Economic Incentives Increase Access to Depression Care

Employer-based health insurance is the major means by which we pay for health care in America.

For years APA has been a leader, through its Business Initiative and the American Psychiatric Foundation's Partnership for Workplace Mental Health, in working with employers to alert them to the morbidity associated with untreated mental illness in the workplace, particularly depression.

The economic losses associated with absenteeism and with reduced productivity of depressed employees have led many employers to advocate for better insurance coverage and incentives for the treatment of depression. Based in part on pressure from employers, the Aetna Company, one of the world's largest insurance companies, has decided to pay increased fees for primary care physicians to screen patients for depression and to provide follow-up care for patients who are then started on anti-depressant medications.

In this program, severely depressed patients may be referred by the primary care physician to a psychiatrist for care. The depression screening involves a written test and the Patient Health Questionnaire (PHQ-9), which was developed at Columbia University and tested in a variety of settings. Physicians participating in the Aetna program are in six states and will be paid 30 percent to 40 percent more for a routine visit when the depression screening questionnaire is used.

Since family physicians and other primary care doctors write an estimated two-thirds of prescriptions for antidepressants in the United States and are often the gate-keepers for referral to psychiatrists and mental health professionals, this Aetna program, which will be carefully evaluated, is an important breakthrough in providing financial support for depression treatment. With nearly half of lost productivity in the United States attributed to major depression, with an estimated cost of $44 billion annually, this Aetna program will be carefully reviewed by other major payers, HMOs, and employer groups, as well as professional organizations such as APA. (To learn more about how APA is working to improve quality by working with the business community, see Viewpoints column by Norman Clemens, M.D., on page 20).

Of course, any such study of treatment costs or savings cannot lose sight of the key concern, which is making sure that each patient gets the depression treatment that is best for him or her. Antidepressants are often seen as the first-line treatment, as they are in the Aetna program. However, many well-designed studies show that psychotherapy, especially cognitive-behavioral therapy, is also beneficial for patients with depression and that cognitive therapy is as effective as antidepressant medication for milder depression. A study by Robert DeRubeis, Ph.D., and colleagues in the April 4, 2005, Archives of General Psychiatry showed that cognitive therapy can be as effective as medication for initial treatment of moderate to severe depression, although cognitive therapy requires a high level of therapist expertise.

The APA practice guideline for treatment of depression emphasizes that the choice of treatment depends on patient preference and the specialized skills of clinicians. The presence of significant psychosocial stressors, intrapsychic conflict, interpersonal difficulties, or comorbid Axis II conditions indicate a need for psychotherapy as well as medication treatment.

Why are economic incentives encouraging depression treatment so important? We know that, depending on the study, only between 5 percent and 40 percent of depressed patients seen in primary care receive appropriate treatment and follow-up. In the U.S. comorbidity study, only one-third of people with depression received any care at all. According to burden-of-illness studies, by 2020 depression will be the leading cause of disability worldwide.

APA is working to improve the quality of depression treatment across health care settings through projects such as the National Depression Management Leadership Initiative of the American Psychiatric Institute for Research and Education—a collaboration between APA, the American Academy of Family Physicians, and the American College of Physicians—to increase the availability and quality of depression care through standardized use of the PHQ-9 (Psychiatric News, June 3, 2005).

Other efforts include the APA Business Initiative's partnership with the Kansas City employer coalition on the Community Initiative on Depression, which leveraged the business community to address care for depression delivered not only in primary care settings, but oncology and cardiology as well (Psychiatric News, May 6, 2005).

The Aetna program is a leader in turning a spotlight on effective and early diagnosis and treatment for this major medical/psychiatric condition. You can be sure that APA will study the results of this initiative with great interest. ▪