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Cost-effectiveness of Systematic Depression Treatment for High Utilizers of General Medical Care
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.
ABSTRACT
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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.
INTRODUCTION
DESPITE the prevalence1, 2
and effect3, 4 of depression in
primary care, current management often falls short of recommended standards.5, 6, 7, 8 Several
randomized trials during the last decade demonstrate that organized treatment
programs significantly improve the quality and outcomes of primary care depression
treatment. Schulberg et al9 demonstrated that
depression screening followed by guideline-based pharmacotherapy or psychotherapy
significantly improved outcomes compared with usual care. Katon et al10, 11, 12 have described 3
models of collaborative care (shared management by primary care physicians
and consulting psychiatrists or psychologists) that significantly improved
both quality of depression treatment and clinical outcomes. Mynors-Wallis
et al13 have demonstrated the effectiveness
of brief, structured psychotherapy provided in primary care. We have recently
described the effectiveness of a population-based depression screening and
treatment program for high utilizers of medical care.14
Willingness to implement proven depression treatment programs will depend
on the balance of additional benefits and additional costs. Cost-effectiveness
analyses of 2 of the interventions described earlier in the introduction show
modest increases in outpatient treatment costs.15, 16
Neither of these studies examined the effect of improved depression treatment
on overall health services utilization. The consistent association between
depression and increased use of medical services17, 18, 19, 20, 21
suggests that improved depression treatment could reduce general medical expenditures,
partially or fully offsetting costs of depression treatment. To our knowledge
to date, that possibility has not been examined in experimental studies.
This article examines incremental cost and cost-effectiveness of a population-based
program to identify and treat depression among high utilizers of general medical
care. As reported previously,14 this program
resulted in increased probability of initiating depression treatment, increased
intensity of depression treatment, and significant improvements in both clinical
and functional outcomes.
PARTICIPANTS AND METHODS
STUDY SETTING
The study was conducted within selected primary care clinics at Dean
Health Plan of Wisconsin, Dean; Harvard Pilgrim Health Care of Massachusetts
(HPHC), Boston; and Group Health Cooperative of Washington (GHC), Seattle.
Participating physicians in Dean worked in group-model clinics serving suburban
and rural patients, while GHC and HPHC clinics were staff-model facilities
serving urban and suburban areas. Participating physicians were primarily
family practitioners at GHC, internists at HPHC, and a mixture at Dean. At
all 3 sites, outpatient specialty mental health care was provided by employed
or affiliated clinicians. Self-referral for mental health was allowed for
most Dean members and for all GHC and HPHC members. Typical coverage limits
for specialty mental health visits were: at Dean, a yearly limit of $1800
with no visit copayments; at GHC, 20 psychotherapy visits per year covered
with copayments of $10 to $20; and at HPHC, 20 psychotherapy visits per year
covered with copayments of $5 for the first 8 visits and $35 thereafter. Both
GHC and HPHC covered psychiatric visits for medication management at parity
with medical visits (ie, no annual limit, copayments equal to those for medical
visits).
SCREENING AND RECRUITMENT OF PARTICIPANTS
Methods and results of the 2-stage screening process are described in
an earlier publication.22 At all 3 sites, administrative
databases were used to identify members in participating clinics between the
ages of 23 and 63 years with continuous coverage during the past 2 years.
Visitation data at each site were used to select those whose number of outpatient
medical visits exceeded the 85th percentile for each of the last 2 years (either
7 or 8 visits per year). We excluded those patients receiving active depression
treatment during the last 90 days (ie, specialty mental health visits or use
of antidepressant medication at a therapeutic dose for at least 1 month) and
those for whom the depression treatment program would be clearly inappropriate
(ie, diagnosis of a bipolar or psychotic disorder during the prior 2 years,
diagnosis of substance abuse during the prior 120 days, or diagnosis of a
near-terminal medical condition such as metastatic malignancy). Eligible members
(n = 7203) were contacted for telephone screening that included the depression
module of the Structured Clinical Interview for DSM-IV (Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition).23 Those meeting DSM-IV criteria
for current major depression, as well as those reporting a recent (ie, prior
2 years) major depression now in partial remission (n = 1475) were eligible
for a second telephone assessment approximately 2 weeks later. This assessment
included a telephone administration of the 17-item Hamilton Depression Rating
Scale (HDRS)24 and screening for current substance
use. Those reporting any current illicit drug use and those reporting potentially
harmful levels of alcohol use (more than 8 drinks per week for women or 12
drinks per week for men) were excluded. Participants with HDRS scores of 15
or more were invited to participate in the randomized trial. Of 1295 patients
completing the second-stage screening, 410 (32%) were eligible, and 407 consented
to enroll in the randomized trial.
