CONTEXT: Evidence consistently indicates that depression has adversely affected work productivity. Estimates of the cost impact in lost labor time in the US workforce, however, are scarce and dated.
OBJECTIVE: To estimate the impact of depression on labor costs (i.e., work absence and reduced performance while at work) in the US workforce.
DESIGN, SETTING, and PARTICIPANTS: All employed individuals who participated in the American Productivity Audit (conducted August 1, 2001–July 31, 2002) between May 20 and July 11, 2002, were eligible for the Depressive Disorders Study. Those who responded affirmatively to two depression-screening questions (n=692) as well as a 1:4 stratified random sample of those responding in the negative (n=435), were recruited for and completed a supplemental interview using the Primary Care Evaluation of Mental Disorders Mood Module for depression, the Somatic Symptom Inventory, and a medical and treatment history for depression. Excess lost productive time (LPT) costs from depression were derived as the difference in LPT among individuals with depression minus the expected LPT in the absence of depression projected to the US workforce.
MAIN OUTCOME MEASURE: Estimated LPT and associated labor costs (work absence and reduced performance while at work) due to depression.
RESULTS: Workers with depression reported significantly more total health-related LPT than those without depression (mean, 5.6 h/wk vs. an expected 1.5 h/wk, respectively). Eighty-one percent of the LPT costs are explained by reduced performance while at work. Major depression accounts for 48% of the LPT among those with depression, again with a majority of the cost explained by reduced performance while at work. Self-reported use of antidepressants in the previous 12 months among those with depression was low ( 30%) and the mean reported treatment effectiveness was only moderate. Extrapolation of these survey results and self-reported annual incomes to the population of US workers suggests that US workers with depression employed in the previous week cost employers an estimated $44 billion per year in LPT, an excess of $31 billion per year compared with peers without depression. This estimate does not include labor costs associated with short- and long-term disability.
CONCLUSIONS: A majority of the LPT costs that employers face from employee depression is invisible and explained by reduced performance while at work. Use of treatments for depression appears to be relatively low. The combined LPT burden among those with depression and the low level of treatment suggests that there may be cost-effective opportunities for improving depression-related outcomes in the US workforce.

CONTEXT: Uncertainties exist about prevalence and correlates of major depressive disorder (MDD).
OBJECTIVE: To present nationally representative data on prevalence and correlates of MDD by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM- IV) criteria, and on study patterns and correlates of treatment and treatment adequacy from the recently completed National Comorbidity Survey Replication (NCS-R).
DESIGN: Face-to-face household survey conducted from February 2001 to December 2002.
SETTING: The 48 contiguous United States.
PARTICIPANTS: Household residents ages 18 years or older (N=9090) who responded to the NCS-R survey.
MAIN OUTCOME MEASURES: Prevalence and correlates of MDD using the World Health Organization’s (WHO) Composite International Diagnostic Interview (CIDI), 12-month severity with the Quick Inventory of Depressive Symptomatology Self- Report (QIDS-SR), the Sheehan Disability Scale (SDS), and the WHO disability assessment scale (WHO-DAS). Clinical reinterviews used the Structured Clinical Interview for DSM-IV.
RESULTS: The prevalence of CIDI MDD for lifetime was 16.2% (95%confidence interval [CI], 15.1-17.3) (32.6-35.1 million US adults) and for 12-month was 6.6% (95% CI, 5.9-7.3) (13.1-14.2 million US adults). Virtually all CIDI 12-month cases were independently classified as clinically significant using the QIDS-SR, with 10.4% mild, 38.6% moderate, 38.0% severe, and 12.9% very severe. Mean episode duration was 16 weeks (95% CI, 15.1-17.3). Role impairment as measured by SDS was substantial as indicated by 59.3% of 12-month cases with severe or very severe role impairment. Most lifetime (72.1%) and 12-month (78.5%) cases had comorbid CIDI/DSM-IV disorders, with MDD only rarely primary. Although 51.6% (95% CI, 46.1-57.2) of 12-month cases received health care treatment for MDD, treatment was adequate in only 41.9% (95% CI, 35.9- 47.9) of these cases, resulting in 21.7% (95% CI, 18.1-25.2) of 12-month MDD being adequately treated. Sociodemographic correlates of treatment were far less numerous than those of prevalence.
CONCLUSIONS: Major depressive disorder is a common disorder, widely distributed in the population, and usually associated with substantial symptom severity and role impairment. While the recent increase in treatment is encouraging, inadequate treatment is a serious concern. Emphasis on screening and expansion of treatment needs to be accompanied by a parallel emphasis on treatment quality improvement.

Employers who are developing strategies to reduce health-related productivity loss may benefit from aiming their interventions at the employees who need them most. We determined whether depression’s negative productivity impact varied with the type of work employees performed. Subjects (246 with depression and 143 controls) answered the Work Limitations Questionnaire and additional work questions. Occupational requirements were measured objectively. In multiple regression analyses, productivity was most influenced by depression severity (P < 0.01 in 5/5 models). However, certain occupations also significantly increased employee vulnerability to productivity loss. Losses increased when employees had occupations requiring proficiency in decision-making and communication and/or frequent customer contact (P < 0.05 in 3/5 models). The Work Limitations Questionnaire can help employers to reduce productivity loss by identifying health and productivity improvement priorities.

