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 WE E N
T H E N AT I O N A L AL L I A N C E F O R T H E ME N T A L L Y I L L
A N D T H E N AT I O N A L P H A R M A C E U T I C A L C O U N C I L
Depression
A C L O S E R L O O K A T
C
linical depression, or major depressive disorder, is a
widespread and debilitating illness that cost Americans
$44 billion in 1990, making it one of the nation’s ten
most costly diseases.
1
The Global Burden of Disease study
determined that major depression ranked second among all
diseases in disability attributable to illness.
2
An estimated one-
fifth of all disability is caused by mental illness, primarily
depression and anxiety.
3
A 1990-1992 national survey found
that 17.1 percent of those in the U.S.
have had a major depressive episode
during their lifetimes.
4
Depression is a
causal factor in the deaths of
approximately 18,000 Americans
every year, including 40 to 70 percent
of all suicides.
5,6
Unfortunately, fewer
than half of those suffering from
depression seek treatment.
7
Of the
almost 21 percent of patients with
clinically significant symptoms who
see a doctor, only 1.2 percent report
depression as the reason for the visit.
8
Successful treatment for depression
relies on proper diagnosis. Clinical
depression is often missed because
sufferers mistakenly perceive the illness as a normal
depression that will naturally disappear without treatment.
The National Institute of Mental Health estimates that only
one-third of people with major depressive episodes will ever
seek treatment.
9
In addition, primary care physicians
frequently do not diagnose depression accurately. One study
found that only 43 percent of depressed patients were
recognized as such by their primary care doctors.
10
Furthermore, most patients who receive treatment do not
obtain an appropriate level of care.
11
In the last decade, several organizations have disseminated
guidelines for diagnosing and treating depression, including
the American Psychiatric Association (APA)
12
and the Agency
for Healthcare Research and Quality (AHRQ).
13
The AHRQ
guidelines list ten “clinical clues” for use in screening,
including female gender, age under 40, other medical
conditions, substance abuse, and personal and family history
of depression. According to the APA guidelines, initial
treatment for depression should include antidepressant
medication, psychotherapy, or a combination of the two.
Severe cases may also be treated with electroconvulsive
therapy. The choice of treatment may depend on severity and
patient preferences.
Antidepressants are grouped into classes based on how they
work. The main classes are TCAs, MAOIs, and SSRIs. Any
individual antidepressant is effective in only 60 to 70 percent
of patients.
14
Thus, some patients will need to try another
medication if the first is unsuccessful. TCAs and MAOIs were
the first antidepressant drug classes. While these drugs are
helpful in patients with severe depression with atypical
features, they are generally not considered first-line therapy
due to their potential for serious side effects.
15
While all
antidepressants have side effects, newer classes such as SSRIs,
which first became available in the 1980s, generally produce
milder side effects than TCAs and MAOIs. The most frequent
side effects of SSRIs are gastrointestinal disorders and sexual
dysfunction,
16
but the most commonly prescribed TCAs
frequently cause weight gain, sedation, and dizziness, and less
often cause low blood pressure and heart problems.
17
Patients
taking MAOIs must severely limit their consumption of alcohol,
most cheeses, and other foods rich in tyramine because when
combined with MAIOs, tyramine can accumulate to dangerous
levels and cause sudden high blood pressure.
18
APA guidelines recommend that patients being treated with
antidepressants receive an additional four to five months of
drug therapy following remission of acute symptoms to allow
complete resolution of the episode.
12
Recent research
underscores the importance of maintenance therapy beyond
this time for certain patients, especially those with multiple
episodes of depression, and points out a need for improved
treatment of depression by primary care providers. One-
quarter to more than a third of patients treated with
antidepressants suffer relapse or recurrence of symptoms
after achieving remission.
14,19
Those who stop taking
antidepressants soon after remission are most likely to
experience relapse, while those who continue therapy on their
initial antidepressant are least likely to relapse.
20
Recent research shows that the price for treating depression
according to accepted guidelines has declined over time.
21
Because depressed patients, particularly those not in
treatment, are high-cost users of health care, consuming two to
four times more resources than other patients do, successful
diagnosis and treatment of depression has the potential to
reduce total health care costs and offset costs associated with
lost workdays (see box on next page).
22,23
Despite efforts to increase awareness and diagnosis of
depression, as well as significant advances in therapy,
depression remains widely untreated. The federal
government’s report Healthy People 2010 sets the goal of
extending treatment to 50 percent of people with major
depressive disorders.
11
Although this would represent a
significant improvement over past treatment rates, half of
severely depressed individuals would remain untreated.
1990 SOCIETAL COSTS OF DEPRESSION
In 1990, the societal costs of depression were estimated to be $44 billion,
making it one of the ten most costly diseases in the U.S.
6
Absenteeism and diminished work performance are acute issues surrounding
depression. A recent analysis of data from two national surveys found that
workers with major depression experienced reduced productivity valued at
$182-$395 over a 30-day period.
24
And these costs do not encompass the full
impact of depression, which also includes the pain and suffering of depressed
patients and their families as well as loss in quality of life.