TREATMENT ASSIGNMENT
Prior to patient screening, physicians were randomly assigned (using
computer-generated random numbers) to the intervention or usual care group.
As each patient was screened for participation, this treatment assignment
was concealed from interviewers (using sealed envelopes) until after the point
of enrollment in the randomized trial.
Patients in the practices of usual care physicians were informed that
telephone screening suggested depression, and they were advised that care
was available in the primary care clinic. Patients in the practices of intervention
group physicians were invited to participate in the depression management
program (DMP) described below. All analyses were based on the assignment of
the responsible primary care physician at the time of randomization (ie, intent
to treat).
DEPRESSION MANAGEMENT PROGRAM
The DMP was a primary care–based intervention including education
and telephone care management for all patients, antidepressant pharmacotherapy
for most, and psychiatric consultation for those failing to respond to algorithm-based
primary care treatment.
Prior to patient enrollment, all physicians in the intervention group
completed a 2-hour training session focused on initial assessment of depression
and initiation of antidepressant treatment.
Immediately after enrollment, each patient in the intervention group
was invited to schedule an evaluation visit with his or her primary care physician.
This structured visit (lasting approximately 30 minutes) included confirmation
of the diagnosis of depression as well as assessment of prior treatment history,
important complicating factors (psychotic symptoms, history of mania), and
contraindications to antidepressant treatment. If appropriate, the physician
initiated antidepressant treatment. Physicians also asked patients to schedule
specific positive activities (eg, physical exercise or social activities)
at least 2 times per week.
The protocol for antidepressant pharmacotherapy called for the use of
sertraline as the first-line antidepressant, with an initial dose of 50 mg/d.
Depending on response and adverse effects, dose could be increased to 100
mg/d after 4 weeks, with further increases to a maximum of 200 mg/d. Nortriptyline
was the second-line medication, with an initial dose of 25 mg every night
and a maximum dose of 100 mg/d. Follow-up visits with the primary care physician
were scheduled at approximately 1 week, 3 weeks, 6 weeks, and 10 weeks after
initiation of treatment, with later visits recommended every 10 weeks.
Prior to the initial visit, patients in the intervention program were
mailed written and videotaped educational materials discussing the nature
of depression, the relationship between depression and medical illness, and
the effectiveness of depression treatment. Patients initiating antidepressant
treatment were also enrolled in the Rhythms education program (Pfizer Pharmaceuticals,
New York, NY) which included periodic mailings during a 3-month period.
Treatment coordinators monitored all patients in the intervention program,
including those who were initially declining treatment. Scheduled phone contacts
for monitoring of treatment response, treatment adherence, and medication
adverse effects occurred at approximately 2 weeks and 10 weeks, with additional
calls at 18 weeks, 30 weeks, and 42 weeks, depending on clinical need. Coordinators
also monitored records of visits made and prescriptions refilled. Treating
physicians received written feedback reports following each telephone monitoring
call, as well as notification of any apparent treatment dropout.
At each site, one or more psychiatric consultants were available to
provide as-needed consultation—either telephone consultation with treating
physicians or consultation visits with intervention patients. Primary care
physicians were advised to seek consultation for any patient with persistent
depression after 18 weeks.
USUAL CARE CONTROL GROUP
For patients assigned to the "usual care" group, no additional services
were provided to either physicians or patients. Physicans received no information
regarding patients' paticipation. Patients could, however, receive any services
normally available (eg, antidepressant medication, referral to specialty mental
health care).
CLINICAL ASSESSMENTS
All participants in the intervention and usual care groups were contacted
for blinded telephone assessments (including the HDRS) at 6 weeks, 3 months,
6 months, and 12 months after enrollment. Analyses of clinical effectiveness
used the "depression-free days" measure described by Lave et al.16
This method uses data at each assessment to estimate depression-free days
during an interval between 2 assessments. Each day in the interval is assigned
a value between 1 ("depression free," or an HDRS score  7) and 0 ("fully
symptomatic," or an HDRS score  22) using a linear interpolation of clinical
ratings at the beginning and end of the interval. The number of depression-free
days for the 12-month period equals the sum for each interval.