BACKGROUND: The prevalence of major depressive disorder (MDD) is highest in working age people and depression causes significant impairment in occupational functioning. Work productivity and work absence should be incorporated into clinical assessments but currently available scales may not be optimized for clinical use. This study seeks to validate the Lam Employment Absence and Productivity Scale (LEAPS), a 10-item self-report questionnaire that takes 3-5 minutes to complete.
METHODS: The study sample consisted of consecutive patients attending a Mood Disorders outpatient clinic who were in full- or part-time paid work. All patients met DSM-IV criteria for MDD and completed during their intake assessment the LEAPS, the self-rated version of the Quick Inventory for Depressive Symptomatology (QIDS-SR), the Sheehan Disability Scale (SDS) and the Health and Work Performance Questionnaire (HPQ). Standard psychometric analyses for validation were conducted.
RESULTS: A total of 234 patients with MDD completed the assessments. The LEAPS displayed excellent internal consistency as assessed by Cronbach's alpha of 0.89. External validity was assessed by comparing the LEAPS to the other clinical and work functioning scales. The LEAPS total score was significantly correlated with the SDS work disability score (r = 0.63, p < 0.01) and the Global Work Performance rating from the HPQ (r = -0.79, p < 0.01). The LEAPS total score also increased with greater depression severity.
CONCLUSION: The LEAPS displays good internal and external validity in a population of patients with MDD attending an outpatient clinic, which suggests that it may be a clinically useful tool to assess and monitor work functioning and productivity in depressed patients.

OBJECTIVES: The study tested an intervention aimed at improving work functioning among middle-aged and older adults with depression and work limitations.
METHODS: A randomized clinical trial allocated an initial sample of 431 eligible employed adults (age ≥45) to a work-focused intervention (WFI) or usual care. Inclusion criteria were depression as measured by the Patient Health Questionnaire–9 (PHQ-9) and at-work limitations indicated by a productivity loss score ≥5% on the Work Limitations Questionnaire (WLQ). Study sites included 19 employers and five related organizations. Telephone-based counseling provided three integrated modalities: care coordination, cognitive-behavioral therapy strategy development, and work coaching and modification. Effectiveness (change in productivity loss scores from preintervention to four months postintervention) was tested with mixed models adjusted for confounders. Secondary outcomes included change in WLQ work performance scales, self- reported absences, and depression.
RESULTS: Of 1,227 eligible employees (7% of screened), 431 (35%) enrolled and 380 completed the study (12% attrition). At-work productivity loss improved 44% in the WFI group versus 13% in usual care (difference in change, p<.001). WFI group scores on the four WLQ scales improved 44% to 47%, significantly better than in usual care (p<.001 for each scale). Absence days declined by 53% in the WFI group versus 13% in usual care (difference in change, p<.001). Mean PHQ-9 depression symptom severity scores declined 51% for WFI versus 26% for usual care (difference in change, p<.001).
CONCLUSIONS: The WFI was more effective than usual care at four-month follow-up. Given increasing efforts to provide more patient-centered, value-based care, the WFI could be an important resource.

BACKGROUND: The economic burden of depression was estimated to be $43.7 billion in 1990. A subsequent study reported a cost burden of $52.9 billion using revised prevalence data and a refined workplace cost estimation approach. The objective of the current report is to provide a 10-year update of these estimates using the same methodological framework.
METHOD: Using a human capital approach, we developed prevalence-based estimates of 3 major cost categories: (1) direct costs, (2) mortality costs arising from depression-related suicides, and (3) costs associated with depression in the workplace. Cost-of-illness estimates from 1990 were updated to reflect the experience in 2000 using current epidemiologic data and publicly available population, wage, and cost information.
RESULTS: Whereas the treatment rate of depression increased by over 50%, its economic burden rose by only 7%, going from $77.4 billion in 1990 (inflation-adjusted dollars) to $83.1 billion in 2000. Of the 2000 total, $26.1 billion (31%) were direct medical costs, $5.4 billion (7%) were suicide-related mortality costs, and $51.5 billion (62%) were workplace costs.
CONCLUSIONS: The economic burden of depression remained relatively stable between 1990 and 2000, despite a dramatic increase in the proportion of depression sufferers who received treatment. Future research will incorporate additional costs associated with depression sufferers, including the excess costs of their coexisting psychiatric and medical conditions and attention to the role of painful conditions as a driver of these costs.

BACKGROUND: The economic burden of depression was estimated to be $43.7 billion in 1990. A subsequent study reported a cost burden of $52.9 billion using revised prevalence data and a refined workplace cost estimation approach. The objective of the current report is to provide a 10-year update of these estimates using the same methodological framework.
METHOD: Using a human capital approach, we developed prevalence-based estimates of three major cost categories: (1) direct costs, (2) mortality costs arising from depression-related suicides, and (3) costs associated with depression in the workplace. Cost-of-illness estimates from 1990 were updated to reflect the experience in 2000 using current epidemiologic data and publicly available population, wage, and cost information.
RESULTS: Whereas the treatment rate of depression increased by over 50%, its economic burden rose by only 7%, going from $77.4 billion in 1990 (inflation-adjusted dollars) to $83.1 billion in 2000. Of the 2000 total, $26.1 billion (31%) were direct medical costs, $5.4 billion (7%) were suicide-related mortality costs, and $51.5 billion (62%) were workplace costs.
CONCLUSIONS: The economic burden of depression remained relatively stable between 1990 and 2000, despite a dramatic increase in the proportion of depression sufferers who received treatment. Future research will incorporate additional costs associated with depression sufferers, including the excess costs of their coexisting psychiatric and medical conditions and attention to the role of painful conditions as a driver of these costs.

BACKGROUND: Expanding access to high-quality depression treatment will depend on the balance of incremental benefits and costs. We examine the incremental cost-effectiveness of an organized depression management program for high utilizers of medical care.
METHODS: Computerized records at three health maintenance organizations were used to identify adult patients with outpatient medical visit rates above the 85th percentile for two consecutive years. A two-step screening process identified patients with current depressive disorders, who were not in active treatment. Eligible patients were randomly assigned to continued usual care (n = 189) or to an organized depression management program (n=218). The program included patient education, antidepressant pharmacotherapy initiated in primary care (when appropriate), systematic telephone monitoring of adherence and outcomes, and psychiatric consultation as needed. Clinical outcomes (assessed using the Hamilton Depression Rating Scale on four occasions throughout 12 months) were converted to measures of “depression-free days.” Health services utilization and costs were estimated using health plan–standardized claims.
RESULTS: The intervention program led t o an adjusted increase of 47.7 depression-free days throughout 12 months (95% confidence interval [CI], 28.2-67.8 days). Estimated cost increases were $1008 per year (95% CI, $534-$1383) for outpatient health services, $1974 per year for total health services costs (95% CI, $848- $3171), and $2475 for health services plus time-in-treatment costs (95% CI, $880-$4138). Including total health services and time-in-treatment costs, estimated incremental cost per depression-free day was $51.84 (95% CI, $17.37-$108.47).
CONCLUSIONS: Among high utilizers of medical care, systematic identification and treatment of depression produce significant and sustained improvements in clinical outcomes as well as significant increases in health services costs.

