By Frederik Joelving
NEW YORK (Reuters Health) - Spending on depression has gone up by nearly a third with no clear improvement in the quality of care, according to Medicaid claims data from Florida.
The uptick in spending was fueled mainly by prescriptions of psychiatric drugs, in particular antipsychotics, while the use of psychotherapy and hospitalizations dropped between 1996 and 2006.
"With the decline in use of hospitalization and antidepressants going generic, the cost of treating depression could have been expected to be falling over this period, but this didn't happen," said Thomas G. McGuire, a professor of health economics at Harvard Medical School in Boston.
"Patients were getting more drugs, mainly more antipsychotics, driving total treatment costs up not down," he told Reuters Health in an email.
Quality of care measures included how much treatment patients' received - both in person, from a doctor, and in sustained use of their prescribed medications.
Although "adequate" use of antidepressants improved slightly during the study period, follow-up visits with the doctor became less common as did the number of visits for psychotherapy.
"The juxtaposition of increased mental health care spending per (Medicaid) enrollee without a substantial improvement in depression quality of care is striking," McGuire and his colleagues wrote in the Archives of General Psychiatry.
According to The National Institute of Mental Health, nearly 15 million American adults suffer from major depression.
Antidepressants like Pfizer's Zoloft, Forest Laboratories' Lexapro and Eli Lilly's Prozac are the mainstay drug treatment for depression, but the medications have never been proven to work any better than talk therapy.
When antidepressants fail, doctors may choose to prescribe antipsychotic drugs, some of which have won regulatory approval as add-ons to antidepressants.
Antipsychotics include Johnson & Johnson's Risperdal, Eli Lilly's Zyprexa, Bristol-Myers Squibb and Otsuka Pharmaceutical's Abilify and AstraZeneca's Seroquel.
The drugs were the top-selling class of medicines in the U.S. in 2009 with $14.6 billion in sales, according to IMS Health, a market research firm.
Like antidepressants, antipsychotics can cause weight gain, and they also carry an increased risk of diabetes, tremors and in some cases stroke.
The new study is based on data from Florida's Medicaid program, the state and federal health insurance for the poor. It includes people aged 18 to 64 who were treated for depression at either a hospital or a doctor's office.
The researchers found that mental health spending per patient rose from $2,802 to $3,610 over a decade.
Antidepressant use rose slightly from 81 percent to 87 percent, while antipsychotic use soared from 26 percent to 42 percent.
"Antipsychotics are powerful drugs with significant side effects," said McGuire. "While there are clinical reasons to include antipsychotics in treatment of depression (our study excluded patients with psychoses), it is not clear that the additional risks and costs are justified."
On the other hand, the proportion of depressed people who got psychotherapy fell from 57 percent to 38 percent. Five percent ended up in the hospital, down from nine percent a decade earlier.
The researchers say it's unlikely that changes in the kinds of patients treated can account for the trends they found. Instead, they argue that their findings may in part be chalked up to effective marketing by drugmakers.
They caution that their data may not represent national trends, but highlight the need to improve the quality of care for people with depression and study the widespread use of antipsychotics.
SOURCE: http://bit.ly/s5Ns3g Archives of General Psychiatry, December 6, 2011.