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1996 Through 2005

Catherine A. Fullerton, MD, MPH; Alisa B. Busch, MD, MS; Sharon-Lise T. Normand, PhD; Thomas G. McGuire, PhD; Arnold M. Epstein, MD

Arch Gen Psychiatry. 2011;68(12):1218-1226. doi:10.1001/archgenpsychiatry.2011.146

Context  During the past decade, the introduction of generic versions of newer antidepressants and the release of Food and Drug Administration warnings regarding suicidality in children, adolescents, and young adults may have had an effect on cost and quality of depression treatment.

Objectives  To examine longitudinal trends in health service utilization, spending, and quality of care for depression.

Design  Observational trend study.

Setting  Florida Medicaid enrollees, between July 1, 1996, and June 30, 2006.

Patients  Annual cohorts aged 18 to 64 years diagnosed as having depression.

Main Outcome Measures  Mental health care spending (adjusted for inflation and case mix), as well as its components, including inpatient, outpatient, and medication expenditures. Quality-of-care measures included medication adherence, psychotherapy, and follow-up visits.

Results  Mental health care spending increased from a mean of $2802 per enrollee to $3610 during this period (29% increase). This increase occurred despite a mean decrease in inpatient spending from $641 per enrollee to $373 and was driven primarily by an increase in pharmacotherapy spending (up 110%), the bulk of which was due to spending on antipsychotics (949% increase). The percentage of enrollees with depression who were hospitalized decreased from 9.1% to 5.1%, and the percentage who received psychotherapy decreased from 56.6% to 37.5%. Antidepressant use increased from 80.6% to 86.8%, anxiety medication use was unchanged at 62.7% and 64.4%, and antipsychotic use increased from 25.9% to 41.9%. Changes in quality of care were mixed, with antidepressant use improving slightly, psychotherapy utilization fluctuating, and follow-up visits decreasing.

Conclusions  During a 10-year period, spending for Medicaid enrollees with depression increased substantially, with minimal improvements in quality of care. Antipsychotic use contributed significantly to the increase in spending, while contributing little to traditional measures of quality of care.

Author Affiliations: Departments of Psychiatry (Dr Busch) and Health Care Policy (Drs Fullerton, Busch, Normand, McGuire, and Epstein), Harvard Medical School, Departments of Biostatistics (Dr Normand) and Health Policy and Management (Dr Epstein), Harvard School of Public Health, Department of Psychiatry, Cambridge Health Alliance (Dr Fullerton), McLean Hospital (Dr Busch), and Division of General Medicine, Brigham and Women's Hospital (Dr Epstein), Boston, Massachusetts.

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