BACKGROUND: 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.
METHOD: 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.
RESULTS: 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.
CONCLUSIONS: 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.

CONTEXT: Depression is a leading cause of functional impairment in elderly individuals and is associated with high medical costs, but there are large gaps in quality of treatment in primary care.
OBJECTIVE: To determine the incremental cost-effectiveness of the Improving Mood Promoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression.
DESIGN: Randomized controlled trial with recruitment from July 1999 to August 2001.
SETTING: Eighteen primary care clinics from eight health care organizations in five states.
PARTICIPANTS: A total of 1801 patients 60 years or older with major depression (17%), dysthymic disorder (30%), or both (53%).
INTERVENTION: Patients were randomly assigned to the IMPACT intervention (n = 906) or to usual primary care (n = 895). Intervention patients were provided access to a depression care manager supervised by a psychiatrist and primary care physician. Depression care managers offered education, support of antidepressant medications prescribed in primary care, and problem-solving treatment in primary care (a brief psychotherapy).
MAIN OUTCOME MEASURES: Total outpatient costs, depression-free days, and quality-adjusted life-years.
RESULTS: Relative to usual care, intervention patients experienced 107 (95% confidence interval [CI], 86 to 128) more depression-free days over 24 months. Total out-patient costs were $295 (95% CI, −$525 to $1115) higher during this period. The incremental outpatient cost per depression-free day was $2.76 (95% CI, −$4.95 to $10.47) and incremental outpatient costs per quality-adjusted life year ranged from $2519 (95% CI, −$4517 to $9554) to $5037 (95% CI, −$9034 to $19 108). Results of a bootstrap analysis suggested a 25% probability that the IMPACT intervention was “dominant” (i.e., lower costs and greater effectiveness).
CONCLUSIONS: The IMPACT intervention is a high- value investment for older adults; it is associated with high clinical benefits at a low increment in health care costs.

CONTEXT: Although outreach and enhanced treatment interventions improve depression outcomes, uptake has been poor in part because purchasers lack information on their return on investment.
OBJECTIVE: To estimate the costs and benefits of enhanced depression care for workers from the societal and employer-purchaser perspectives.
DESIGN: Cost-effectiveness and cost-benefit analyses using state-transition Markov models. Simulated movements between health states were based on probabilities drawn from the clinical literature.
PARTICIPANTS: Hypothetical cohort of 40-year-old workers.
INTERVENTION: Enhanced depression care consisting of a depression screen and care management for those depressed vs. usual care.
MAIN OUTCOME MEASURES: Our base-case cost-effectiveness analysis was from the societal perspective; costs and quality-adjusted life-years were used to compute the incremental cost-effectiveness of the intervention relative to usual care. A secondary cost-benefit analysis from the employer’s perspective tracked monetary costs and monetary benefits accruing to employers during a 5-year time horizon.
RESULTS: From the societal perspective, screening and depression care management for workers result in an incremental cost-effectiveness ratio of $19,976 per quality- adjusted life-year relative to usual care. These results are consistent with recent primary care effectiveness trials and within the range for medical interventions usually covered by employer-sponsored insurance. From the employer’s perspective, enhanced depression care yields a net cumulative benefit of $2895 after 5 years. In one-way and probabilistic sensitivity analyses, these findings were robust to a variety of assumptions.
CONCLUSIONS: If these results can be replicated in effectiveness trials directly assessing effects on work outcomes, they suggest that enhanced treatment quality programs for depression are cost-beneficial to purchasers.

BACKGROUND: 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.
METHOD: 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.
RESULTS: 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.
CONCLUSIONS: 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.

OBJECTIVE: This study used the Medical Expenditures Panel Survey (MEPS) to estimate the cost of diabetes, depression, and comorbid diabetes and depression over 8 years.
METHODS: An 8-year pooled dataset was created using the household and medical provider components of MEPS. Medical expenditures were adjusted to a common 2014 dollar value. Analyses used responses of 147,095 individuals >=18 years of age for the years 2004–2011. The dependent variable in this study was total healthcare expenditure and the primary independent variables were diabetes and depression status. A two-part (probit/GLM) model was used to estimate the annual medical spending and marginal effects were calculated for incremental cost.
RESULTS: In the pooled sample, after adjusting for socio-demographic factors, comorbidities and time trend covariates, the incremental cost of depression only was $2654 (95% CI 2343–2966), diabetes was $2692 (95% CI 2338–3046), and both was $6037 (CI 95% 5243–6830) when compared to patients with none. Based on the unadjusted mean, annual average aggregate cost of depression only was estimated at $238.3 billion, diabetes only $150.1 billion and depression and diabetes together was $77.6 billion. Conclusion: Costs at both the individual and aggregate level are significant, with comorbid diagnoses resulting in higher incremental costs than the sum of the costs for each diagnosis alone. In addition, while the cost of depression increased over time, the cost of diabetes decreased over time, much due to decreased inpatient costs. This study highlights the tremendous cost savings possible through more aggressive screening, diagnosis, and treatment of depression.

