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Gregory E. Simon, MD, MPH; Willard G. Manning, PhD; David J. Katzelnick, MD; Steven D. Pearson, MD; Henry J. Henk, MS; Cindy P. Helstad, PhD

Arch Gen Psychiatry. 2001;58:181-187.

Background  Expanding access to high-quality depression treatment will depend on the balance of incremental benefits and costs. We examine the incremental cost-effectiveness of an organized depression management program for high utilizers of medical care.

Methods  Computerized records at 3 health maintenance organizations were used to identify adult patients with outpatient medical visit rates above the 85th percentile for 2 consecutive years. A 2-step screening process identified patients with current depressive disorders, who were not in active treatment. Eligible patients were randomly assigned to continued usual care (n = 189) or to an organized depression management program (n = 218). The program included patient education, antidepressant pharmacotherapy initiated in primary care (when appropriate), systematic telephone monitoring of adherence and outcomes, and psychiatric consultation as needed. Clinical outcomes (assessed using the Hamilton Depression Rating Scale on 4 occasions throughout 12 months) were converted to measures of "depression-free days." Health services utilization and costs were estimated using health plan–standardized claims.

Results  The intervention program led to an adjusted increase of 47.7 depression-free days throughout 12 months (95% confidence interval [CI], 28.2-67.8 days). Estimated cost increases were $1008 per year (95% CI, $534-$1383) for outpatient health services, $1974 per year for total health services costs (95% CI, $848-$3171), and $2475 for health services plus time-in-treatment costs (95% CI, $880-$4138). Including total health services and time-in-treatment costs, estimated incremental cost per depression-free day was $51.84 (95% CI, $17.37-$108.47).

Conclusions  Among high utilizers of medical care, systematic identification and treatment of depression produce significant and sustained improvements in clinical outcomes as well as significant increases in health services costs.

From the Center for Health Studies, Group Health Cooperative, Seattle, Wash (Dr Simon); the Department of Health Studies, University of Chicago, Chicago, Ill (Dr Manning); the Dean Foundation for Health Research and Education, Madison, Wis (Drs Katzelnick and Henk); the Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, Mass (Dr Pearson); and State Medical Society of Wisconsin, Madison (Dr Helstad).

Corresponding author and reprints: Gregory E. Simon, MD, MPH, Center for Health Studies, 1730 Minor Ave, Suite 1600, Seattle, WA 98101-1448 (e-mail: simon.g{at}ghc.org).

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