The costs of depression Kessler, Ronald C
The Psychiatric clinics of North America,
03/2012, Letnik:
35, Številka:
1
Journal Article
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The data reported herein show clearly that major depression is a commonly occurring and burdensome disorder. The high prevalence, early age of onset, and high persistence of MDD in the many different ...countries where epidemiologic surveys have been administered confirm the high worldwide importance of depression. Although evidence is not definitive that MDD plays a causal role in its associations with the many adverse outcomes reviewed here, there is clear evidence that depression has causal effects on a number of important mediators, making it difficult to assume anything other than that depression has strong causal effects on many dimensions of burden. These results have been used to argue for the likely cost -effectiveness of expanded depression treatment from a societal perspective. Two separate, large-scale, randomized, workplace depression treatment effectiveness trials have been carried out in the United States to evaluate the cost effectiveness of expanded treatment from an employer perspective. Both trials had positive returns on investment to employers. A substantial expansion of worksite depression care management programs has occurred in the United States subsequent to the publication of these trials. However, the proportion of people with depression who receive treatment remains low in the United States and even lower in other parts of the world. A recent US study found that only about half of workers with MDD received treatment in the year of interview and that fewer than half of treated workers received treatment consistent with published treatment guidelines. Although the treatment rate was higher for more severe cases, even some with severe MDD often failed to receive treatment. The WMH surveys show that treatment rates are even lower in many other developed countries and consistently much lower in developing countries. Less information is available on rates of depression treatment among patients with chronic physical disorders, but available evidence suggests that expanded treatment could be of considerable value. Randomized, controlled trials are needed to expand our understanding of the effects of detection and treatment of depression among people in treatment for chronic physical disorders. In addition, controlled effectiveness trials with long-term follow-ups are needed to increase our understanding of the effects of early MDD treatment interventions on changes in life course role trajectories, role performance, and onset of secondary physical disorders.
Epidemiological data are reviewed on the prevalence, course, socio-demographic correlates, and societal costs of major depression throughout the world. Major depression is estimated in these surveys ...to be a commonly occurring disorder. Although estimates of lifetime prevalence and course vary substantially across countries for reasons that could involve both substantive and methodological processes, the cross-national data are clear in documenting meaningful lifetime prevalence with wide variation in age-of-onset and high risk of lifelong chronic-recurrent persistence. A number of sociodemographic correlates of major depression are found consistently across countries, and cross-national data also document associations with numerous adverse outcomes, including difficulties in role transitions (e.g., low education, high teen childbearing, marital disruption, unstable employment), reduced role functioning (e.g., low marital quality, low work performance, low earnings), elevated risk of onset, persistence and severity of a wide range of secondary disorders, and increased risk of early mortality due to physical disorders and suicide.
To review progress developing clinical decision support tools for personalized treatment of major depressive disorder (MDD).
Over the years, a variety of individual indicators ranging from biomarkers ...to clinical observations and self-report scales have been used to predict various aspects of differential MDD treatment response. Most of this work focused on predicting remission either with antidepressant medications versus psychotherapy, some antidepressant medications versus others, some psychotherapies versus others, and combination therapies versus monotherapies. However, to date, none of the individual predictors in these studies has been strong enough to guide optimal treatment selection for most patients. Interest consequently turned to decision support tools made up of multiple predictors, but the development of such tools has been hampered by small study sample sizes. Design recommendations are made here for future studies to address this problem.
Recommendations include using large prospective observational studies followed by pragmatic trials rather than smaller, expensive controlled treatment trials for preliminary development of decision support tools; basing these tools on comprehensive batteries of inexpensive self-report and clinical predictors (e.g., self-administered performance-based neurocognitive tests) versus expensive biomarkers; and reserving biomarker assessments for targeted studies of patients not well classified by inexpensive predictor batteries.
Clinical trials have identified numerous prescriptive predictors of mental disorder treatment response, ie, predictors of which treatments are best for which patients. However, none of these ...prescriptive predictors is strong enough alone to guide precision treatment planning. This has prompted growing interest in developing precision treatment rules (PTRs) that combine information across multiple prescriptive predictors, but this work has been much less successful in psychiatry than some other areas of medicine. Study designs and analysis schemes used in research on PTR development in other areas of medicine are reviewed, key challenges for implementing similar studies of mental disorders are highlighted, and recent methodological advances to address these challenges are described here.
Discovering prescriptive predictors requires large samples. Three approaches have been used in other areas of medicine to do this: conduct very large randomized clinical trials, pool individual-level results across multiple smaller randomized clinical trials, and develop preliminary PTRs in large observational treatment samples that are then tested in smaller randomized clinical trials. The third approach is most feasible for research on mental disorders. This approach requires working with large real-world observational electronic health record databases; carefully selecting samples to emulate trials; extracting information about prescriptive predictors from electronic health records along with other inexpensive data augmentation strategies; estimating preliminary PTRs in the observational data using appropriate methods; implementing pragmatic trials to validate the preliminary PTRs; and iterating between subsequent observational studies and quality improvement pragmatic trials to refine and expand the PTRs. New statistical methods exist to address the methodological challenges of implementing this approach.
