By Marilynn Larkin
NEW YORK—U.S. efforts to increase insurance coverage for depression have resulted in a "modest" increase in treatment, but barriers remain, researchers say.
"The increase in psychotherapy for depression since 2007 is a promising sign and may reflect both the passage of mental health parity and evolving attitudes towards treatment of depression," Dr. Benjamin Druss of Emory University in Atlanta told Reuters Health by email. "However, these treatment rates may plateau unless we are able to expand the mental health workforce who can effectively deliver them, particularly those who accept Medicaid."
Dr. Druss and colleagues analyzed use of health services and spending for depression treatment in the US using Medical Expenditure Panel Surveys (MEPS) data from 1998, 2007 and 2015. Overall, data were obtained for more than 86,000 individuals with a mean age of 37; about half were women and a majority (73%) were white.
As reported online April 24 in JAMA Psychiatry, rates of outpatient depression treatment rose from 2.36 per 100 population in 1998 to 3.47 in 2015. The proportion of those treated with psychotherapy dropped from 53.7% in 1998 to 43.2% in 2007 and then increased to 50.4% in 2015. By contrast, the proportion receiving pharmacotherapy remained steady at around 81.9% at all three time points.
The relative growth in treated prevalence was 21.8% from 1998 to 2007 and 20.6% from 2007 to 2015. However, "marked departures" from the general increase occurred in various age groups. From 1998 to 2007, the prevalence among 50 to 64 year olds increased from 3.50 per 100 population to 4.95 (relative increase, 41.7%); among those 65 and older, the relative increase was 50.5%, from 2.17 per 100 to 3.28.
By contrast, during the same period, the treated prevalence among those under 18 decreased slightly, while treatment among those ages 18-34 increased slightly.
The pattern reversed from 2007 to 2015: treatment prevalence rose 10.6% among those ages 50 to 64, but by only 3.1% in those 65 and older. By contrast, a 64.9% increase was seen in those under age 18, and a 46.8% increase among those ages 18-34.
After adjustment for inflation using 2015 US dollars, prescription expenditures for depression treatment decreased from $848 per person per year in 1998 to $603 per year in 2015, and the mean number of prescriptions decreased from 7.64 in 1998 to 7.03 in 2015.
National expenditures for outpatient treatment of depression increased from $12,430,000 in 1997 to $15,554,000 in 2007 and to $17,404,000 in 2015. By contrast, the percentage coming from self-pay (uninsured) individuals decreased from 32% in 1998 to 29% in 2007, and to 20% in 2015. The decrease was associated primarily with increasing Medicaid coverage, according to the authors, because the percentage of this spending covered was 19% in 1998, 15% in 2007, and 36% in 2015.
"Taking our findings in the context of other literature suggesting that major depression may still be undertreated, reducing financial barriers alone may not address the treatment gap," lead author Dr. Jason Hockenberry, also of Emory University, said in an email to Reuters Health. "For so long the focus has been on financial barriers as a major driver of the treatment gap, we need to consider other drivers that are potentially at work in strong ways."
Dr. Ravi Shah, Assistant Professor of Psychiatry and Medical Director, Psychiatry Faculty Practice Organization at Columbia University Irving Medical Center in New York City, who was not involved in the study, commented, "The bottom line is that depression treatment is improving significantly, and we still have a long way to go."
"Mental health awareness has dramatically increased over the last 10 years," he told Reuters Health by email. Like Dr. Druss, he noted, "This is in part due to changing laws (mental health parity, Medicaid expansion with the Affordable Care Act, etc)...(and) in part to dramatically decreased stigma and increased awareness around mental health."
"Most importantly, people seem to more readily and openly accept the notion that mental health treatment is beneficial," he said. "I think that in part explains why you see people age 50-64 with a 10% increase in depression treatment, <18-34 with a 48% increase in depression treatment, and <18 years with a 65% increase in depression treatment. The younger people were most affected by these large trends."
"Psychotherapy is back on the rise but remains around 50% of depression treatment compared to 80% for medications," he noted. "I think this has to do with the cost, not just in dollars, but in time and mental effort, required to participate meaningfully in psychotherapy."
"I do not think it is readily obvious to most clinicians how much more common medication use for depression is than psychotherapy," he added. "This is important information to consider as we think about how to best design mental health services that people want and need."
The study was supported in part by the Commonwealth Fund.
JAMA Psychiatry 2019.
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