The Mindfield of Depression

    On his first hour-long visit, the psychiatrist delves deeper into A’s background and symptoms. The physician asks whether A has a family history of mental illness. He diagnoses clinical depression, prescribes an antidepressant and explains that depression is an illness with roots in both brain chemistry and life stresses. He tells A that modern antidepressants take several weeks to "kick in" but are usually--though not always--effective. The doctor also cautions that the drugs often have side effects, including drowsiness, weight gain and sexual dysfunction. Over the next three months they meet for an hour each week, 12 sessions, so that the psychiatrist can monitor the medication, answer A’s questions and conduct a short, focused course of psychotherapy.

    Employee B, plagued by pain, fatigue and other symptoms, sees her primary-care physician for a checkup. After a 15-minute appointment, the physician finds nothing physically wrong and asks her to fill out a short mental-health-oriented questionnaire. The form is faxed to a company specializing in behavioral health care, which grades it and informs the primary-care physician that the patient’s answers indicate clinical depression. The physician calls B, visits with her briefly and prescribes an antidepressant.

    A week later, B receives an early-evening phone call from a counselor at the behavioral-health company who might be a social worker, a nurse or an uncredentialed health-care worker. During the first call, the counselor asks whether B is taking her medication and gauges her current state of mind in a 10- to 15-minute visit. If it appears that B’s depression is becoming dangerously worse, the counselor can ask for advice from his superiors. The counselor makes three more semi-scripted phone calls over the next six months. During that time, B is also mailed a series of six pamphlets explaining the nature of depression, the effectiveness and drawbacks of antidepressants, and other strategies for coping with the illness.

    Both cases are hypothetical. But each represents the ideal course of treatment espoused by one of two warring factions in the mental-health industry. Along with the advent of managed care has come a decrease in relative and absolute terms in the amount that employers contribute to their employees’ behavioral health care. From 1988 to 1997 the average dollar amount, adjusted for inflation, dropped from $151.54 to $69.61 per employee per year and from 6.1 to 3.1 percent of total health-care expenditures. "And that trend has continued," says Ed Hustead of The Hay Group, the consulting firm that conducted the survey. The mental-health coverage experienced by Patient A, it’s been calculated, will raise health-care premiums by as much as 5 percent. The treatment received by Patient B, bundled together with similar programs for conditions like heart disease, asthma and diabetes, will cost from $1 to $5 per employee per month. Still, proponents insist that savings associated with improved worker productivity will make it essentially "cost neutral." As a workforce executive, which course of treatment would you consider to be more effective for you or a coworker? Which would be more cost-effective for the company? The answers are as complicated and elusive as the dangerous illness behind them.

Fighting a stealth epidemic
    These facts are not in dispute:

• Depression is a widespread illness. According to a recently published study in the Journal of the American Medical Association, 16.2 percent of the U.S. adult population will experience major depression at some time in their life; 6.6 percent suffered an episode in the past year.

• Depression is a major drain on business productivity and profits. Another recent JAMA-published study calculated that depressed workers cost their employers $44 billion each year: 19 percent of that because of increased absenteeism but a surprising 81 percent because of "presenteeism"--defined as employees who show up for work but perform at only a fraction of their capabilities.

• Depression is poorly diagnosed. For a variety of reasons, including the stigma still attached to the disease, only 33 percent of all depression sufferers, according to the same study, receive medication for their disease.

    Dr. Jerome Vaccaro, a psychiatrist and CEO of PacifiCare Behavioral Health in Laguna Hills, California, says, "Yes, it’s badly undertreated. Even psychiatrists and psychologists, when they see hopeless, helpless patients, miss the diagnosis more than half the time. But we’ve got data to show that we’re driving that figure down." Like similar companies nationwide--including Wausau Benefits and Magellan Behavioral Health--PacifiCare is a specialized mental-health subcontractor to larger health insurance companies, assisting HMOs and PPOs in offering programs like the one used by Patient B. "They’re practical, they work, and the best of them bring together the best science of depression medicine," Vaccaro says. The plans cut traditional paid-by-the-hour mental-health specialists--psychiatrists and psychologists--out of the loop.