OBJECTIVE: The report estimates the treatment costs, cost-offset effects, and cost-effectiveness of Collaborative Care of depressive illness in primary care.
STUDY DESIGN: Treatment costs, cost-offset effects, and cost-effectiveness were assessed in two randomized, controlled trials. In the first randomized trail (N = 217), consulting psychiatrists provide enhanced management of pharmacotherapy and brief psychoeducational interventions to enhance adherence. In the second randomized trial (N = 153). Collaborative Care was implemented through brief cognitive-behavioral therapy and enhanced patient education. Consulting psychologist provided brief psychotherapy supplemented by educational materials and enhanced pharmacotherapy management.
RESULTS: Collaborative Care increased the costs of treating depression largely because of the extra visits required to provide the interventions. There was a modest cost offset due to reduced use of specialty mental health services among Collaborative Care patients, but costs of ambulatory medical care services did not differ significantly between the intervention and control groups. Among patients with major depression there was a modest increase in cost-effectiveness. The cost per patient successfully treated was lower for Collaborative Care than for Usual Care patients. For patients with minor depression. Collaborative Care was more costly and not more cost-effective than Usual Care.
CONCLUSIONS: Collaborative Care increased depression treatment costs and improved the cost-effectiveness of treatment for patients with major depression. A cost offset in specialty mental health costs, but not medical care costs, was observed. Collaborative Care may provide a means of increasing the value of treatment services for major depression.

OBJECTIVE: The authors evaluated the incremental cost-effectiveness of stepped collaborative care for patients with persistent depressive symptoms after usual primary care management.
METHOD: Primary care patients initiating antidepressant treatment completed a standardized telephone assessment 6-8 weeks after the initial prescription. Those with persistent major depression or significant subthreshold depressive symptoms were randomly assigned to continued usual care or collaborative care. The collaborative care included systematic patient education, an initial visit with a consulting psychiatrist, 2-4 months of shared care by the psychiatrist and primary care physician, and monitoring of follow-up visits and adherence to medication regimen. Clinical outcomes were assessed through blinded telephone assessments at 1, 3, and 6 months. Health services utilization and costs were assessed through health plan claims and accounting data.
RESULTS: Patients receiving collaborative care experienced a mean of 16.7 additional depression-free days over 6 months. The mean incremental cost of depression treatment in this program was $357. The additional cost was attributable to greater expenditures for antidepressant prescriptions and outpatient visits. No offsetting decrease in use of other health services was observed. The incremental cost-effectiveness was $21.44 per depression-free day.
CONCLUSIONS: A stepped collaborative care program for depressed primary care patients led to substantial increases in treatment effectiveness and moderate increases in costs. These findings are consistent with those of other randomized trials. Improving outcomes of depression treatment in primary care requires investment of additional resources, but the return on this investment is comparable to that of many other widely accepted medical interventions.

BACKGROUND: Expanding access to high-quality depression treatment will depend on the balance of incremental benefits and costs. We examine the incremental cost-effectiveness of an organized depression management program for high utilizers of medical care.
METHODS: Computerized records at three health maintenance organizations were used to identify adult patients with outpatient medical visit rates above the 85th percentile for 2 consecutive years. A two-step screening process identified patients with current depressive disorders, who were not in active treatment. Eligible patients were randomly assigned to continued usual care (n = 189) or to an organized depression management program (n = 218). The program included patient education, antidepressant pharmacotherapy initiated in primary care (when appropriate), systematic telephone monitoring of adherence and outcomes, and psychiatric consultation as needed. Clinical outcomes (assessed using the Hamilton Depression Rating Scale on 4 occasions throughout 12 months) were converted to measures of ""depression-free days."" Health services utilization and costs were estimated using health plan-standardized claims.
RESULTS: The intervention program led to an adjusted increase of 47.7 depression-free days throughout 12 months (95% confidence interval [CI], 28.2-67.8 days). Estimated cost increases were $1008 per year (95% CI, $534-$1383) for outpatient health services, $1974 per year for total health services costs (95% CI, $848-$3171), and $2475 for health services plus time-in-treatment costs (95% CI, $880-$4138). Including total health services and time-in-treatment costs, estimated incremental cost per depression-free day was $51.84 (95% CI, $17.37-$108.47).
CONCLUSIONS: Among high utilizers of medical care, systematic identification and treatment of depression produce significant and sustained improvements in clinical outcomes as well as significant increases in health services costs.

CONTEXT: Depression is a leading cause of disability worldwide, but treatment rates in primary care are low.
OBJECTIVE: To determine the cost-effectiveness from a societal perspective of two quality improvement (QI) interventions to improve treatment of depression in primary care and their effects on patient employment.
DESIGN: Group-level randomized controlled trial conducted June 1996 to July 1999.
SETTING: Forty-six primary care clinics in six community-based managed care organizations.
PARTICIPANTS: One hundred eighty-one primary care clinicians and 1356 patients with positive screening results for current depression.
INTERVENTIONS: Matched practices were randomly assigned to provide usual care (n = 443 patients) or to 1 of 2 QI interventions offering training to practice leaders and nurses, enhanced educational and assessment resources, and either nurses for medication follow-up (QI-meds; n = 424 patients) or trained local psychotherapists (QI-therapy; n = 489). Practices could flexibly implement the interventions, which did not assign type of treatment.
MAIN OUTCOME MEASURES: Total health care costs, costs per quality-adjusted life-year (QALY), days with depression burden, and employment over 24 months, compared between usual care and the two interventions.
RESULTS: Relative to usual care, average health care costs increased $419 (11%) in QI-meds (P =.35) and $485 (13%) in QI-therapy (P =.28); estimated costs per QALY gained were between $15 331 and $36 467 for QI-meds and $9478 and $21 478 for QI-therapy; and patients had 25 (P =.19) and 47 (P =.01) fewer days with depression burden and were employed 17.9 (P =.07) and 20.9 (P =.03) more days during the study period.
CONCLUSIONS: Societal cost-effectiveness of practice-initiated QI efforts for depression is comparable with that of accepted medical interventions. The intervention effects on employment may be of particular interest to employers and other stakeholders.

