Organized treatment programs for depression in primary care have been proven effective across a wide range of patient populations and health care systems, according to background information in the article. "Broad implementation of improved depression care programs will depend on the balance of benefits and added costs," the authors write. "Depression has large economic effects outside the health care system, including disability, lost work productivity, reduced educational attainment and relationship disruption. Ideally, decisions about the value of depression care programs should consider these broader economic effects."
Gregory E. Simon, M.D., M.P.H., and colleagues at Group Health Research Institute, Seattle, conducted a randomized trial comparing two depression care programs with continued usual care. Between November 2000 and June 2004, 600 primary care patients at seven primary care clinics within one prepaid health care plan were assigned to one of three groups. A group of 207 was assigned to telephone care management, which involved up to five outreach calls for monitoring, support, feedback and care coordination; 198 were assigned to telephone care management plus psychotherapy, which added on eight sessions of structured cognitive behavioral therapy over the phone with up to four additional reinforcement calls; and 195 were assigned to usual care.
Telephone assessments were conducted periodically over 24 months, and costs were measured using health plan accounting records. Over the 24-month study, the telephone care management program led to an average gain of 29 depression-free days and a $676 increase in outpatient health care costs compared with usual care. Care management plus psychotherapy led to a gain of 46 depression-free days at a cost of $397.
"Willingness to pay for time free of depression is a simple (albeit far from perfect) method for summarizing various economic benefits of improved depression care," the authors write. "Our previous research suggests that primary care patients treated for depression are on average willing to pay approximately $10 (in 2000 U.S. dollars) for an additional day free of depression." In the current study, telephone care management alone had a negative net benefit even if the cost of a depression-free day was placed at $20; however, the telephone care management plus psychotherapy program delivered a positive benefit if a depression-free day was valued at $9 or more.
"The primary goal of depression treatment is to relieve suffering and improve function, not to decrease health care costs. We certainly do not intend to imply that depression treatment is justified only if it is either cost neutral or cost saving. Our findings do, however, offer some guidance to insurers or health care systems considering efforts to improve care for depression," the authors conclude. "The balance of added benefits and added costs was more favorable for the more intensive program. Efforts to improve depression treatment in primary care should consider incorporating structured psychotherapy interventions."