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Depression: Implications for State and Local Healthcare Programs

Strategies for Selected Groups


David Fassler, M.D., Clinical Associate Professor, Department of Psychiatry, University of Vermont, Burlington, Vermont

Frank Johnson, Executive Director, Office of Employee Health Benefits, Augusta, Maine

Ted Rooney, M.P.H., Partner, Health and Work Outcomes, Brunswick, Maine

In many cases, depression is an illness that manifests itself early in life. Research shows that 50 percent of depressed adults had their first episode before the age of 20. The key signs and symptoms of depression in children are similar to the symptoms in adults, and include:

  • Frequent persistent sadness.
  • Feelings of hopelessness, helplessness, and irritability, and physical ailments.
  • Significant behavior change or loss of interest in usual activities.
  • Changes in sleep patterns, appetite, or energy.
  • Missed school or poor school performance.
  • Thoughts about death, suicide, or running away.

Depression in children is caused by both biological and environmental factors. When children are evaluated for depression, it is critical that all of the following be completed: medical history, family history, school history, social history, physical exam, an interview with the child, and a meeting with the parents.

Suicide is a very serious concern for depressed young people. Suicide is the leading cause of death among college students, the third-leading cause of death among those age 15-24, and the sixth-leading cause of death of children age 5-14. More than 5,000 children and adolescents commit suicide each year, though research indicates that for each completed suicide, 100-200 attempts are made.

There is evidence that treatment for depressed children can be quite effective; however, very few good studies on this issue exist. One study that was conducted focused on children age 7-17 and Prozac use and found that 56 percent of the children followed on Prozac were rated much improved after 1 year versus the 33-percent improvement rate in the placebo group.

Policymakers and healthcare providers need to focus more attention on the issues of childhood depression. Parents must act as advocates for their children and work to identify resources available within the support community and within State and local governments to provide a high quality of care for these children.

Although symptoms of depression are similar across age groups, policymakers and practitioners must also recognize that children and adults suffering from depression have very different needs for services and treatment options.

In the State of Maine, several innovative initiatives were put in place in an effort to improve the services available to the working-age adult community suffering from depression. Frank Johnson, of the Maine Employee Health Benefits program, described the Maine Health Management Coalition (MHMC). MHMC is made up of 31 Maine employers, the State Medicaid program, and nonprofit organizations, whose mission is to bring together the purchaser and provider communities to measure and continuously improve the value of healthcare services delivered to the citizens of Maine.

The MHMC researched a wide variety of healthcare topics, and based on the findings that the costs of mental health in Maine outpaced the costs for cancer, diabetes, and hypertension, the group focused on depression as one of their first issues. For example, 1998 data collected on mental health claims in the Maine State Employee Health Benefits Program found that:

  • Seven percent of active members had a depression claim.
  • Incidence ranged from 2-13 percent among those employed by the State.
  • Antidepressant drugs were the fourth-most-expensive subset of drugs being purchased in the State, consuming nearly 11 percent of the 1999 pharmaceutical dollars.

A special committee established to examine the issue in greater detail recommended six primary initiatives to the MHMC board for improvement of services for depression to employees in the State. The recommendations were to develop:

  • A telephone employee-screening program.
  • A depression awareness and education program.
  • A patient call-back center.
  • A medication quality indicator study.
  • Model health benefits for mental health coverage.
  • Comprehensive practice profiles.

The Maine Health Information Center (MHIC), a nonprofit organization made up of multiple stakeholders, including the State of Maine and the MHMC, serves as the contractor for the MHMC depression initiatives. MHIC has developed a set of working goals to assist MHMC to address the issues of depression in the workplace. These goals were established in an effort to:

  • Increase employer awareness about the prevalence, impact, and stigma of depression.
  • Get employees with this condition into treatment.
  • Improve the treatment system available to workers.
  • Measure, evaluate, and improve outcomes.

In order to raise private sector employer awareness, MHIC held employer meetings and established a framework to help employers understand the costs and benefits associated with improving employee health. MHIC also has provided education on depression to 3,500 employees. Subsequently, a help line was established and more than 5 percent of the employees who participated in the education program called the hotline for assistance; 75 percent of these callers were ultimately diagnosed with depressive symptoms.

It was highlighted that one key ingredient to success is involving the stakeholders in the planning and development process, because there needs to be buy-in from all of the constituencies. In addition, creativity is crucial, as no one person or organization has any time or money to invest into new projects, therefore, everyone must use creative mechanisms to get the job done. Finally, the collection of credible and usable data is the key to being able to provide effective interventions for employees.

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