Trends in U.S. Outpatient Depression Treatment, 1998-2007: An Overall Increase in Treatment, But a Decline in Psychotherapy
Marcus SC, Olfson M. National trends in the treatment for depression from 1998 to 2007. Arch Gen Psychiatry. 2010;67(12):1265-1273.
By Kim L. Farina, Ph.D.
Data from two national surveys on medical expenditures in U.S. households were analyzed to determine trends in outpatient treatment of depression between 1998 and 2007.1 The national outpatient depression-treatment rate rose from 2.37 per 100 persons (1998) to 2.88 per 100 persons (2007). This increase reflects a decrease in the proportion of treated individuals receiving psychotherapy (53.5% in 1998 to 43.1% in 2007) and no change in the proportion receiving antidepressant medication. The rate of increase observed during this study period was slower than that of the previous decade (1987-1997).2
The rates of outpatient depression treatment significantly increased among several specific sociodemographic groups, including African-Americans, Medicare beneficiaries, and adults with fewer than 12 years of education. Contrastingly, there was a significant decline in the number of white patients who received outpatient treatment for depression.
In the published report of their findings, study investigators commented, "Despite continued growth in the percentage of Americans receiving treatment for depression, it is likely that a substantial number of individuals with depression remain untreated for their symptoms." The authors cited community prevalence estimates of 6.6% to 7.1% for past-year major depression among adults and noted that these estimates are higher than the estimated 2007 prevalence of treated adult depression (2.59% to 4.95%) derived from the Medical Expenditure Panel Survey (MEPS). Historically, untreated mood disorders are more common in older than younger males, African Americans than whites, and males than females. The substantial increases in outpatient treatment of depression among older adults, African Americans, and males, among others seen in this study, are encouraging.
National expenditures for the outpatient treatment of depression increased from $10.05 billion (1998) to $12.45 billion (2007), in constant dollars (1998 dollars inflated to 2007 dollars using the medical component of the CPI). Nearly 37% of the 2007 expenditures came from Medicare, Medicaid, or another public source. There were marked increases in Medicare expenditures for overall outpatient depression care and, notably, for antidepressant medications, reflecting in part the implementation of the Medicare Part D drug benefit.
During the course of both survey years, approximately 75% of patients who received treatment for depression were prescribed an antidepressant. Further comparison revealed a decrease in the percentage of individuals who received selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants and an increase in the percentage of those given newer antidepressants. The authors remarked that while differences in efficacy among these classes of antidepressants have not been consistently found, SSRIs and other newer antidepressants seem to be better tolerated. They also speculate that recent prescribing practices may be due, in part, to pharmaceutical marketing strategies.
Fewer people underwent psychotherapy for their depression in 2007 than in 1998. An analysis of whether or not this trend away from psychotherapy reflected patient preferences or health-system factors fell outside the scope of this study.
Combination treatment of depression that incorporates both antidepressants and psychotherapy is associated with better outcomes when compared with medication alone. Several demographic groups treated for depression, especially Medicare beneficiaries and adults with fewer than 12 years of education, became significantly less likely to receive both psychotherapy and antidepressant medication during the study period. The authors of this report raised a note of caution regarding the decline in recent years in the probability of certain demographic groups to receive combined treatment.
Findings of this study, conducted by mental health experts at the Center for Education and Research on Mental Health at Rutgers, came from analyses of the household data component of the 1998 (n = 22,953) and 2007 (n = 29,370) MEPS. The surveys and this study were sponsored by the Agency for Healthcare Research and Quality.
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