25
Lost
Productivity =
$23.8 billion
Direct
Treatment =
$12.4 billion
Premature
Death =
$7.5 billion
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
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.
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.
Spending for antidepressants rose 86
percent from 1994 to 1997. Volume factors
(increased numbers of people with
depression receiving prescriptions for
antidepressants, and increased intensity
and duration of drug therapy) contributed
much more to spending growth than did
price factors.
Fifty-four percentage points of the overall
86 percent spending growth came from an
increase in the percentage of patients who
filled prescriptions for antidepressants.
The size of this effect is consistent with
increasing awareness among consumers
and health care providers of the benefits
of treatment for depression.
Price
Factors
Volume
Factors
FACTORS INFLUENCING DRUG SPENDING
FOR DEPRESSION 1994-1997
Factors Influencing Growth in Rx Expenditures: % Positive Impact % Negative Impact
Total Growth in Expenditures +86
Growth Due to Volume Factors +66
Changes in the Number of Prescriptions per Person for Established Drugs -14
Changes in the Number of Prescriptions per Person for New Entrants +17
Changes in Days of Therapy for Established Drugs +9
Changes in Days of Therapy for New Entrants +0
Patients per 1000 Health Plan Enrollees +54
Growth Due to Price Factors +20
Inflation +7
Changes in Mix of Established Drugs +11
Price of New Entrants +2
Source: MEDSTAT’s Marketscan database
METHODOLOGY
This study separately analyzed
prescription drug spending
growth for two large national
claims databases, one
representing managed care plan
enrollees and the other
representing those covered by
large employer-provided health
benefit plans. The study defined
and assessed several factors
affecting the price per day of
therapy and the volume of
therapy — the number of days of
therapy received and the number
of patients receiving drug therapy.
The analysis also examined the
effects of price and volume
changes for established drugs on
the market during the entire
period of analysis and for new
drugs that were first marketed
during this period.
Spending on drugs for treating
depression was 33 percent
higher in 2000 than in 1998.
Again, volume factors
contributed more to growth
than did price factors.
Likewise, the greatest impact
was again from the increase in
the percentage of people
treated with antidepressants
Price
Factors
Volume
Factors
FACTORS INFLUENCING DRUG SPENDING
FOR DEPRESSION 1998-2000
Factors Influencing Growth in Rx Expenditures: % Positive Impact % Negative Impact
Total Growth in Expenditures +33
Growth Due to Volume Factors +22
Changes in the Number of Prescriptions per Person for Established Drugs -4
Changes in the Number of Prescriptions per Person for New Entrants +3
Changes in Days of Therapy for Established Drugs +3
Changes in Days of Therapy for New Entrants 0
Patients per 1000 Health Plan Enrollees +20
Growth Due to Price Factors +11
Inflation +10
Changes in Mix of Established Drugs +0.5
Price of New Entrants +1
Source: MEDSTAT’s Marketscan database
0
50
100
150
200
250
300
350
All TCAs SSRIs All Other
1994
1997
SPENDING PER CAPITA FOR ANTIDEPRESSANT MEDICATIONS
In both 1994 and 1997, per capita spending was highest for the
SSRI class of antidepressants. Per capita spending on SSRIs
rose 47 percent from 1994 ($212) to 1997 ($311). But per capita
spending on TCAs was much lower in 1997 ($34) than in 1994
($49).
Source: MEDSTAT’s Marketscan database
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FOR MORE INFORMATION ABOUT
DEPRESSION, PLEASE CONTACT:
National Alliance for the Mentally Ill
www.nami.org
1-888-999-6264
National Institute of Mental Health (NIMH)
www.nimh.nih.gov/
(301) 443-4513
American Psychiatric Association
www.psych.org
1-888-357-7924
American Psychological Association
www.apa.org
1-800-374-2721
1
Greenberg PE, Stiglin LE, Finkelstein S, Berndt E.
Depression: A neglected major illness. J Clin Psychiatr.
1993;54(11):419-424.
2
Mental Health: A Report of the Surgeon General.
Chapter 1: Introduction and Themes. Washington, DC:
U.S. Department of Health and Human Services, 2000.
3
Whalley D, McKenna S. Measuring quality of life in
patients with depression or anxiety. Pharmacoecon.
1995;8(4):305-315.
4
Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and
12-month prevalence of DSM-IV-R psychiatric
disorders in the United States: results from the
National Comorbidity Survey. Arch Gen Psychiatr.
1994;51:8-19.
5
Agency for Health Care Policy and Research (AHCPR).
Clinical Practice Guideline. Depression in Primary Care
Vol. 2. Treatment of Major Depression. AHCPR Pub. No.
93-0551, Rockville, MD, U.S. Department of Health and
Human Services, 1993.
6
Greenberg PE, Stiglin LE, Finkelstein S, Berndt E. The
economic burden of depression in 1990. J Clin
Psychiatr. 1993b;54(11):405-418.