    Programs like PacifiCare’s are a 21st-century addition to the movement toward disease management. Managed health is designed to educate patients and give them more control over their treatment while cutting down on the number of expensive office visits to primary care physicians and specialists. For more than 15 years, disease-management programs have been used to treat chronic conditions like cardiovascular disease, asthma and diabetes--and their use for depression is increasing rapidly. The American Association of Health Plans reports that in 2001, 56.6 percent of health plans offered disease-management programs for depression, a figure that jumped to 81.1 percent the following year.

    Not everyone views this development favorably. Many experts say that depression, which affects the mind, shouldn’t be compared to "physical" illnesses that affect less complicated and better-understood organs. Among the most insidious aspects of depression, they emphasize, is that the disease causes individuals to hide what many perceive to be a "shameful" illness from others, and to believe with hyper-pessimistic certainty that no treatment or recovery is possible. Most members of the mental-health community, according to the positions of organizations like the American Psychological Association, believe that an essential component of a treatment is extensive interaction between and patient and a medical professional--the foundation of what disease management aims to manage away. Dr. Norman Clemens, a professor of psychiatry at Case Western Reserve University in Cleveland and chairman of the American Psychiatric Association’s Committee on APA/Business relations, says, "There are some fairly simple depressions that can be treated by a [primary care physician] with medication, but the threshold for referral to a specialist should be very low. This is a lethal disease. It’s foolish to save pennies when you could be saving a life."

    Dr. Stephen Heidel, a San Diego-based psychiatrist who has an MBA as well as a medical degree and has designed and implemented EAPs for local employers, says, "A questionnaire is not a diagnosis. A diagnosis is a diagnosis." He says that a face-to-face meeting with a clinical psychiatrist, trained to pick up subtle aspects of a patient’s expression, affect and body language, is necessary before the appropriate treatment, if any, is begun. He contends that harried primary doctors, whether they’ve been specially trained or not, will tend to miss the signs of depression or, just as bad, pick up on them and "take a shot" at treating patients themselves. As for proper treatment, he says that the best results in treating depression come from combining drugs and "talk" therapy. "That’s the gold standard," he says.

    Jerome Vaccaro scoffs at this point of view. "Many patients faced with this disease and the stigma attached to it will never agree to be seen by a psychiatrist." They’ll only agree to be treated by their primary care doctor, he says, "whom they already know and trust."

Psych war
    The argument is part of a much larger and older dispute. Until the early 1980s, health plans that paid for mental-health care spent most of their money on patient hospitalizations and outpatient visits to psychiatrists, psychologists and licensed social workers who conducted fairly open-ended talk therapies. Toward the end of the 1980s, however, two important events coincided: the advent of managed health care and the arrival of the first medications such as Prozac that were truly effective and relatively free of side effects.

    Physicians began prescribing antidepressants. The psychiatric and psychological communities discovered that shorter-range talk therapies seemed to work pretty well in combination with drugs. A 2001 New England Journal of Medicine study found that when used together, antidepressants and cognitive therapy helped 85 percent of patients suffering from chronic major depression. The success rate for patients treated with cognitive therapy alone or drugs alone hovered around 50 percent. By the late 1990s, however, disease-management programs for depression began to proliferate. The drugs-plus-talk advocates say that the patients who drop through the cracks will cost companies far more in lost productivity than will be saved in insurance premiums.

    Add pressure from advocacy groups pushing for "mental-health parity" in public and private health plans, and it’s obvious that some kind of resolution is needed.

    It may be coming. In June, a major JAMA-published study, "The Epidemiology of Major Depressive Disorder," defined adequate treatment for the disease as "either (1) at least four outpatient visits with any type of physician for pharmacotherapy that included use of either an antidepressant or mood stabilizer for a minimum of 30 days, or (2) at least eight outpatient visits with any professional in the specialty mental health sector for psychotherapy lasting a mean of at least 30 minutes."

    And several weeks ago, President Bush’s New Freedom Commission on Mental Health released its lengthy report. It didn’t set minimum standards for treatment, or weigh in specifically on the battling approaches. It did endorse reimbursements for e-health and telemedicine services and recommended that the U.S. Department of Health and Human Services lead a review of "how to best deliver and finance these services in consultation with private payers, insurers, state agencies and other federal programs." Ultimately, of course, it will be the marketplace--not politicians or even physicians--that will decide.