Advances in pragmatic precision psychiatry will require moving beyond the current focus on randomized clinical trials and adopting an iterative discovery-confirmation process that integrates observational and experimental studies in real-world clinical populations.
Mental health problems in college and their associations with academic performance are not well understood. The main aim of this study was to investigate to what extent mental health problems are ...associated with academic functioning.
As part of the World Mental Health Surveys International College Student project, 12-month mental health problems among freshmen (N = 4921) was assessed in an e-survey of students at KU Leuven University in Leuven, Belgium. The associations of mental health problems with academic functioning (expressed in terms of academic year percentage or AYP and grade point average GPA) were examined across academic departments.
Approximately one in three freshman reports mental health problems in the past year, with internalizing and externalizing problems both associated with reduced academic functioning (2.9–4.7% AYP reduction, corresponding to 0.2–0.3 GPA reduction). The association of externalizing problems with individual-level academic functioning was significantly higher in academic departments with comparatively low average academic functioning.
Limited sample size precluded further investigation of interactions between department-level and student-level variables. No information was available on freshman secondary school academic performance.
Mental health problems are common in college freshman, and clearly associated with lower academic functioning. Additional research is needed to examine the potentially causal nature of this association, and, if so, whether interventions aimed at treating mental health problems might improve academic performance.
•Approximately one in three freshman reports mental health problems in the past year.•12 month internalizing and externalizing mental health problems are associated with a decrease of 2.9–4.7% in AYP (or 0.2–0.3 GPA) in college.•This decrease in AYP is negatively correlated with departmental performance.
According to current classification systems, patients with major depressive disorder (MDD) may have very different combinations of symptoms. This symptomatic diversity hinders the progress of ...research into the causal mechanisms and treatment allocation. Theoretically founded subtypes of depression such as atypical, psychotic, and melancholic depression have limited clinical applicability. Data-driven analyses of symptom dimensions or subtypes of depression are scarce. In this systematic review, we examine the evidence for the existence of data-driven symptomatic subtypes of depression.
We undertook a systematic literature search of MEDLINE, PsycINFO and Embase in May 2012. We included studies analyzing the depression criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) of adults with MDD in latent variable analyses.
In total, 1176 articles were retrieved, of which 20 satisfied the inclusion criteria. These reports described a total of 34 latent variable analyses: 6 confirmatory factor analyses, 6 exploratory factor analyses, 12 principal component analyses, and 10 latent class analyses. The latent class techniques distinguished 2 to 5 classes, which mainly reflected subgroups with different overall severity: 62 of 71 significant differences on symptom level were congruent with a latent class solution reflecting severity. The latent class techniques did not consistently identify specific symptom clusters. Latent factor techniques mostly found a factor explaining the variance in the symptoms depressed mood and interest loss (11 of 13 analyses), often complemented by psychomotor retardation or fatigue (8 of 11 analyses). However, differences in found factors and classes were substantial.
The studies performed to date do not provide conclusive evidence for the existence of depressive symptom dimensions or symptomatic subtypes. The wide diversity of identified factors and classes might result either from the absence of patterns to be found, or from the theoretical and modeling choices preceding analysis.
...depression is a heterogeneous entity experienced with various combinations of signs and symptoms, severity levels, and longitudinal trajectories. ...core features of the condition have been ...described over thousands of years, long before the advent of contemporary classifications, and in diverse communities and cultures. More efficient prevention of depression is likely to have powerful impacts on the Sustainable Development Goals for a country and the health of individuals and families. 5 The experiences of depression and recovery are unique for each individual Depression is the result of a set of factors, typically the interaction of proximal adversities with genetic, social, environmental, and developmental risk and resilience factors. Empowering individuals, families, and communities to work with professionals who can learn from their experiences and help demand the implementation of known preventive and therapeutic strategies and to hold health-care systems and decision makers accountable is vital. 7 A formulation is needed to personalise care Detection and diagnosis of depression on the basis of symptoms, function, and duration should be accompanied by a clinical review or formulation for each person, which takes into account individual values and preferences, life stories, and circumstances.
The economic burden of depression in the United States--including major depressive disorder (MDD), bipolar disorder, and dysthymia--was estimated at $83.1 billion in 2000. We update these findings ...using recent data, focusing on MDD alone and accounting for comorbid physical and psychiatric disorders.
Using national survey (DSM-IV criteria) and administrative claims data (ICD-9 codes), we estimate the incremental economic burden of individuals with MDD as well as the share of these costs attributable to MDD, with attention to any changes that occurred between 2005 and 2010.
The incremental economic burden of individuals with MDD increased by 21.5% (from $173.2 billion to $210.5 billion, inflation-adjusted dollars). The composition of these costs remained stable, with approximately 45% attributable to direct costs, 5% to suicide-related costs, and 50% to workplace costs. Only 38% of the total costs were due to MDD itself as opposed to comorbid conditions.
Comorbid conditions account for the largest portion of the growing economic burden of MDD. Future research should analyze further these comorbidities as well as the relative importance of factors contributing to that growing burden. These include population growth, increase in MDD prevalence, increase in treatment cost per individual with MDD, changes in employment and treatment rates, as well as changes in the composition and quality of MDD treatment services.
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