OBJECTIVE: This study examined the incremental cost-effectiveness of a collaborative care intervention for depression compared with consult-liaison care.
METHODS: A total of 354 patients in a Department of Veterans Affairs (VA) primary care clinic who met the criteria for major depression or dysthymia were randomly assigned to one of the two care models. Under the collaborative care model, a mental health team provided a treatment plan to primary care providers, telephoned patients to encourage adherence, reviewed treatment results, and suggested modifications. Outcomes were assessed at three and nine months by telephone interviews. Health care use and costs were also assessed.
RESULTS: A significantly greater number of collaborative care patients were treated for depression and given prescriptions for antidepressants. The collaborative care patients experienced an average of 14.6 additional depression-free days over the nine months. The mean incremental cost of the intervention per patient was $237 US dollars for depression treatment and $519 US dollars for total outpatient costs. A majority of the additional expenditures were accounted for by the intervention. The incremental cost-effectiveness ratio was $24 US dollars per depression-free day for depression treatment costs and $33 US dollars for total outpatient cost.
CONCLUSIONS: Better coordination and communication under collaborative care was associated with a greater number of patients being treated for depression and with moderate increases in days free of depression and in treatment cost. Additional resources are needed for effective collaborative care models for depression treatment in primary care.

CONTEXT: Context Depression is a leading cause of functional impairment in elderly individuals and is associated with high medical costs, but there are large gaps in quality of treatment in primary care.
OBJECTIVE: To determine the incremental cost-effectiveness of the Improving Mood Promoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression.
DESIGN: Randomized controlled trial with recruitment from July 1999 to August 2001.
SETTING: Eighteen primary care clinics from eight health care organizations in five states.
PARTICIPANTS: A total of 1801 patients 60 years or older with major depression (17%), dysthymic disorder (30%), or both (53%).
INTERVENTION: Patients were randomly assigned to the IMPACT intervention (n = 906) or to usual primary care (n = 895). Intervention patients were provided access to a depression care manager supervised by a psychiatrist and primary care physician. Depression care managers offered education, support of antidepressant medications prescribed in primary care, and problem-solving treatment in primary care (a brief psychotherapy).
MAIN OUTCOME MEASURES: Total outpatient costs, depression-free days, and quality-adjusted life-years.
RESULTS: Relative to usual care, intervention patients experienced 107 (95% confidence interval [CI], 86 to 128) more depression-free days over 24 months. Total outpatient costs were $295 (95% CI, −$525 to $1115) higher during this period. The incremental outpatient cost per depression-free day was $2.76 (95% CI, −$4.95 to $10.47) and incremental outpatient costs per quality-adjusted life-year ranged from $2519 (95% CI, −$4517 to $9554) to $5037 (95% CI, −$9034 to $19 108). Results of a bootstrap analysis suggested a 25% probability that the IMPACT intervention was “dominant” (i.e., lower costs and greater effectiveness).
CONCLUSIONS: The IMPACT intervention is a high-value investment for older adults; it is associated with high clinical benefits at a low increment in health care costs.

OBJECTIVE: This study comprehensively assessed the work outcomes of employees with depression.
METHODS: We collected baseline and six-month follow-up survey data from 229 employees with depression and two employee comparison groups: a group of healthy patients for the control group (N=173) and a group with rheumatoid arthritis (N=87), a frequent source of work disability. Outcomes included new unemployment and, within the employed subgroup, job retention (versus job turnover), presenteeism (that is, diminished on-the-job performance and productivity), and absenteeism.
RESULTS: At the six-month follow-up, persons with depression had more new unemployment— 14 percent for persons in the dysthymia group, 12 percent for persons in the major depression group, and 15 percent for persons in the group with both dysthymia and major depression, compared with 2 percent for persons in the control group and 3 percent for persons in the rheumatoid arthritis group. Among participants who were still employed, those with depression had significantly more job turnover, presenteeism, and absenteeism.
CONCLUSIONS: In addition to helping employees with depression obtain high-quality depression treatment, new interventions may be needed to help them to overcome the substantial job upheaval that this population experiences.

OBJECTIVES: The study tested an intervention aimed at improving work functioning among middle-aged and older adults with depression and work limitations.
METHODS: A randomized clinical trial allocated an initial sample of 431 eligible employed adults (age ≥45) to a work-focused intervention (WFI) or usual care. Inclusion criteria were depression as measured by the Patient Health Questionnaire–9 (PHQ-9) and at-work limitations indicated by a productivity loss score ≥5% on the Work Limitations Questionnaire (WLQ). Study sites included 19 employers and five related organizations. Telephone-based counseling provided three integrated modalities: care coordination, cognitive-behavioral therapy strategy development, and work coaching and modification. Effectiveness (change in productivity loss scores from preintervention to four months postintervention) was tested with mixed models adjusted for confounders. Secondary outcomes included change in WLQ work performance scales, self- reported absences, and depression.
RESULTS: Of 1,227 eligible employees (7% of screened), 431 (35%) enrolled and 380 completed the study (12% attrition). At-work productivity loss improved 44% in the WFI group versus 13% in usual care (difference in change, p<.001). WFI group scores on the four WLQ scales improved 44% to 47%, significantly better than in usual care (p<.001 for each scale). Absence days declined by 53% in the WFI group versus 13% in usual care (difference in change, p<.001). Mean PHQ-9 depression symptom severity scores declined 51% for WFI versus 26% for usual care (difference in change, p<.001).
CONCLUSIONS: The WFI was more effective than usual care at four-month follow-up. Given increasing efforts to provide more patient-centered, value-based care, the WFI could be an important resource.

