Treatment for Depression More Than Triples
in the US in the Last 10 Years
By Shankar Vedantam

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.

The sea change probably does not stem from an actual increase in depression. 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.

"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."
Washington Post January 9, 2002; Page A01