Psychiatry and primary careCourse of depression, health services costs, and work productivity in an international primary care study
Introduction
Depression is consistently associated with increased utilization of health services. In US community samples, respondents with depression report significantly greater use of general medical services [1]. In US primary care samples, health services costs for depressed patients are typically 50% to 100% greater than those for comparable patients without depressive disorder [2], [3], [4], [5]. While depression among primary care patients is typically associated with greater medical comorbidity, differences in health care utilization have persisted after adjustment for comorbid medical illness [2], [4], [5].
Depressive disorders are also associated with a substantial burden of disability and lost work productivity. Studies conducted in the US among community samples [6] and primary care patients [7], [8] find that depressive disorders are associated with two-fold or greater rates of disability days due to illness. A recent cross-national primary care study documented a similar association among diverse samples of primary care patients in 14 countries [9]. As observed with health services costs, this additional lost productivity associated with depression is not accounted for by comorbid medical illness [8], [9]. In various estimates of the economic burden of depression, costs associated with lost work productivity typically exceed resources allocated to treatment [10].
All of the data cited above consider cross-sectional comparisons of depressed and nondepressed samples. A cross-sectional association between depression and measures of economic burden does not necessarily imply that recovery (either spontaneous or following treatment) from depression would reduce that burden. Lost work productivity or greater health service utilization among those suffering from depression could result from some relatively fixed confounding factor or from some behavioral response to depression that, once established, may not change following recovery.
An accumulating body of evidence indicates that recovery from depression is associated with decreases in general medical expenditures and lost productivity due to illness. Among patients treated in clinical trials, recovery from depression is associated with substantial improvement in work participation and functioning [11]. Among US primary care patients, recovery from depression is associated with decreased health services costs, increased labor force participation, and decreased time missed from work due to illness [12].
Here we use data from a cross-national primary care study to examine economic correlates of recovery from depression. At six diverse primary care sites, systematic screening identified primary care patients with current major depression. Because our intent was to focus on predictors, process, and outcomes of treatment, those already receiving treatment for depression were excluded. Clinical outcomes, lost work productivity and health services utilization were monitored over the next year. These data allow us to examine whether longitudinal associations between depression, lost work productivity, and health services utilization as previously observed in US samples will generalize to primary care settings in other countries.
Section snippets
Methods
The The Longitudinal Investigation of Depression Outcomes (LIDO) project [13] was a longitudinal study of depressive symptoms, quality of life, and health services use among primary care patients in Barcelona (Spain), Be’er Sheva (Israel), Melbourne (Australia), Porto Alegre (Brazil), St. Petersburg (Russia), and Seattle (USA). At each site, investigators identified one or more primary care clinics considered typical of local health care delivery. As described in an earlier publication [13]
Results
Of 4,662 patients eligible following screening, 2,359 (51%) completed the diagnostic assessment. Baseline participation rates at individual sites ranged from 40% in Barcelona to 62% in Melbourne. Compared to those completing the baseline assessment, those declining to participate were slightly younger (mean age 40.5 yrs vs. 41.6 yrs, P=.022), less often female (65.0% vs. 68.6%, p=<0.01), had lower mean CES-D scores (24.7 vs. 26.4, P<0.01), and had higher SF-12 physical component summary scores
Discussion
As expected, we found that recovery from depression was associated with less severe depressive symptoms at baseline. Patients with more favorable depression outcomes also had lower health services costs and fewer days of work loss at some sites, but none of these relationships were statistically significant. Comparisons of health services costs during the follow-up period showed a generally similar pattern across sites. Costs were numerically lower for patients with more favorable outcomes, but
References (31)
- et al.
Recovery from depression, work productivity, and health care costs among primary care patients
Gen Hosp Psychiatry
(2000) Psychiatric disorder and functional somatic symptoms as predictors of health care use
Psychiatric Med
(1992)- et al.
Health care costs of primary care patients with recognized depression
Arch Gen Psychiatry
(1995) - et al.
Health care costs associated with depressive and anxiety disorders in primary care
Am J Psychiat
(1995) - et al.
Depressive symptoms and the cost of health services in HMO patients age 65 and overa four-year prospective study
JAMA
(1997) - et al.
Medical costs attributed to depression among patients with a history of high medical expenses in a health maintenance organization
Arch Gen Psychiatry
(1996) - et al.
Depression, disability days, and days lost from work in a prospective epidemiologic survey
JAMA
(1990) - et al.
Health-related quality of life in primary care patients with mental disorders
JAMA
(1995) - et al.
Disability and depression among high utilizers of health care
Arch Gen Psychiatry
(1992) - et al.
Common mental disorders and disability across cultures
JAMA
(1994)
The economic burden of depression in 1990
J Clin Psychiatry
Treatments of depression and the functional capacity to work
Arch Gen Psychiatry
Longitudinal Investigation of Depression Outcomes (The LIDO Study) in primary care in six countriesComparative assessment of local health systems and resource utilization
Int J Meth Psychiatric Res
The CES-D scalea self report depression scale for research in the general population
Applied Psychological Measurement
SF-12how to score the SF-12 Physical, and Mental Health Summary Scales
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- 1
The Longitudinal Investigation of Depression Outcomes (LIDO) study is a cross-national observational study of major depresion and its correlates. It has been carried out in six field study centers involved in the development of the WHOQOL measure (Australia, Brazil, Israel, Spain, USA, and the Russian Federation). Development and conduct of the study was a collaboratoive effort between the Research Team, a panel of Stdy Advisors, and the Site Investigatiors in each of the six field centers. Eli Lilly and Compmay, Indianapolis, Indiana, USA, provided the overall project sponsorship, and Health Research Associates, Inc. (HRA), served as the International Coordinating Agenc for the study. The LIDO Group consists of: The Research Team: Donald Patrick (University of Washington, Seattle, Washington, USA); Don Buesching/Carol Andrejasich/Michael Treglia (Eli Lilly and Company, Indianapolis, Indiana, USA); Mona Martin/Don Bushnell (Health Research Associates, Inc., Seattle, Washington, USA); Diane Jones-Palm (Health Research Associates, European Office, Frankfurt, Germany); Stephen McKenna (Galen Research, Manchester, England); and John Orley/Rex Billington (World Health Organization, Mental Health Division, Geneva, Switzerland). Study Advisors: Greg Simon (Group Health Cooperative of Puget Sound, Seattle, Washington, USA); Daniel Chisholm/Martin Knapp (Institute of Psychiatry, London, England); Diane Whalley (Galen Research, Manchester, England); and Paula Diehr (University of Washington, Seattle, Washington, USA). Site Investigators: Helen Herrman (University of Melbourne, Australia); Marcelo Fleck (Federal University of the State of Rio Grande do Sul, Brazil); Marianne Amir (Ben-Gurion University of the Negev, Be’er Sheva, Israel); Ramona Lucas (Barcelona, Spain); Aleksandr Lomachenkov (V.M. Bekhterev Psychoneurological Research Institute, St. Petersburg, Russia); and Donald Patrick (University of Washington, Seattle, Washington, USA).