OBJECTIVE: To test whether an intervention to improve primary care depression management significantly improves productivity at work and absenteeism over two years.
SETTING AND SUBJECTS: Twelve community primary care practices recruiting depressed primary care patients identified in a previsit screening.
RESEARCH DESIGN: Practices were stratified by depression treatment patterns before randomization to enhanced or usual care. After delivering brief training, enhanced care clinicians provided improved depression management over 24 months. The research team evaluated productivity and absenteeism at baseline, 6, 12, 18, and 24 months in 326 patients who reported full-or part-time work at one or more completed waves.
RESULTS: Employed patients in the enhanced care condition reported 6.1% greater productivity and 22.8% less absenteeism over 2 years. Consistent with its impact on depression severity and emotional role functioning, intervention effects were more observable in consistently employed subjects where the intervention improved productivity by 8.2% over two years at an estimated annual value of US 1982 dollars per depressed full-time equivalent and reduced absenteeism by 28.4% or 12.3 days over two years at an estimated annual value of US 619 dollars per depressed full-time equivalent.
CONCLUSIONS: This trial, which is the first to our knowledge to demonstrate that improving the quality of care for any chronic disease has positive consequences for productivity and absenteeism, encourages formal cost-benefit research to assess the potential return-on-investment employers of stable workforces can realize from using their purchasing power to encourage better depression treatment for their employees.

OBJECTIVE: To test a new program’s effectiveness in reducing depression’s work burden.
METHODS: A brief telephonic program to improve work functioning was tested in an early-stage randomized controlled trial (RCT) involving 79 Maine State Government employees who screened-in for depression and at-work limitations (treatment group=59; usual care group=27). Group differences in baseline to follow-up change scores on The Work Limitations Questionnaire (WLQ), WLQ Absence Module and PHQ-9 depression severity scale were tested with analysis of covariance.
RESULTS: While there were no baseline group differences (p≥.05), by follow-up the treatment group had significantly better scores on every outcome and differences in the longitudinal changes were all statistically significant (p=.0.27 to .0001).
CONCLUSIONS: The new program was superior to usual care. The estimated productivity cost savings are $6041.70 per participant annually.

OBJECTIVES: The study tested an intervention aimed at improving work functioning among middle-aged and older adults with depression and work limitations.
METHODS: A randomized clinical trial allocated an initial sample of 431 eligible employed adults (age ≥45) to a work-focused intervention (WFI) or usual care. Inclusion criteria were depression as measured by the Patient Health Questionnaire–9 (PHQ-9) and at-work limitations indicated by a productivity loss score ≥5% on the Work Limitations Questionnaire (WLQ). Study sites included 19 employers and five related organizations. Telephone-based counseling provided three integrated modalities: care coordination, cognitive-behavioral therapy strategy development, and work coaching and modification. Effectiveness (change in productivity loss scores from preintervention to four months postintervention) was tested with mixed models adjusted for confounders. Secondary outcomes included change in WLQ work performance scales, self- reported absences, and depression.
RESULTS: Of 1,227 eligible employees (7% of screened), 431 (35%) enrolled and 380 completed the study (12% attrition). At-work productivity loss improved 44% in the WFI group versus 13% in usual care (difference in change, p<.001). WFI group scores on the four WLQ scales improved 44% to 47%, significantly better than in usual care (p<.001 for each scale). Absence days declined by 53% in the WFI group versus 13% in usual care (difference in change, p<.001). Mean PHQ-9 depression symptom severity scores declined 51% for WFI versus 26% for usual care (difference in change, p<.001).
CONCLUSIONS: The WFI was more effective than usual care at four-month follow-up. Given increasing efforts to provide more patient-centered, value-based care, the WFI could be an important resource.

OBJECTIVE: The Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial [randomized controlled trial (RCT)] found that collaborative care management of depression in older primary care patients was significantly more effective than the usual care. We examined how an adapted version of IMPACT is working in the "real-world" setting of an HMO 3 years after the conclusion of the trial. METHOD: Two hundred ninety-seven adults treated according to IMPACT protocol "poststudy" (PS) at a large group model HMO were compared to the 141 participants (historical control) in the intervention arm of the RCT at the same site. The Patient Health Questionnaire (PHQ-9) was used to compare depression severity at baseline and six months. We also compared treatment contacts, use of antidepressants and psychotherapy and total health care costs.
RESULTS: The RCT and PS groups were equivalent regarding baseline depression scores (14.5 vs. 14.2, P = .72), 6-month scores (5.6 vs. 6.3, P=.28) and percent experiencing 50% improvement in depression (68% vs. 70%, P=.83). Antidepressant use was similar (85% and 90%, P=.57). Treatment contacts were fewer in PS than RCT (14 vs. 20, Pb.001).
CONCLUSIONS: An adapted version of the IMPACT program implemented at a large HMO achieved similar clinical improvements in depression as the clinical trial despite a lower number of intervention contacts.
D 2006 Elsevier Inc. All rights reserved.

OBJECTIVE: The Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial [randomized controlled trial (RCT)] found that collaborative care management of depression in older primary care patients was significantly more effective than the usual care. We examined how an adapted version of IMPACT is working in the "real-world" setting of an HMO three years after the conclusion of the trial. METHOD: Two hundred ninety-seven adults treated according to IMPACT protocol "poststudy" (PS) at a large group model HMO were compared to the 141 participants (historical control) in the intervention arm of the RCT at the same site. The Patient Health Questionnaire (PHQ-9) was used to compare depression severity at baseline and six months. We also compared treatment contacts, use of antidepressants and psychotherapy and total health care costs.
RESULTS: The RCT and PS groups were equivalent regarding baseline depression scores (14.5 vs. 14.2, P = .72), 6-month scores (5.6 vs. 6.3, P=.28) and percent experiencing 50% improvement in depression (68% vs. 70%, P=.83). Antidepressant use was similar (85% and 90%, P=.57). Treatment contacts were fewer in PS than RCT (14 vs. 20, Pb.001).
CONCLUSIONS: An adapted version of the IMPACT program implemented at a large HMO achieved similar clinical improvements in depression as the clinical trial despite a lower number of intervention contacts.
D 2006 Elsevier Inc. All rights reserved.

