Depression treatment rates increase over past decade, but psychotherapy declines

"Depression is a leading cause of disability, lost productivity and health care expenditure," the authors write as background information in the article. During the 1990s, the rate of depression treatment increased substantially, from 0.73 percent in 1987 to 2.33 percent in 1997. Among those who were treated, the use of antidepressant medications increased from 37.3 percent to 74.5 percent, and the use of psychotherapy decreased from 71.1 percent to 60.2 percent. These trends have been attributed to the introduction and promotion of selective serotonin reuptake inhibitors (SSRIs) and other newer antidepressants, publication of practice guidelines to diagnose and treat depression and the development of screening tools for primary care.

However, several factors -- including the proliferation of managed behavioral care organizations, the changes in benefits among private mental health insurance plans and concerns about the safety of antidepressants in young people -- may have impeded the growth of depression care in the most recent decade. Steven C. Marcus, Ph.D., of Philadelphia Veterans Affairs Medical Center and the University of Pennsylvania, Philadelphia, and Mark Olfson, M.D., M.P.H., of Columbia University and the New York State Psychiatric Institute, New York, assessed national trends in outpatient treatment of depression between 1998 and 2007 using two nationally representative surveys.

Between 1998 (when 22,935 participants were surveyed) and 2007 (when 29,370 individuals participated), the rate of outpatient depression treatment increased from 2.37 per 100 people to 2.88 per 100 people. The percentage of treated patients who used antidepressants did not change significantly -- from 73.8 percent to 75.3 percent. Of those, the percentage receiving tricyclic antidepressants or SSRIs declined and the percentage receiving newer antidepressants increased.

Of treated patients, the percentage receiving psychotherapy declined from 53.6 percent to 43.1 percent between 1998 and 2007. "Of those who received psychotherapy, the average number of psychotherapy visits and expenditures for these visits also significantly decreased," the authors write. "There was also a significant decline in the mean [average] number of outpatient depression care visits per treated person."

It is unclear whether the decline in psychotherapy use is due to patient preferences or other factors, including scarcity of psychotherapists, the authors note. "A review of the literature concerning treatment preferences, however, revealed that most patients with depression prefer psychotherapy or counseling over antidepressant medications," they write. "However, although third-party coverage of antidepressants and other psychotropic medications is typically generous, significant limits commonly exist on coverage of psychotherapy services."

"As national health care reform unfolds, it will be important to develop clinical policies that promote access to effective treatments for depression," they conclude. "Health care reform will extend coverage to an estimated 32 million uninsured Americans. Meeting the mental health care needs of these individuals, who currently have a low rate of depression treatment, will post a formidable challenge to general medical and mental health educators and practitioners."