ESTIMATION OF HEALTH SERVICES COSTS
Health plan administrative data systems were used to extract data on
all services either provided by or paid for by the health plans during the
12 months prior to and the 12 months after randomization. For these analyses,
outpatient visits included all contacts with medical or ancillary providers
(excluding radiology, pathology, and laboratory). Specialty mental health
visits were defined according to provider specialty rather than visit content.
All units of service were assigned standard codes (ie, Current Procedural Terminology, Fourth Revision [CPT-4] codes and International Classification of Diseases, Ninth Revision [ICD-9] codes for visits and procedures, National Drug Codes for prescribed drugs, and diagnosis-related groups for hospitalizations).
Standard codes were then translated into unit prices using Medicare's Prospective
Payment System diagnosis-related groups for inpatient stays; Medicare's 1996
fee schedule25 for inpatient physician services,
outpatient visits, and procedures; and Red Book average wholesale prices (First
Data Bank, San Bruno, Calif) for prescribed drugs. Costs of the depression
screening program and costs of monitoring by the treatment coordinator were
estimated using actual input costs (labor and overhead). Screening cost per
DMP patient was calculated as total screening costs for patients of DMP physicians
divided by the number of patients randomized.
ESTIMATION OF TIME-IN-TREATMENT COSTS
Follow-up assessments included detailed questions regarding time required
for outpatient visits (including travel and waiting time). Time "lost" for
each day of inpatient treatment was estimated at 16 hours. These time estimates
were multiplied by the actual number of outpatient visits and hospital days
during follow-up (based on claims data). Time costs were estimated using predicted
wage rates based on age, sex, education, and baseline physical and mental
health status, site, and treatment group.
DATA ANALYSIS
Clinical effectiveness (depression-free days) was modeled using ordinary
least squares regression. Hospital admissions were compared using a negative
binomial regression model with a log link. Outpatient visit and estimated
cost measures were compared using Blough et al's formulation26
of the traditional 2-part model (ie, one equation estimating the probability
of any cost and a gamma regression with log link estimating the level of cost).
This method avoids potential difficulties introduced by transformation and
retransformation.27 We estimated a similar
2-part model for time-in-treatment costs; total social costs are the sum of
health services costs and time-in-treatment costs. Standard errors and confidence
intervals for utilization, cost, effectiveness, and cost-effectiveness were
estimated by bootstrapping (with 1000 replications).28, 29
All models include adjustment for age, sex, study site, baseline measures
of depression severity and health status, and for clustering of patients within
physicians. Models for utilization measures included indicator variables for
any use in the prior year and adjustment for the logarithm of prior use. Tests
for dominance of usual care (ie, positive incremental costs with negative
incremental benefits) or dominance of the intervention (ie, negative incremental
costs with positive incremental benefits) were also evaluated using the bootstrap
method with 1000 replications. An  error level of .05 (2-sided) was
used for all tests of statistical significance. Analyses were conducted using
version 5.0 of the STATA software package (Stata Corp, College Station, Tex).
RESULTS
STUDY SAMPLE
Patients assigned to the DMP (n = 218) and those assigned to usual care
(n = 189) did not differ significantly on baseline measures (Table 1). Utilization and estimated cost results are based on the
374 patients (92% of those randomized) enrolled in respective health plans
throughout the 12-month follow-up period. Treatment effectiveness and cost-effectiveness
results are based on the 369 patients (91% of those randomized) enrolled for
12 months who completed all 4 blinded follow-up assessments. Neither follow-up
participation nor disenrollment was related to clinical or demographic characteristics
assessed at baseline.
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Table 1. Baseline Comparisons of Patients Assigned to DMP and Usual
Care Groups*
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TREATMENT EFFECTIVENESS
Effects of the DMP on treatment received and patient outcomes have been
reported in an earlier publication.14 During
the first 6 months of treatment, DMP patients were significantly more likely
either to receive any antidepressant treatment (82% vs 32%, P<.001) or to fill at least 3 antidepressant prescriptions (69%
vs 18%, P<.001). As shown in Figure 1, the proportion of depression free days increased in both
groups over time, but this proportion was greater in the DMP group at every
follow-up assessment. The total number of depression-free days (ie, the area
under the curves shown in Figure 1)
was 229.3 days in the DMP group compared with 181.9 days among patients receiving
usual care. The adjusted difference was 47.4 days (95% confidence interval,
26.6-68.2).
