Professor Moshe Kotler

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Professor Moshe Kotler
Social and Economic Burden of Depression
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Mood Disorders

• Mood Disorders
• Major Depression
• Dysthymia
• Bipolar Disorder
• Cyclothymic Disorder
• Mood Disorder due to medical condition
• Substance induced mood disorder

• Subtypes of mood disorders
• Seasonal Affective disorder
• Postpartum Disorder
• Diagnosis for further study
• Premenstrual Dysphoric disorder

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Diagnosing depressionDSM-IV

• How is it defined?

• Five (or more) of the following symptoms for two
  weeks (or more), one of the symptoms
• must be (a) or ( b)
• 1. Depressed mood.
• 2. Reduced level of interest or
  pleasure in activities.
• 3. A considerable loss or gain of
  weight.
• 4. Difficulty falling or staying
  asleep, or sleeping more than usual.
• 5. Behavior is agitated or slowed down.
  
• Feeling fatigued, or diminished energy.
• Thoughts of worthlessness or extreme guilt.
• Ability to think, concentrate, or make
  decisions is reduced.
• Frequent thoughts of death or suicide, or
  attempt of suicide.
• Not a Mixed Episode.
• The person's symptoms are a cause of great
  distress or difficulty in functioning at home,
  work, or other important areas.
• Not caused by substance use or a medical
  disorder.

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Symptoms
How does it look?

• Physical symptoms
• Sleep disturbance
• Psychomotor retardation
• Fatigue, loss of energy
• Appetite disturbances
• Aches and pains, headaches

• Emotional symptoms
• Sad most of the day
• Thoughts of death or suicide
• Thoughts of worthlessness
• or guilt
• Concentration difficulties
• Loss of interest
• Anxious
• Stressed

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Energy
Appetite
Suicide
Sleep
Depression
Psychomotor
Interest
Guilt
Concentration
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How does it feel?
Brenda's story "It was really hard to
get out of bed in the morning. I just wanted to
hide under the covers and not talk to anyone. I
didnt feel much like eating and I lost a lot of
weight. Nothing seemed fun anymore. I was tired
all the time, yet I wasnt sleeping well at
night. But I knew that I had to keep going
because Ive got kids and a job. It just felt so
impossible, like nothing was going to change or
get better.
Rob's story  "At first I was feeling sad all
the time, even though I had no reason to be. Then
the sadness turned into anger, and I started
having fights with my family and friends. I felt
really bad about myself, like I wasnt good
enough for anyone. It got so bad that I wished I
would go to bed and never wake up.
http//www.pueblo.gsa.gov/cic_text/health/stories-
dep/stories.htm
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How common is it?
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Epidemiology of Depression

• Point prevalence - at any given moment 5 -
• 340 million worldwide, 18 in the USA.
• Lifetime prevalence 20 in women 10 in men
• Reoccurrence rate 75
• Suicide 10-15 of depressed people

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How Bad is it?

• WHO (World Health Organization) identifies
  depression as a leading cause of disability
  worldwide
• currently 4th highest cause of disability
• expected to be 2nd by 2020
• Depressed patients compared to non-depressed
• X 3 visit primary care provider
• X 2 increased risk of death
• X 26 increased risk of suicide
• X 2-5 increased in days absent from work
• Impaired social function

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Social Economic Burden

• Quality of life
• Self reported functional status and quality of
  life decrement.
• Functional impairment and decreased well-being
  greater that most chronic medical conditions.
• HMO (Medicare health maintenance organization)
  found depression to be the third leading cause of
  loss in quality of life at the population level.
  
• Loss of work productivity
• Twofold increase in days of disability due to
  illness.
• 50 increase in time lost from work.
• Cost of health service
• 50 increase in costs of total health service.
• This increase in costs is not due to depression
  treatment, which accounts for only 5-10 of the
  observed increase.

Improvement in depression state ? significantly
improves these undesired effects
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Treating Depression

• 70 respond to treatment but only 30 of them
  achieve remission

Relapse
Remission
Recurrence
Increasing symptoms
Healthy
Major Depression
Continuation 6-9 months
Maintenance
Acute
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Treating Depression
57.3 depressed people receiving any treatment
only 21.7 receive adequate treatment
adequate dose, adequate duration, augmentation
if necessary, maintenance 42.7 depressed people
receiving no treatment
42.7
57.3
Source Kessler RC, et al. JAMA.
20032893095-3105.
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Treating Depression

• Low treatment rates due to
• stigmatization of mental illnesses.
• difficulty of sufferers to realize they need
  treatment.
• beliefs that treatment is ineffective slow
  acting, side effects, causes addiction, etc.
• Some populations especially vulnerable to under
  treatment
• Ethnic minorities - African-Americans
• Older persons, young adults
• Medically uninsured

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Suicide

• Depressed patience have a suicide risk of 10-15
  lifetime
• Estimates suggest that between 8-25 unsuccessful
  attempts for every successful
• 11th Leading Cause of Death in the United States
  (2000)
• 3rd Leading Cause of Death for People Under 25
  Years of Age
• 2/3 Of All Who Attempt Suicide Are Under the Age
  of 30
• 
  
• 1/2 Of All People Over 40 Who Attempt Suicide Are
  Successful in Their Attempt
• Men Commit Suicide 4 Times More Frequently Than
  Women, Although Women Make Attempts 3 Times More
  Often Than Men
• Single or Divorced Individuals Over the Age of 35
  Are 4 Times More Likely to Commit Suicide Than
  Married Individuals.
• 80 who commit suicide give warning.

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Economical burden

• How much does it cost?

43.7 Billion US 1990
Source Greenberg P, et al. The Economic Burden
of Depression in 1990. J Clin Psych, 5411,
November 1993.
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Economical burden TrendUS 1990 ? 2000

• Source Greenberg P, et al. The Economic Burden
  of Depression in the United States How Did it
  Change Between 1990 and 2000? J Clin Psych,
  6412, December 2003.

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Conclusions
1990 2000

• Number of people suffering from depression
  remained stable 17.5 18.1 million
• Moderate increase of economic burden
  77.4 83.1 billion
• Overall treatment rate increased by over 50
  4.9 7.9 million
• Increased number of depressed patients working
  10.4 11.4 million
• Total number of suicides fell
• Lower cost per treated case
• Increase of quality of treatment

More patience treated More depressed patients
work Less costs per case
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Dynamics of Treating Depression Cost, Access
Quality

• Total cost remained relatively stable, from 77.4
  billion to 83.1 billion (measured on a
  consistent basis)

• Far more depressed people were treated in 2000
  than in 1990 (44 v. 28)
• Far more depressed people were employed in 2000
  than in 1990 (11.4m v. 10.4m)

• Only 20 of depression sufferers currently
  receive appropriate care