Economic Grand Rounds: Financial Burden of Medical Care and Risk of Forgoing Care Among Europeans With Depressive Symptoms

Depression disorders, one of the major causes of disability-adjusted life years (DALY) ( 1 ), have been shown to be underdiagnosed and undertreated and are associated with worse physical health ( 2 ), increased health care utilization ( 3 ), increased medical costs ( 4 ), and high out-of-pocket expenditures ( 5 ). Despite the fact that a high financial burden may prevent access to health care, little is known about the financial burden of people with depressive symptoms. This is of particular importance because health care professionals rarely discuss costs issues with their patients ( 6 ) and because high health care costs may represent a barrier to treatment compliance ( 7 ). In this study, we sought to examine the associations between the presence or absence of depressive symptoms and an individual's financial burden, as well as whether the person forwent care because of costs they would have to pay.

We used baseline (2004) self-reported data from the Survey of Health, Ageing, and Retirement in Europe (SHARE) ( 8 ), which included noninstitutionalized individuals 50 years or older. Methodological details of SHARE have been published previously ( 9 ). The analytic sample consisted of 16,696 individuals ages 50–79 years. Out-of-pocket payments ("About how much did you pay for all your outpatient care/prescribed drugs, during the last 12 months?") did not include health insurance premiums and reimbursements from employers ( 10 ). In order to gather data on the financial burden of out-of-pocket medical expenses, we expressed out-of-pocket expenditures as a percentage of household income. We also analyzed whether individuals forwent medical care because of costs during the past 12 months ("During the last 12 months, did you forgo any types of care because of the costs you would have to pay?"). The presence or absence of clinically significant depressive symptoms was defined by a score <3 on the European Depression (EURO-D) scale, a validated 12-item instrument ( 11 ). Possible scores on this scale range from 0 to 12, with higher scores indicating increased severity of depressive symptoms. We performed logistic regressions adjusting for age, gender, marital status, education, subjective health, and chronic diseases.

The overall prevalence of depressive symptoms was 26%. Countries' prevalence varied between a low of 17%–18% in Denmark, Austria, and Switzerland and a high of 31%–35% in Italy and Spain.

The data on out-of-pocket medical expenses as a percentage of household income across the two groups show that individuals with depressive symptoms were significantly more likely than those without such symptoms to have out-of-pocket expenses ≥1% of their income ( Table 1 ). The presence of depressive symptoms also tripled the proportion of people who forwent health care because of costs (9.8% for persons with depression, and 3.1% for those without depression ( Table 1 ). The crude odds of spending ≥1% of income for outpatient care and prescribed drugs were 32% (odds ratio [OR]=1.3, 95% confidence interval [CI]=1.2–1.5) and 15% (OR=1.2, 95% CI–1.1–1.4) higher, respectively, for people with depressive symptoms, compared with those without such symptoms ( Table 1 ). However, these associations did not remain significant after adjustment for potential confounders ( Table 1 ). Having depressive symptoms increased the risk of forgoing medical care because of costs, even after adjustment for confounding variables (adjusted OR=2.4, 95% CI=1.8–3.0) in all countries except Sweden. Country-level ORs ranged from 1.9 in Germany (95% CI=1.1–3.1) to 4.1 in Greece (95% CI=2.4–6.8).