Improving Depression Treatment by Integrated Care

OBJECTIVE
To identify the clinical and economic implications of depression in the workplace and review how integrated care models can improve overall patient outcomes.


SUMMARY
Depression is a significant financial burden to the employer due to lost days of work and decreased productivity. Employers are demanding return on the investment for their increasing health care expenditures. The cost of depression to employers may be contained by delivering care using integrated models that leverage primary care provider treatment with care management and mental health consultation.


CONCLUSION
There is a need to reduce silos in the organization and financing of mental health care to prevent cost shifting that provides no benefit to patients, payers or providers. Poor mental health care will likely lead to a rise in absenteeism and presenteeism.

I n order to understand how we can improve the treatment of d e p ression, it is useful to assess the problem from diff e re n t perspectives. We know much about the impact of depre s s i o n and its treatment from the patient and provider perspectives, but we rarely consider the ramifications of the disease on the purc h a s e r. P u rchasers have considerably more leverage than they curre n t l y e x e rt in the quality of care health systems deliver. In part i c u l a r, p u rchasers may be able to encourage health systems to pro v i d e better quality care by advocating for the adoption of integrated c a re models that are emerging for the treatment of depression and other chronic diseases. Before purchasers can advocate for these models, they must have evidence of the clinical and economic value these models pro d u c e .

■ ■ Depression in the Workplace
The private employer insures about 60% of Americans and is a major purchaser of health care for most working Americans. 1 Because 1 out of every 10 Americans suffer from depression annua l l y, the likelihood of a coworker being affected by depression in the workplace is high. 2 In fact, absenteeism from depression is estimated to be about 1.6 days of work lost per employee per month which is equivalent to about 1,500 lost days per month for a company with 1,000 employees. 3 Absenteeism results in i n c reased workload for other employees, reduced output, and lost income from hiring temporary workers.
In addition, reduced productivity at work, or "presenteeism," is a significant but underrecognized concern for employers. It has been re p o rted that employees who suffer from depression work at about 70% of their optimal pro d u c t i v i t y. 4 -7 Also, 62% of employees re p o rt decreased mental functioning that ultimately affects their output and time management.
In 2000, depression cost employers an estimated $51.5 billion. 8 A p p roximately 70% of that cost was due to absenteeism while the rest was attributed to productivity loss. This is a significant financial p roblem for employers, who are already paying $26.1 billion for d e p ression tre a t m e n t . 8 Employers are faced with a complex i s s u e -i n c reased numbers of employees being diagnosed with d e p ression, increased rates of treatment for depression, and i n c reases in pharmaceutical costs. Employers are seeking newer and better solutions to this problem, ones that can demonstrate s u fficient re t u rn on investment to warrant adoption.

■■ Integrated Care Models
T h e re are a number of potential solutions to improve the clinical and economic outcomes of depression treatment. Integrated care models that are currently available focus on 3 aspects of care that a re essential for the treatment of depression. The first step, using a screening tool, is to identify patients who may have depre s s i o n . As we know, the majority of patients who receive treatment for d e p ression do so from their primary care physician (PCP). 9 T h e I m p r oving Depression Treatment by Integrated Care

A B S T R AC T
OBJECTIVE: To identify the clinical and economic implications of depression in the workplace and review how integrated care models can improve overall patient outcomes.
SUMMARY: Depression is a significant financial burden to the employer due to lost days of work and decreased productivity. Employers are demanding return on the investment for their increasing health care expenditures. The cost of depression to employers may be contained by delivering care using integrated models that leverage primary care provider treatment with care management and mental health consultation.
CONCLUSION: There is a need to reduce silos in the organization and financing of mental health care to prevent cost shifting that provides no benefit to patients, payers or providers. Poor mental health care will likely lead to a rise in absenteeism and presenteeism.
reason may be partly because managed care organizations are shifting the burden of depression and anxiety treatment away fro m mental health specialists to PCPs. 1 0 In addition, to reduce cost, many managed behavioral health care organizations limit the number of specialty care visits a depressed patient can make. 1 1 , 1 2 Even in short PCP visits, simple screening tools for depression can aid the PCP in recognizing patients who may be at risk for d e p ression or have clinically definable disease.
In our initial program designed 10 years ago, trained nurses identified patients with depression and provided care management to them over 2 years using a decision-tree care plan ( Figure 1). Nurses assessed disease severity, educated patients about tre a t m e n t options, and monitored their pro g ress over time. In today' s models, c a re managers are also supervised by either a psychiatrist or a p h a rmacist.
While pharmacists can provide patient education and m o n i t o r i n g , they also have unique expertise in providing a l t e rnatives for drugs that are intolerable or clinically ineffective. In the future, utilization of pharmacists may be the most costeffective solution for managing patients with complex medication regimens in the managed care setting. In addition, the shortage of psychiatrists may significantly increase the demand for advanced p h a rmacy practitioners to fill these care management needs.

