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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 Antidepressants are grouped into classes based on how they
widespread and debilitating illness that cost Americans work. The main classes are TCAs, MAOIs, and SSRIs. Any
$44 billion in 1990, making it one of the nation’s ten individual antidepressant is effective in only 60 to 70 percent
most costly diseases.1 The Global Burden of Disease study of patients.14 Thus, some patients will need to try another
determined that major depression ranked second among all medication if the first is unsuccessful. TCAs and MAOIs were
diseases in disability attributable to illness.2 An estimated one- the first antidepressant drug classes. While these drugs are
fifth of all disability is caused by mental illness, primarily helpful in patients with severe depression with atypical
depression and anxiety.3 features, they are generally not considered first-line therapy
due to their potential for serious side effects.15 While all
A 1990-1992 national survey found antidepressants have side effects, newer classes such as SSRIs,
that 17.1 percent of those in the U.S. which first became available in the 1980s, generally produce
have had a major depressive episode milder side effects than TCAs and MAOIs. The most frequent
during their lifetimes.4 Depression is a side effects of SSRIs are gastrointestinal disorders and sexual
causal factor in the deaths of dysfunction,16 but the most commonly prescribed TCAs
approximately 18,000 Americans frequently cause weight gain, sedation, and dizziness, and less
every year, including 40 to 70 percent often cause low blood pressure and heart problems.17 Patients
of all suicides.5,6 Unfortunately, fewer taking MAOIs must severely limit their consumption of alcohol,
than half of those suffering from most cheeses, and other foods rich in tyramine because when
depression seek treatment.7 Of the combined with MAIOs, tyramine can accumulate to dangerous
almost 21 percent of patients with levels and cause sudden high blood pressure.18
clinically significant symptoms who
see a doctor, only 1.2 percent report APA guidelines recommend that patients being treated with
depression as the reason for the visit.8 antidepressants receive an additional four to five months of
drug therapy following remission of acute symptoms to allow
Successful treatment for depression complete resolution of the episode.12 Recent research
relies on proper diagnosis. Clinical underscores the importance of maintenance therapy beyond
depression is often missed because this time for certain patients, especially those with multiple
sufferers mistakenly perceive the illness as a normal episodes of depression, and points out a need for improved
depression that will naturally disappear without treatment. treatment of depression by primary care providers. One-
The National Institute of Mental Health estimates that only quarter to more than a third of patients treated with
one-third of people with major depressive episodes will ever antidepressants suffer relapse or recurrence of symptoms
seek treatment.9 In addition, primary care physicians after achieving remission.14,19 Those who stop taking
frequently do not diagnose depression accurately. One study antidepressants soon after remission are most likely to
found that only 43 percent of depressed patients were experience relapse, while those who continue therapy on their
recognized as such by their primary care doctors.10 initial antidepressant are least likely to relapse.20
Furthermore, most patients who receive treatment do not
obtain an appropriate level of care.11 Recent research shows that the price for treating depression
according to accepted guidelines has declined over time.21
In the last decade, several organizations have disseminated Because depressed patients, particularly those not in
guidelines for diagnosing and treating depression, including treatment, are high-cost users of health care, consuming two to
the American Psychiatric Association (APA)12 and the Agency four times more resources than other patients do, successful
for Healthcare Research and Quality (AHRQ).13 The AHRQ diagnosis and treatment of depression has the potential to
guidelines list ten “clinical clues” for use in screening, reduce total health care costs and offset costs associated with
including female gender, age under 40, other medical lost workdays (see box on next page).22,23
conditions, substance abuse, and personal and family history
of depression. According to the APA guidelines, initial Despite efforts to increase awareness and diagnosis of
treatment for depression should include antidepressant depression, as well as significant advances in therapy,
medication, psychotherapy, or a combination of the two. depression remains widely untreated. The federal
Severe cases may also be treated with electroconvulsive government’s report Healthy People 2010 sets the goal of
therapy. The choice of treatment may depend on severity and extending treatment to 50 percent of people with major
patient preferences. depressive disorders.11 Although this would represent a
significant improvement over past treatment rates, half of
severely depressed individuals would remain untreated.
D
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.
SYMPTOMS OF 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.
300
Average $ Spent Per Capita
250
In both 1994 and 1997, per capita spending was highest for the
200 SSRI class of antidepressants. Per capita spending on SSRIs
1994 rose 47 percent from 1994 ($212) to 1997 ($311). But per capita
150
1997 spending on TCAs was much lower in 1997 ($34) than in 1994
100 ($49).
50
Source: MEDSTAT’s Marketscan database
0
All TCAs SSRIs All Other