to 15 percent of the population will suffer from a major depressive disorder (MDD) in their lifetime, and it is estimated that MDD is present in 5.3 percent of the population in any given year.

Of critical concern is that the severity and impact of chronicity of this disease often gets overlooked. Depression is extremely difficult to diagnose and manifests itself in a wide variety of ways. The criteria for diagnosis of depression are often applied somewhat arbitrarily, and although depression is a common illness, it can easily be disguised, because those who suffer from it often function successfully in society.

The key depressive symptoms can be broken into three general areas:

  • Affected mood: Irritability, loss of interest or pleasure in most activities, feelings of worthlessness or guilt.
  • Affected cognition: Difficulty thinking, concentrating, or making decisions.
  • Affected physicality: Weight loss, weight gain, insomnia, hypersomnia, fatigue, or loss of energy.

Of significant concern to both care providers and policymakers are the costs associated with depression, both direct (healthcare costs) and indirect (reduced productivity and lost wages). Research indicates that people diagnosed with depression have general medical costs twice those of healthy individuals and visit hospital emergency rooms with significantly greater frequency. In addition, depression is the cause of $30-50 billion of lost productivity annually, and many employers report that depression is a moderate-to-large problem within their workplace setting.

Pharmaceutical costs are also overwhelming. Seven of the top 10 drugs covered by managed care programs in many States are medications for depressive disorders. Though there is a high occurrence of noncompliance with medications and other forms of treatment, it is important for policymakers to acknowledge that effective and successful treatment protocols for depressive illnesses in this country does exist.

These treatments are not being appropriately integrated, however. It is estimated that 50 percent of the individuals suffering from depression are getting no form of treatment, and 50 percent of those receiving pharmaceutical treatment are being treated unnecessarily. This is a phenomenon that must be addressed to ensure that the patients in need of care do receive it and that patients are not given pharmaceutical treatment unless their illnesses warrant it.

It is critical for policymakers to focus on issues of depression at this time because the problem is growing, according to Dr. Pinkus, and there is a significant evidence base for effective pharmacological and psychotherapeutic treatments. In addition, several effective models of treatment in primary care are being developed for depression.

Because depression is a complex disease that has varied diagnoses and degrees of severity, there is a need for linkages between and among various care systems such as social services, substance abuse, and other specialty care.

Barriers to providing quality care for depression include:

  • Stigma about mental illness in general.
  • The false notion that mental health costs are rising and mental health quality is suffering (making it difficult for people to get the adequate treatment that they need).
  • Lack of knowledge about the system.
  • Lack of attention focused on ineffective and inappropriate strategies.
  • The ongoing struggle between the primary care model and the managed care model as to how to adequately treat cases of depression.

A paradigm shift is necessary to address some of these barriers and challenges. This shift requires the promotion of patient-provider interactions between healthcare and mental health specialties, improved information systems, and the involvement of all affected parties: patients, plans, providers, practices/delivery systems, and purchasers.

Additional health services research is needed to measure outcomes (i.e., quality of life, work functioning, and long-term health) in various practice settings, within diverse populations, and for a variety of pharmatheraputics and combinations of treatments.


Ford DE. Managing patients with depression: is primary care up to the challenge? J Gen Intern Med. 2000;15:344-5.

Katon W, VonKorff LE, Walker E, SG, Bush T, et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA 1995;273:1026-31.

Simon GE, VonKorff M, Rutter C, Wagner E. Randomized trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care. BMJ 2000;320:550-4.

Wagner E. The role of patient care teams in chronic disease management. BMJ 2000;320:569-72.

Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA 2000;283:212-20.

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