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By Shankar Vedantam
Washington Post Staff Writer
Wednesday, January 9, 2002; Page A01
The number of people being treated for depression has increased
dramatically in the united States in the past decade, marking a profound
shift in how Americans cope with the common emotional disorder, the most
comprehensive study to date shows.
Drugs such as Prozac have become the mainstay for the vast majority of
those being treated, even as doctors spend less time with patients and
offer comparatively less psychotherapy, researchers said yesterday in
reporting the results of the study.
The sea change probably does not stem from an actual increase in
depression, experts said. Instead, it is most likely connected to the
destigmatization of mental health problems in general and depression in
particular, the rise of managed-care insurance plans, and the arrival of
powerful drugs including Prozac, accompanied by multimillion-dollar
marketing campaigns.
"The increase in the treatment of depression cuts broadly across
the population and extends to Hispanics and African Americans [and]
people who are unemployed and uninsured," said Mark Olfson, the
lead author and an associate professor of clinical psychiatry at
Columbia University and the New York State Psychiatric Institute.
"These changes reflect broader changes in attitudes toward the
treatment of depression and a decrease in stigma."
Between 1987 and 1997, the percentage of Americans being treated for
depression more than tripled nationwide, from 0.7 percent to 2.3
percent. Medicines, which were prescribed to about a third of patients
in 1987, were given to almost three-quarters a decade later.
Simultaneously, patient visits to doctors for depression fell by a
third, from about 12 visits per patient to eight, with large numbers
being treated by primary care physicians and others outside the field of
mental health.
While the news almost certainly means that fewer people with depression
are suffering in silence, the results also have generated concern that
some of the patients may not be getting the treatment they need, and
that some might be getting misdiagnosed or overdiagnosed. "What we
don't know about is the quality of the care people are getting, but
there are reasons to suggest there are problems with quality," said
Harold Pincus, vice chairman for psychiatry at the University of
Pittsburgh and one of the study's authors.
Substantial numbers of patients receive a single prescription for
medicines and do not refill it, he said. Because the drugs often take a
month to have an effect, one prescription is unlikely to do very much.
But overburdened primary care doctors have no incentive to conduct the
kind of long-term follow-up treatment that chronic conditions such as
depression demand, and that means that many patients may not be getting
the best treatment.
Psychiatrists say that most depression -- including major depression, in
which patients may find it difficult to get out of bed in the morning or
are suicidal -- still goes untreated. While estimates of prevalence
vary, studies indicate 5 percent to 10 percent of Americans are affected
by major depression each year, according to the researchers who
published their study in today's issue of the Journal of the American
Medical Association.
"There was such under-treatment of depression that the increase in
treatment for depression almost certainly represents a good thing,"
said Benjamin Druss, an assistant professor of psychiatry and public
health at Yale University and one of the study's authors.
The study, which used data from surveys that interviewed tens of
thousands of American families, started the same year that Prozac,
launched in 1987, began to change the treatment landscape. Part of a
class of medicines that boosts the levels of a neurotransmitter called
serotonin, Prozac and its sisters quickly came to be prescribed for a
vast array of conditions and disorders.
As managed-care companies demanded a shift from open-ended Freudian
models of treatment and lengthy periods of psychoanalysis, the
antidepressants were heralded as quick and effective. An important
reason they were embraced early on is that they were believed to have
fewer side effects than earlier medicines.
In the period of the study and the five years since, the medicines have
come to supplant psychotherapy in many settings, even though some forms
of psychotherapy have been found to be as effective, and even though the
combination of medicines and psychotherapy has often been found to be
the most effective of all. Between 1987 and 1997, the study found that
the number of people receiving any psychotherapy declined from 71
percent to 60 percent.
Psychologists complain that the drugs do not address the underlying
causes of depression, and end up being more expensive than psychotherapy
in the long term because they are less effective at preventing relapse.
"Survey after survey has shown that given a choice between
psychotherapy and antidepressant medication, the majority of patients
prefer psychotherapy," said Geoffrey M. Reed, assistant executive
director for professional development at the American Psychological
Association. "The trend being reported in this article is contrary
to what we know of patient preferences." "It's much more
likely and much easier for the physician to say, 'Okay, you're feeling
depressed, here, try this pill,' instead of exploring the option of
psychotherapy and make a recommendation to a
mental health provider," he said.
Pincus, who is also director of the Rand Corp.'s health program at
Pittsburgh, said that the split in insurance coverage between behavioral
care and medical care encourages the schism between psychotherapy and
psychopharmacology, by ensuring that the behavioral plans have no
incentive to improve primary care and primary care doctors have no
incentive to provide long-term behavioral care. "The biggest
problem is the failure to
take a longitudinal perspective on the illness," he said.
"These are chronic illnesses -- it's not a one-shot deal."
© 2002 The Washington Post Company
Beth Powell
AMHCA Director of Public Policy and Professional Issues
801 N. Fairfax Street, Suite 304
Alexandria, VA 22314
703-548-6002, ext. 105
www.amhca.org
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