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Proportion of days "depression free" calculated according to the
method of Lave et al.16 For each group, the
area under the curve reflects the total number of depression-free days during
12 months.
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HEALTH SERVICES UTILIZATION AND ESTIMATED COSTS
As presented in Table 2,
DMP patients made approximately 2 additional outpatient visits during the
follow-up period (adjusted difference, 3.2 visits). While hospitalizations
during the follow-up period were slightly more frequent in the DMP group,
this difference was not statistically significant (P
= .14). For both hospitalizations and outpatient visits, specialty mental
health care accounted for less than 10% of utilization in both groups.
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Table 2. Service Utilization by DMP and Usual Care Patients During
12 Months After Randomization*
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Estimated outpatient costs were $675 higher in the DMP group, with antidepressant
prescriptions accounting for $412 of this difference (Table 3). Direct intervention program costs (ie, screening and monitoring
by the treatment coordinator) were approximately $135 per patient. Estimated
inpatient costs were $839 higher in the DMP group, but confidence limits for
inpatient costs were considerably wider than those for outpatient costs.
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Table 3. Unadjusted Cost Components for DMP and Usual Care Groups*
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INCREMENTAL COST AND COST-EFFECTIVENESS
As presented in Table 4,
estimates of incremental cost clearly exceeded zero for all 3 categories examined
(outpatient health services, total health services, and health services plus
time in treatment). After adjustment, outpatient services and inpatient services
each contributed approximately $1000 to incremental costs, while time costs
contributed approximately $500. Incremental cost-effectiveness ratios for
the comparison of DMP with usual care are given in the third column of Table 4. Outpatient services and inpatient
services each contributed approximately $20 per additional depression-free
day. In a bootstrap analysis, dominance of DMP over usual care (ie, greater
effectiveness and lower cost) was seen in only 1 of 1000 cases, and dominance
of usual care over DMP was never observed.
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Table 4. Incremental Cost of Depression Screening and Treatment*
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COMMENT
In a population of high utilizers of general medical care, an organized
DMP produced significant and sustained gains in time free of depression, as
well as significant increases in estimated health services costs and time
in treatment costs. These findings place this DMP in the same category as
most proven medical treatments: achieving better health requires investment
of additional resources. Decision makers must choose among competing uses
of health resources based on expected value (the cost per gain in health outcomes).
Interpretation of these data should consider several limitations. First,
our results might not generalize to other populations (eg, elderly adults,
uninsured people, those who are not high utilizers of medical services) or
to dissimilar health care systems. Second, we do not consider broader perspectives
such as costs to the employer (eg, lost work productivity) or the larger society
(eg, educational attainment, marital stability). Third, our notification of
usual care patients regarding diagnoses of depression, while necessary for
ethical reasons, may have led some patients to seek depression treatment,
and reduced differences between groups in clinical effectiveness and cost.
Fourth, actual implementation of this program might produce less dramatic
effects on treatment received, leading to smaller effects on both utilization
and outcomes. Finally, our cost estimates are based on standard prices and
might not reflect true costs of providing services. For example, drug prices
for large institutional purchasers may be 10%-20% lower than average wholesale
prices, and expected future costs of generic alternatives may be lower still.
Consequently, our results may overstate pharmacy costs (the largest single
component of incremental cost).
We identify 2 limitations in the scope of our analyses that might lead
to less favorable cost-effectiveness estimates. First, a 12-month period may
underestimate long-term effectiveness (which continued to increase throughout
12 months) and overestimate long-term cost (which might decline during maintenance
treatment).30 Second, we do not include the
effects of treatment not captured by HDRS scores, such as the observed improvements
in social function and general health perception.14
While the incremental cost of this program may seem greater than for
other primary care interventions, most of this apparent difference probably
reflects differences in methods. Lave et al16
reported incremental health services costs of approximately $740 for guideline-based
pharmacotherapy and $840 for interpersonal psychotherapy (compared with usual
primary care). VonKorff et al15 reported incremental
costs of $260 to $490 for a collaborative care treatment program among patients
with major depression. Both of these reports included only outpatient health
services costs. Neither report considered costs of identifying eligible patients
or monitoring participation in the treatment program. If our analysis is restricted
to comparable categories (ie, excluding screening costs, treatment coordinator
costs, and inpatient costs), incremental costs were approximately $550.