OBJECTIVE: To determine the long-term effects on total healthcare costs of the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) program for late-life depression com- pared with usual care.
STUDY DESIGN: Randomized controlled trial with enrollment from July 1999 through August 2001. The IMPACT trial, conducted in primary care practices in eight delivery organizations across the United States, enrolled 1801 depressed primary care patients 60 years or older. Data are from the two IMPACT sites for which 4-year cost data were available. Trial enrollment across these two health maintenance organizations was 551 patients.
METHODS: Participants were randomly assigned to the IMPACT intervention (n = 279) or to usual primary care (n = 272). Intervention patients had access to a depression care manager who provided education, behavioral activation, support of antidepressant medication management prescribed by their regular primary care provider, and problem-solving treatment in primary care for up to 12 months. Care managers were supervised by a psychiatrist and a primary care provider. The main outcome measures were healthcare costs during four years.
RESULTS: IMPACT participants had lower mean total healthcare costs ($29 422; 95% confidence interval, $26 479-$32 365) than usual care patients ($32 785; 95% confidence interval, $27 648-$37 921) during four years. Results of a bootstrap analysis suggested an 87% probability that the IMPACT program was associated with lower healthcare costs than usual care.
CONCLUSION: Compared with usual primary care, the IMPACT program is associated with a high probability of lower total healthcare costs during a 4-year period.

Depression is a relatively common disease that has more impact on employers' health care costs and workplace productivity than many chronic medical conditions. This article describes the costs of depression, both direct and indirect, and discusses effective employer strategies for dealing with depression in the workplace.

OBJECTIVE: We examined the relationships among depressive symptoms, physician diagnosis of depression, and charges for care.
STUDY DESIGN: We used a prospective observational design.
POPULATION: Five hundred eight new adult patients were randomly assigned to senior residents in family practice and internal medicine.
OUTCOMES MEASURED: Self-reports of health status assessment (Medical Outcomes Study Short Form-36) and depressive symptoms (Beck Depression Inventory) were determined at study entry and at 1-year follow-up. Physician diagnosis of depression was determined by chart audit; charges for care were monitored electronically.
RESULTS: Symptoms of depression and the diagnosis of depression were associated with charges for care. Statistical models were developed to identify predictors for the occurrence and magnitude of medical charges. Neither depressive symptoms nor diagnosis of depression significantly predicted the occurrence of charges in the areas studied, but physician diagnosis of depression predicted the magnitude of primary care and total charges.
CONCLUSIONS: A complex relationship exists among depressive symptoms, the diagnosis of depression, and charges for medical care. Understanding these relationships may help primary care physicians diagnose depression and deliver primary care to depressed patients more effectively while managing health care expenditures.

CONTEXT: Uncertainties exist about prevalence and correlates of major depressive disorder (MDD).
OBJECTIVE: To present nationally representative data on prevalence and correlates of MDD by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, and on study patterns and correlates of treatment and treatment adequacy from the recently completed National Comorbidity Survey Replication (NCS-R).
DESIGN: Face-to-face household survey conducted from February 2001 to December 2002.
SETTING: The 48 contiguous United States.
PARTICIPANTS: Household residents ages 18 years or older (N = 9090) who responded to the NCS-R survey.
MAIN OUTCOME MEASURES: Prevalence and correlates of MDD using the World Health Organization's (WHO) Composite International Diagnostic Interview (CIDI), 12-month severity with the Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR), the Sheehan Disability Scale (SDS), and the WHO disability assessment scale (WHO-DAS). Clinical reinterviews used the Structured Clinical Interview for DSM-IV.
RESULTS: The prevalence of CIDI MDD for lifetime was 16.2% (95% confidence interval [CI], 15.1-17.3) (32.6-35.1 million US adults) and for 12-month was 6.6% (95% CI, 5.9-7.3) (13.1-14.2 million US adults). Virtually all CIDI 12-month cases were independently classified as clinically significant using the QIDS-SR, with 10.4% mild, 38.6% moderate, 38.0% severe, and 12.9% very severe. Mean episode duration was 16 weeks (95% CI, 15.1-17.3). Role impairment as measured by SDS was substantial as indicated by 59.3% of 12-month cases with severe or very severe role impairment. Most lifetime (72.1%) and 12-month (78.5%) cases had comorbid CIDI/DSM-IV disorders, with MDD only rarely primary. Although 51.6% (95% CI, 46.1-57.2) of 12-month cases received health care treatment for MDD, treatment was adequate in only 41.9% (95% CI, 35.9-47.9) of these cases, resulting in 21.7% (95% CI, 18.1-25.2) of 12-month MDD being adequately treated. Sociodemographic correlates of treatment were far less numerous than those of prevalence.
CONCLUSIONS: Major depressive disorder is a common disorder, widely distributed in the population, and usually associated with substantial symptom severity and role impairment. While the recent increase in treatment is encouraging, inadequate treatment is a serious concern. Emphasis on screening and expansion of treatment needs to be accompanied by a parallel emphasis on treatment quality improvement.

ABSTRACT: Quality healthcare outcomes depend upon patients’ adherence to recommended treatment regimens. Patient nonadherence can be a pervasive threat to health and wellbeing and carry an appreciable economic burden as well. In some disease conditions, more than 40% of patients sustain significant risks by misunderstanding, forgetting, or ignoring healthcare advice. While no single intervention strategy can improve the adherence of all patients, decades of research studies agree that successful attempts to improve patient adherence depend upon a set of key factors. These include realistic assessment of patients’ knowledge and understanding of the regimen, clear and effective communication between health professionals and their patients, and the nurturance of trust in the therapeutic relationship. Patients must be given the opportunity to tell the story of their unique illness experiences. Knowing the patient as a person allows the health professional to understand elements that are crucial to the patient’s adherence: beliefs, attitudes, subjective norms, cultural context, social supports, and emotional health challenges, particularly depression. Physician–patient partnerships are essential when choosing amongst various therapeutic options to maximize adherence. Mutual collaboration fosters greater patient satisfaction, reduces the risks of nonadherence, and improves patients’ healthcare outcomes.

