Association of higher costs with symptoms and diagnosis of depression

,

Original Research

Association of higher costs with symptoms and diagnosis of depression

J Fam Pract. 2002 June;51(6):540-544

By

Edward J. Callahan, PhD

PDF Download

References

1. deGruy F. Mental health care in the primary care setting. In: Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary Care: America’s Health in the New Era. Washington, DC: National Academy Press; 1996;285-311.

2. Regier DA, Goldberg ID, Taube CA. The de facto US mental health services system: a public health perspective. Arch Gen Psychiatry 1978;35:685-93.

3. Schurman RA, Kramer PD, Mitchell JB. The hidden mental health network. Treatment of mental illness by nonpsychiatrist physicians. Arch Gen Psychiatry 1985;42:89-94.

4. Nutting PA, Franks P, Clancy CM. Referral and consultation in primary care: do we understand what we’re doing? [editorial; comment]. J Fam Pract 1992;35:21-3.

5. Laepine JP, Gastpar M, Mendlewicz J, Tylee A. Depression in the community: the first pan-European study DEPRES (Depression Research in European Society). Int Clin Psychopharmacol 1997;12:19-29.

6. Panel DG. Clinical Practice Guidelines. Vol I. Washington, DC: Agency for Health Care Policy and Research; 1993.

7. Panel DG. Clinical Practice Guidelines. Vol II. Washington, DC: Agency for Health Care Policy and Research; 1993.

8. Katon W. The epidemiology of depression in medical care. Int J Psychiatry Med 1987;17:93-112.

9. Spitzer RL, Williams JB, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study [see comments]. JAMA 1994;272:1749-56.

10. Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER. The economic burden of depression in 1990 [see comments]. J Clin Psychiatry 1993;54:405-18.

11. Kirmayer LJ, Robbins JM. Three forms of somatization in primary care: prevalence, co-occurrence, and sociodemographic characteristics. J Nerv Ment Dis 1991;179:647-55.

12. Kirmayer LJ, Robbins JM, Dworkind M, Yaffe MJ. Somatization and the recognition of depression and anxiety in primary care. Am J Psychiatry 1993;150:734-41.

13. Kirmayer LJ, Robbins JM. Patients who somatize in primary care: a longitudinal study of cognitive and social characteristics. Psychol Med 1996;26:937-51.

14. Callahan EJ, Bertakis KD, Azari R, et al. The influence of depression on physician-patient interaction in primary care. Fam Med 1996;28:346-51.

15. Callahan CM, Kesterson JG, Tierney WM. Association of symptoms of depression with diagnostic test charges among older adults. Ann Intern Med 1997;126:426-32.

16. Simon GE, VonKorff M, Barlow W. Health care costs of primary care patients with recognized depression. Arch Gen Psychiatry 1995;52:850-6.

17. Simon G, Ormel J, VonKorff M, Barlow W. Health care costs associated with depressive and anxiety disorders in primary care. Am J Psychiatry 1995;152:352-7.

18. Carney PA, Rhodes LA, Eliassen MS, et al. Variations in approaching the diagnosis of depression: a guided focus group study. J Fam Pract 1998;46:73-82.

19. Beck AT, Beck RW. Screening depressed patients in family practice. A rapid technique. Postgrad Med 1972;52:81-5.

20. Ware JE, Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30:473-83.

21. Beck AT, Ward CH, Mendelson M. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561-71.

22. Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clin Psychol Rev 1988;8:77-100.

23. Stewart AL, Hays RD, Ware JE, Jr. The MOS short-form general health survey. Reliability and validity in a patient population. Med Care 1988;26:724-35.

24. McHorney CA, Ware JE, Jr, Raczek AE. The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care 1993;31:247-63.

25. Ware JE, Kosinski M, Keller SD. SF-36 Physical and Mental Health Summary Scales: A User’s Manual. Boston: Nimrod Press; 1994.

26. Harter HL. Critical values for Duncan’s new multiple range test. Biometrics 1960;16:671-85.

27. Duan N. Smearing estimates: a nonparametric retransformation method. J Am Stat Assoc 1983;78:605-10.

28. Duan N, Manning WG, Morris CN, Newhouse JP. A comparison of alternative models for the demand for medical care. J Business Econ Stat 1983;1:115-26.