Our estimates of time in treatment costs ($1636 for DMP patients, $1337
for usual care) are much higher than those reported by Lave et al ($122 for
usual care, $214 for pharmacotherapy, $366 for psychotherapy). Some of this
difference reflects our high-utilizing population: an average of 18 medical
visits throughout 12 months, compared with 7 in the Lave et al study. In addition,
our patients' reports of time per visit were 3 times as great as those from
national survey data used by Lave et al. Finally, we monetized time in treatment
using sample-specific wage rates in 1995 dollars rather than national norms
for 1989. Using our methods, the value of patients' time spent on a typical
primary care visit (including travel and waiting time) exceeds the Medicare
fee schedule price. We suspect that decision makers give much less weight
to time costs born by patients than to smaller components of treatment costs
born directly by insurers.
Our data are not consistent with the hypothesis that improved depression
treatment reduces overall health care expenditures during a 12-month period.
Instead, we estimate an increase of $1974, and a complete cost-offset effect
(ie, lower costs in the DMP group) occurred in only 22 of 1000 replications.
The increase in outpatient costs was relatively precise and occurred in areas
targeted by the intervention program (antidepressant prescriptions and follow-up
visits). We did not observe offsetting decreases in other components of outpatient
utilization. The increase in estimated inpatient costs was less precise and
was not clearly linked to any component of the intervention program; this
finding requires replication. We should point out that DMP patients made 3
additional outpatient visits (compared with usual care) while the protocol
called for up to 8 medication monitoring visits. This suggests that effective
depression treatment for high utilizers can integrate with ongoing medical
care, requiring only a small increase in visit rates.
Comparing the value of improved depression treatment with other health
care programs requires a common measure such as cost per quality-adjusted
life-year (QALY). Unfortunately, no method for translating depressive symptom
measures into health utility or QALYs is well established. Our review of available
literature31 suggests that the transition from
fully symptomatic depression (ie, an HDRS score of 22 or higher) to remission
(ie, an HDRS score of 7 or lower) is associated with an improvement in health
utility of approximately 0.35.32, 33, 34, 35
This is slightly more conservative than the estimate of 0.41 used by Lave
et al.16 Applying this measure, the additional
47 depression-free days among DMP patients would equal approximately 0.05
QALYs. Our cost-effectiveness estimates presented in Table 4 would translate to ratios of approximately $22 000
per QALY for outpatient services, $43 100 per QALY for total health services,
and $49 500 per QALY for health services plus time in treatment. Even
before discounting for inflation, our estimated cost-effectiveness ratio is
similar to those for other generally accepted medical interventions36, 37 (such as use of tissue plasminogen
activator for myocardial reperfusion38 and
pharmacotherapy for hypercholesterolemia among patients at moderate risk for
heart disease39).
We should also highlight that our cost-effectiveness estimate is based
on a true experiment rather than the more commonly used decision-analytic
model. Modeling studies typically depend on optimistic assumptions (eg, increased
use of general medical services among depressed patients is completely owing
to depression and completely reversible through treatment) and that treatment
effects transfer perfectly from efficacy studies to actual practice. For this
reason, our estimated cost-effectiveness of depression treatment may be conservative
(ie, less favorable cost per QALY ratios) compared with model-based estimates
in psychiatry and general medicine.
The argument for more equitable funding of mental health treatment is
often framed in terms of cost savings or cost-offset—that improved depression
treatment will reduce overall health care expenditures. Our analyses limited
to health sector costs do not find evidence for such a cost-offset effect.
As we40 and others41
have argued, however, cost savings should not be the primary justification
for providing effective mental health care. Claims focused on cost savings
ignore the true purposes of treatment—reduction in morbidity and improvement
in quality of life. Cost-effectiveness analyses explicitly consider the value
created when money is invested in health services. We find that implementation
of a systematic depression treatment program for high utilizers of medical
services leads to an increase of approximately $40 000 in health services
costs per QALY gained—a cost-effectiveness ratio commensurate with other
generally accepted medical interventions.
AUTHOR INFORMATION
Accepted for publication August 16, 2000.
This study was supported by a research grant from Pfizer Pharmaceuticals,
New York, NY.
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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