Impact of Model
Integrated care models will in all likelihood increase the number of patients who are identified with depression and begin tre a tment. It has been estimated that 50% of all depressed patients in the primary care setting remain undiagnosed. 1 3 In addition, the education integrated care models provide will result in gre a t e r patient understanding about the importance of treatment completion, which will, in turn, curb early discontinuation rates. M o re frequent contacts with care managers along with counseling about medication side effects should result in increased compliance. Patients frequently list intolerable side effects as the p r i m a ry reason for discontinuing their treatment pre m a t u re l y.
A national survey found that, in patients with probable anxiety or depressive disord e r, only about 30% received some form of a p p ropriate tre a t m e n t . 1 4 Although identification of patients is an i m p o rtant first step, the field also needs to improve the tre a t m e n t patients receive once they are identified. The process of ensuring that patients actually fill a prescription and then take the medication a p p ropriately is complex, and we must find ways to bridge gaps in the process. Even after patients initiate therapy, there is still ro o m for potential complications. Care managers can facilitate appro p r i a t e medication switches and encourage patients to continue tre a t m e n t when the initial medication fails. They can also re c o m m e n d

Outcomes Data
We evaluated the clinical and economic outcomes of an integrated c a re model to demonstrate its value to potential purchasers. Over 2 years, about 74% of patients who received our intervention were in probable remission compared with only 40% of patients who received usual care. In addition to improving emotional role functioning to close to population norms, the model had a s i g n i f i c a n t but smaller impact on physical functioning, possibly due to medical comorbidities commonly associated with depre s s i o n . The cost of the program is $130 per year with an additional $134 per year for incremental treatment. Accounting for inflation for year 2005, the total cost of the model was estimated to be $297 per year per treated depressed employee. We recognized that patients improved clinically, but what other benefits accrued and to whom? Over 2 years, the intervention decreased the number of hours of work lost in the previous month from ~20 hours to 4 hours, resulting in an average reduction of 12.3 days of absenteeism, with an annual value of $648 per participating employee (Figure 2). Over 2 years, the intervention also improved productivity at work in the previous 2 weeks, resulting in an average increase of 8.2%, with an annual value of $1,982 per participating employee ( Figure 3).
It is possible for employers to calculate their re t u rn on investment for their depression care program based on a business case model that I have developed. The re t u rn on investment is dependent upon the ratio of annual savings with quality depre s s i o n c a re to the cost of the depression care program and the additional t reatment it stimulates. Return on investment is dependent upon various factors such as hourly wage, sick leave benefit, likelihood of increased revenue with increased pro d u c t i v i t y, likelihood of hiring temps to cover absent employees, the company's contribution to health plan premium, and the prevalence of depre s s i o n in the specific employee population. The re t u rn on investment calculation can be done for any company, health plan, or institution and is available at h t t p : / / w w w. d e p re s s i o n -p r i m a ry c a re . o rg / o rganizations/employers/ c a l c u l a t o r.

■ ■ Conclusion
Primary care providers are faced with a difficult task of a d d ressing a variety of health issues during every visit. Integrated care models such as the one presented here can be the part of the solution to optimize clinical and economic outcomes in the primary care treatment of depression.

ACKNOWLEDGMENTS
The author wishes to acknowledge Mark Schwartz, MBA, for his work on the model for this study. She also acknowledges the physicians, office staff, and patients of the following participating primary care practices:

DISCLOSURES
Funding for this study was contributed by the National Institute of Mental Health and the MacArthur Initiative on Depression and Primary Care and obtained by the author. The author received an honorarium for participating in the symposium upon which this article is based. She discloses that she has received grant/research support from NIMH, the MacArthur Foundation, and the Robert Wood Johnson Foundation.

Improving Depression Treatment by Integrated Care
Intervention Effects on Absenteeism Intervention Effects on Productivity