BACKGROUND: Diagnostic and treatment delay in depression are due to physician and patient factors. Patients vary in awareness of their depressive symptoms and ability to bring depression-related concerns to medical attention.
OBJECTIVE: To inform interventions to improve recognition and management of depression in primary care by understanding patients’ inner experiences prior to and during the process of seeking treatment.
DESIGN: Focus groups, analyzed qualitatively. PARTICIPANTS: One hundred and sixteen adults (79% response) with personal or vicarious history of depression in Rochester NY, Austin TX and Sacramento CA. Neighborhood recruitment strategies achieved socio- demographic diversity.
APPROACH: Open-ended questions developed by a multidisciplinary team and refined in three pilot focus groups explored participants’ “lived experiences” of depression, depression-related beliefs, influences of significant others, and facilitators and barriers to care-seeking. Then, 12 focus groups stratified by gender and income were conducted, audio-recorded, and analyzed qualitatively using coding/editing methods.
MAIN RESULTS: Participants described three stages leading to engaging in care for depression — “knowing” (recognizing that something was wrong), “naming” (finding words to describe their distress) and “explaining” (seeking meaningful attributions). “Knowing” is influenced by patient personality and social attitudes. “Naming” is affected by incongruity between the personal experience of depression and its narrow clinical conceptualizations, colloquial use of the word depression, and stigma. “Explaining” is influenced by the media, socialization processes and social relations. Physical/medical explanations can appear to facilitate care-seeking, but may also have detrimental consequences. Other explanations (characterological, situational) are common, and can serve to either enhance or reduce blame of oneself or others.
CONCLUSIONS: To improve recognition of depression, primary care physicians should be alert to patients’ ill-defined distress and heterogeneous symptoms, help patients name their distress, and promote explanations that comport with patients’ lived experience, reduce blame and stigma, and facilitate care-seeking.

OBJECTIVE: This article estimates the decrease in workplace productivity losses associated with removal of three types of barriers to mental health service use among workers with depression.
METHODS: A model of productivity losses based on the results of a population-based survey of Canadian workers was used to estimate the impact of three types of barriers to mental health service use among workers with depression.
RESULTS: Removing the service need recognition barrier is associated with a 33% decrease in work productivity losses. There is a 49% decrease when all three barriers are removed.
CONCLUSIONS: Our results suggest recognizing the need for treatment is only one barrier to service use; attitudinal and structural barriers should also be considered. The greatest decrease in productivity losses is observed with the removal of all three barriers.

Depression is a common mental disorder, characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, feelings of tiredness, and poor concentration.
Depression can be long-lasting or recurrent, substantially impairing an individual’s ability to function at work or school or cope with daily life. At its most severe, depression can lead to suicide. When mild, people can be treated without medicines but when depression is moderate or severe they may need medication and professional talking treatments.
Depression is a disorder that can be reliably diagnosed and treated by non-specialists as part of primary health care. Specialist care is needed for a small proportion of individuals with complicated depression or those who do not respond to first-line treatments.

Depression is one of the leading causes of disease worldwide. Historically conceived as either a disease of the mind or of the brain, treatment options followed this aetiology. Current diagnostic assessment of depression is based on descriptions of symptoms, their presence and magnitude over time. Epidemiological studies demonstrate that depressive disorders are highly prevalent: displaying high rates of lifetime incidence, early age onset, high chronicity, and role impairment. These studies have deepened our understanding of the course of depression; remission, recovery, relapse and recurrence. An illustration of recovery rates has begun to demonstrate the complexity of the nature and course of depression. The majority recovers; however, recovery may not be permanent and future episodes carry the threat of chronicity. A key variable influencing rates of recovery, relapse, and recurrence is the presence of medical or psychiatric comorbid illnesses. The review considers the literature on Major Depression beginning with a brief historical overview, its classification, and a synthesis of the current knowledge regarding prevalence and course.

Depression is a significant contributor to the global burden of disease and affects people in all communities across the world. Today, depression is estimated to affect 350 million people. The World Mental Health Survey conducted in 17 countries found that on average about 1 in 20 people reported having an episode of depression in the previous year. Depressive disorders often start at a young age; they reduce people’s functioning and often are recurring. For these reasons, depression is the leading cause of disability worldwide in terms of total years lost due to disability. The demand for curbing depression and other mental health conditions is on the rise globally. A recent World Health Assembly called on the World Health Organization and its member states to take action in this direction (WHO, 2012).

American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) is a classification of mental disorders with associated criteria designed to facilitate more reliable diagnoses of these disorders. With successive editions over the past 60 years, it has become a standard reference for clinical practice in the mental health field. Since a complete description of the underlying pathological processes is not possible for most mental disorders, it is important to emphasize that the current diagnostic criteria are the best available description of how mental disorders are expressed and can be recognized by trained clinicians. DSM is intended to serve as a practical, functional, and flexible guide for organizing information that can aid in the accurate diagnosis and treatment of mental disorders. It is a tool for clinicians, an essential educational resource for students and practitioners, and a reference for researchers in the field.

Depression (major depressive disorder or clinical depression) is a common but serious mood disorder. It causes severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working. To be diagnosed with depression, the symptoms must be present for at least two weeks.
Some forms of depression are slightly different, or they may develop under unique circumstances, such as:
Persistent depressive disorder (also called dysthymia) is a depressed mood that lasts for at least two years. A person diagnosed with persistent depressive disorder may have episodes of major depression along with periods of less severe symptoms, but symptoms must last for two years to be considered persistent depressive disorder.