29. Bertakis KD, Azari R, Helms LJ, Callahan EJ, Robbins JA. Gender differences in the utilization of health care services. J Fam Pract 2000;49:147-52.

30. Unutzer J, Patrick DL, Simon G, et al. Depressive symptoms and the cost of health services in HMO patients aged 65 years and older. A 4-year prospective study. JAMA 1997;277:1618-23.

31. Leslie DL, Rosenheck R. Shifting to outpatient care? Mental health care use and cost under private insurance. Am J Psychiatry 1999;156:1250-7.

32. Callahan EJ, Jaéen CR, Crabtree BF, et al. The impact of recent emotional distress and diagnosis of depression or anxiety on the physi-cian-patient encounter in family practice [see comments]. J Fam Pract 1998;46:410-8.

33. Coyne JC, Schwenk TL, Fechner-Bates S. Nondetection of depression by primary care physicians reconsidered [see comments]. Gen Hosp Psychiatry 1995;17:3-12.

34. Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview [see comments]. JAMA 1997;277:678-82.

ABSTRACT

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.

KEY POINTS FOR CLINICIANS

Diagnosis of depression is associated with higher costs.
Failure to diagnose depression may raise laboratory costs.
Diagnosis of depression with few symptoms deserves study.

As US medical care has evolved, physicians have been expected to recognize and treat mental health problems in primary care,¹ “the hidden mental health network.”^2,3 Primary care clinicians are expected to observe signs of possible mental health problems, incorporate those observations into differential diagnoses, and decide which problems to treat or monitor and which to send for consultation or referral.⁴ These decisions can have important financial and health consequences, especially in dealing with depression.

Depression is common in the community⁵ and among primary care patients, 6% to 9% of whom report symptoms of major depression.^6-8 An additional 10% to 15% of primary care patients show signs of less severe but important depressive problems.^8,9 “Subclinical depression” is marked by symptoms that might indicate physical disease, signs of depression, or both; recognition may affect costs of care.^10-13

Research has begun to define the impact of depression on processes¹⁴ and costs of care.^15-17 For example, elderly patients reporting symptoms of depression have more laboratory tests performed at higher cost.¹⁵ Primary care patients diagnosed with depression had total yearly health care costs almost double those of patients without depression, with increased costs secondary to higher medical utilization and not mental health specialty treatment.¹⁶ There is evidence that depressive symptoms and the diagnosis of depression may predict increases in costs of care.¹⁷

Costs of care might be influenced by the model used by primary care physicians to identify depression.¹⁸ For example, a biomedical model might use more laboratory testing to reach a diagnosis of depression by exclusion, whereas a psychosocial model would use fewer laboratory tests while the physician pursues psychosocial issues. To identify optimal strategies for practice, it is important to determine how symptoms of depression and physician diagnosis of depression might interrelate and affect medical care costs.

We explored the following hypotheses: (1) that there are significant differences in each type of charge determined by the presence or absence of symptoms and diagnosis of depression; (2) that depressive symptoms and physician diagnosis of depression predict the occurrence of charges for specialty care, emergency services, laboratory services, and hospitalization; and (3) that depressive symptoms and physician diagnosis of depression predict the magnitude of medical charges for primary care, specialty care, emergency services, laboratory services, hospitalization, and total charges.

Methods

Study design

Five hundred eight adult nonpregnant new patients were assigned randomly to primary care providers in either family practice or general internal medicine clinics in a teaching hospital. Children younger than 18 years and pregnant women were excluded because they are not followed in general internal medicine. At enrollment and follow-up, self-reported depression was determined with the abbreviated Beck Depression Inventory (BDI)¹⁹ and health status was measured with the Medical Outcomes Studies Short Form-36 (MOS SF-36).²⁰ To avoid altering clinician practice, physicians were not provided with either score. Physicians included 105 senior residents (second and third year) in family practice and general internal medicine.

Measures

Beck Depression Inventory. The BDI is a reliable and valid instrument used to measure depressive symptoms.^19,21 The abbreviated version includes 13 items weighted and summed to produce a total score.¹⁹ A score between 9 and 15 indicates moderate depression, and a score of at least 16 indicates severe depression. The BDI is used widely for screening and to assess treatment efficacy.²² In this study, a BDI score between 0 and 8 was considered “low” or normal, and a score of at least 9 was considered “high” or indicative of symptoms of depression.