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Book Forum: DEPRESSION   |    
Caring for Depression: A RAND Study
Frederic Flach, M.D.
Am J Psychiatry 1998;155:302-a-303.
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by Kenneth B. Wells, Roland Sturm, Cathy D. Sherbourne, and Lisa S. Meredith. Cambridge, Mass., Harvard University Press, 1996, 243 pp., $39.95.

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This is a well-written report of research—the Medical Outcomes Study—designed to investigate how depressed patients fare under the care of different medical caregivers and within the context of fee-for-service reimbursement plans compared with prepaid ones. The book begins with a sprightly although traditional review of how the illness of depression is currently defined, its widespread incidence, its serious toll in suffering and economic costs to society, and the methods of treatment now available. In reviewing the literature, the authors point out that, in spite of all the efforts at professional and public education about depression, only about 6% of people with major or minor depression consult a psychiatrist. The general medical sector is the only source of care for at least half of all depressed patients, yet primary care physicians fail to recognize depression in at least half of the patients affected.

The Medical Outcomes Study obviously took an enormous amount of planning and work, involving 20,000 patients and 500 caregivers over a 4-year period. The investigators are to be commended on their enterprising attempt to answer this basic question: How can more cost-effective, high-quality treatment programs be made available for depressed patients?

Their study demonstrated that substantially fewer depressed patients were seen by psychiatrists in prepaid health plans (10%) than in fee-for-service reimbursement plans (22%). Psychiatrists treated more of the seriously ill patients. In general medical practice, depressed patients were more likely to be diagnosed and appropriately treated under fee-for-service plans.

Fifty-nine percent of all depressed patients received no pharmacotherapy whatsoever; 12% used only an antidepressant, 19% used only minor tranquilizers, and 11% used both. Antidepressants appeared to be substantially underused in patients under the care of primary care physicians and nonmedical mental health specialists, but even psychiatrists did not prescribe antidepressants for half of their patients categorized as suffering from high-severity depression. Minor tranquilizers were commonly prescribed by primary care physicians and psychiatrists alike.

Psychotherapy and counseling styles were also assessed. On average, primary care physicians offered 10 minutes or less of counseling, consisting largely of giving advice and education. Psychiatrists and psychologists offered longer sessions, using psychodynamic and behavioral approaches to therapy.

The most effective form of treatment, as measured by symptomatic improvement and improved overall functioning, consisted of a combination of counseling and the appropriate use of antidepressant medication. Combining counseling with antidepressants plus the regular use of minor tranquilizers failed to achieve as high a level of recovery and actually proved to be more costly. Counseling alone seemed to achieve better results than antidepressant medications alone. The best outcomes and highest costs were seen in patients treated by psychiatrists, and the poorest outcomes and lowest costs were seen in those managed by the general medical practitioner. This is hardly a surprise. One would expect psychiatrists to get better results, just as cardiologists specializing in hypertension should get better results when dealing with patients with high blood pressure.

Among patients of general medical and nonmedical mental health practitioners, outcome did not seem to be influenced by type of payment plan, but among patients of psychiatrists, those under a fee-for-service plan improved more substantially, while those under a prepaid plan actually fell prey to new functional limitations.

The authors offer a model for improving the quality of care while containing costs. This model includes the following factors: 1) provider specialty, 2) counseling, 3) antidepressant medication, 4) minor tranquilizers, and 5) costs and health outcome. Essentially, they recommend that antidepressants be used more extensively and in adequate doses and that the regular use of minor tranquilizers should be substantially reduced. Counseling should be routinely provided. Efforts should be made to improve the primary care physician's skills and motivation to detect and treat depression effectively. Given the authors' observations that patients treated by psychiatrists under prepaid health plans manifested a rapid decline in antidepressant medication use over time, short patient-provider relationships, greater use of minor tranquilizers—and significantly poorer outcomes—how treatment is paid for appears to have some relevance.

The conflict between quality of treatment and cost containment refuses to go away. It seems to me that we are in danger of being penny wise and pound foolish, as the old saying goes. If, according to the authors' model, the cost per patient of treatment by primary care physicians is around $1,500 while that by psychiatrists or other mental health professionals working collaboratively with psychiatrists is between $3,000 and $4,000 (with meaningfully better results), isn't the extra expense well worth it?

Nonetheless, it is likely that the primary care physician will continue to be responsible for the majority of depressed patients. Having personally spent years exploring ways to educate primary care physicians in the management of depressed patients, I know it is not a simple matter. Part of the problem, I believe, lies in the fact that most people either think that being depressed is a sign of personal weakness or attach significant stigma to depression as a mental malady. Primary care physicians may be no exception; in order for them to be free to recognize, accept, and deal with depression in their patients, they must also be able to do so in themselves and their families as well. What is clearly needed is a new way to view depression, one that distinguishes between nonpathological depression and those elements of the depressive experience which truly constitute "the illness," one that encourages depressed patients to reach out for help and their physicians to be ready and eager to give it.

This book belongs within easy reach of anyone responsible for mental health care planning. My chief criticism is that it would have benefited from more skilled editing, so that the major points of the authors' important study would stand out more clearly, thus saving readers a fair degree of frustration in their effort to discover what these are and giving them more time to digest the findings and think creatively about their implications.

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