7
Rupp A, Gause E, Regier D. Research policy
implications of cost-of-illness studies for mental
disorders. British Journal of Psychiatry.
1998;36(suppl):19-25.
8
Zung WW, Broadhead WE, Roth ME. Prevalence of
depressive symptoms in primary care. J Fam Pract.
1993;37(4):337-44.
9
National Institute of Mental Health. Depression:
Effective treatments are available. NIH Pub. No. 95-
3590, 1995.
10
Gerber PD, Barrett J, Barrett J, Manheimer E, Whiting
R, Smith R. Recognition of depression by internists in
primary care: a comparison of internist and “gold
standard” psychiatric assessments. J Gen Intern Med.
1989;4(1):7-13.
11
U.S. Department of Health and Human Services.
Healthy People 2010: Understanding and Improving
Health. 2nd ed. Washington, DC: U.S. Government
Printing Office, November 2000.
12
American Psychiatric Association. Practice guideline
for the treatment of patients with major depression.
Am J Psychiatry. 2000;157(4 suppl):1-45.
13
Depression in Primary Care. Vol. 1. Detection and
Diagnosis. AHCPR Publication No. 93-0550. Rockville,
MD: AHCPR, 1993.
14
Horst WD, Preskorn SH. Mechanisms of action and
clinical characteristics of three atypical
antidepressants: vanlafaxine, nefazodone, bupropion.
J Affect Disorders. 1998;51:237-254.
15
Broquet KE. Status of Treatment of Depression. South
Med J. 1999;92(9):848-858.
16
Masand PS, Gupta S. Selective serotonin-reuptake
inhibitors: An update. Harvard Rev Psychiatry.
1999;7(2):69-84.
17
Steffens DC, Krishnan KR, Helms MJ. Are SSRIs better
than TCAs? Comparison of SSRIs and TCAs: A meta-
analysis. Depress Anxiety. 1997;6:10-18.
18
Kent JM, SNaRIs, NaSSs, and NaRIs: New agents for
the treatment of depression. Lancet. 2000;355:911-918.
19
Lin EH, Katon WJ, VonKorff M, Russo JE, Simon GE,
Bush TM, Rutter CM, Walker EA, Ludman E. Relapse of
depression in primary care. Rate and clinical
predictors. Arch Fam Med. 1998;7(5):443-9.
20
Melfi CA, Chawla AJ, Croghan TW, et al. The effects
of adherence to antidepressant treatment guidelines
on relapse and recurrence of depression. Arch Gen
Psych. 1998;55:1128-1132.
21
Frank RG, Busch SH, Berndt ER. Measuring Prices and
Quantities of Treatment for Depression. American
Economic Review. 1998;88(2):106-111.
22
Croghan TW, Obenchain RL, Crown WE. What does
treatment of depression really cost? Health Affairs.
1998;17(4):198-208.
23
Zhang M, Rost KM, Fortney JC, Smith GR. A community
study of depression treatment and employment
earnings. Psychiatr Serv 1999;50(9):1209-1213.
24
Kessler RC, Barber C, Birnbaum HG, Frank RG,
Greenberg PE, Rose RM, Simon GE, Wang P. Depression
in the workplace: effects on short-term disability.
Health Affairs 1999;18(5):163-171.
25
Agency for Health Care Policy and Research
(AHCPR). Treatment of Depression: Newer
Pharmacotherapies. AHCPR Pub. No. 99-E014,
Rockville, MD, U.S. Department of Health and Human
Services, 1999.
26
National Institute of Mental Health. Depression. NIH
Publication No. 00-3561, 2000.
27
American Psychiatric Association. Diagnostic and
statistical manual of mental disorders. 4th ed.
Washington, DC: American Psychiatric Association,
1994.
1DST0091202
ABOUT THIS
PUBLICATION:
The National Alliance for the Mentally Ill
(NAMI) was established in 1979 with the
aim of eradicating mental illness and
improving the quality of life of all those
affected by these illnesses. NAMI is a non-
profit, grassroots self-help and advocacy
organization of over 220,000 consumers,
families, professionals, sponsors, and
friends of people with mental illnesses
such as major depression, bipolar
disorder, schizophrenia, obsessive-
compulsive and anxiety disorders, most of
whom work through more than 1,000 local
and state affiliates.
Since 1953, the National Pharmaceutical
Council (NPC) has sponsored and
conducted scientific, evidence-based
analyses of the appropriate use of
pharmaceuticals and the clinical and
economic value of pharmaceutical
innovation. NPC provides educational
resources to a variety of health care
stakeholders, including patients, clinicians,
payers and policy makers. More than 20
research-based pharmaceutical
companies are members of the NPC.
The National Pharmaceutical Council
1894 Preston White Drive
Reston, VA 20191-5433
Phone: 703-620-6390
Fax: 703-476-0904
www.npcnow.org
National Alliance for the Mentally Ill
Colonial Place Three
2107 Wilson Boulevard
Suite 300
Arlington, VA 22201
Phone: 703-524-7600
www.nami.org
For more information or for additional
resources, please contact:

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