The consequences of depression: the prevalence and cost of depression are beginning to attract attention - includes related information on publication from Agency for Health Care Policy & Research - Special Report: Helping Employees Overcome Depression

The prevalence and cost of depression are beginning to attract attention.

Depression takes an enormous toll on our country: At any given time, it affects nearly 11 million Americans of both sexes, all ages, and all ethnic backgrounds. If untreated, depression leads to suicide in about 15% of the people it affects, and it is associated with chemical substance abuse in many other individuals.

According to researchers at MIT's Sloan School of Management, in Cambridge, Mass., and Analysis Group, Inc., a research and consulting company also in Cambridge, the direct and indirect costs associated with depression in the United States in 1990 totaled more than $43.7 billion. [3] Yet while the cost of depression is now well documented, the illness continues to remain misunderstood.

Identifying the disorder

At its most basic level, depression is a mood disorder--one with which virtually everyone is familiar. According to Stewart H. Reiter, M.D., clinical director of Summit Psychiatric and Counseling Associates in Summit, N.J., for most people, depression can be "a very normal and natural mood that we all experience from time to time."

Almost all of us have, at some point, felt depressed over such stressful life events as job loss, illness, or a death in the family Usually, depression at this level is not long-lived or severe. It may temporarily affect concentration and performance at work. But depression as most people know it isn't a persistent state that results in dysfunction. Depression becomes problematic when it persists.

Specific symptoms

According to the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised (DSM-III-R), major depressive disorder is characterized by the following symptoms, which must be present nearly every day for at least two weeks:

1. Depressed mood most of the day;

2. Loss of interest or pleasure in all, or almost all, activities, most of the day;

3. Significant weight loss or weight gain when not dieting;

4. Sleep disturbances;

5. Psychomotor agitation (for instance, excessive hand wringing) or retardation (such as moving or speaking slowly);

6. Fatigue or loss of energy;

7. Feelings of worthlessness or excessive or inappropriate guilt;

8. Diminished ability to think or concentrate, or indecisiveness;

9. Recurrent thoughts of death or suicide; suicide attempts.

At least one of the first two symptoms, plus at least four other symptoms must be present during the same two-week period in order to meet the DSM-III-R criteria for a major depressive episode.

Other forms of depressive disorder include dysthymia and manic-depression. Dysthymia is generally characterized by a chronic mild depressive syndrome that has been present for at least two years, according to the APA's recently released "Practice Guideline for Major Depressive Disorder in Adults." [4] The National Institute of Mental Health (NIMH), in Bethesda, Md., notes that while the symptoms experienced by people suffering from dysthymia may not be as severe as those that characterize a major depressive episode, they may keep victims from ever feeling really well.

In manic-depression, which is also known as bipolar disorder, the individual goes through either mania alone or both depression and mania on an alternating cycle. In addition to experiencing the symptoms of depression, the NIMH says victims in a manic phase of the cycle may experience:

1. Increased energy;

2. Decreased need for sleep;

3. Increased risk-taking;

4. Unrealistic beliefs in their own abilities;

5. Increased talking and social, physical, and sexual activity;

6. Feelings of mood elevation or irritability;

7. Aggressive response to frustration.

In addition, according to NIMH, individuals suffering from manic-depression may overlook the consequences of their behavior. For example, they may suddenly incur enormous debts, behave promiscuously, make poor business decisions, or break the law and wind up in jail.

Depression sometimes, but not always, coexists with anxiety. Symptoms sometimes overlap. For example, difficulty sleeping and trouble concentrating may characterize both disorders. However, according to Stress, Anxiety and Depression in the Workplace, [5] a report that was published in 1990 by the New York Business Group on Health (NYBGH), a coalition of businesses concerned about health care issues, anxiety is also characterized by symptoms such as trembling or feeling shaky, restlessness, impatience and irritability, and feeling tense or on edge. The physical manifestations of anxiety include shortness of breath, palpitations, sweating, flushes or chills, dizziness, and dry mouth, sometimes accompanied by difficulty in swallowing.

Economic costs of depression

Until very recently, NIMH estimated that the annual cost of depressive illness in the United States was about $27 billion, $17 billion of which reflected time lost from work.6 That figure was large enough to convince many employers that they should implement initiatives to reduce the impact of depression in the workplace.

In mid-1993, however, the landmark study entitled, "The Economic Burden of Depression in 1990," [3,7] Was released. This study, by the MIT and Analysis Group researchers, revealed even more disturbing news about the costs associated with depressive disorders. In 1990, the economic cost of depression was actually much larger than the NIMH had previously estimated: a whopping $43.7 billion. [3]

That figure puts depressive illness almost on a par with other major illnesses such as AIDS, coronary heart disease, and cancer. Depression "afflicts millions of people and costs society tens of billions of dollars each year," the study's authors concluded. [7]

Paul E. Greenberg, Laura E. Stiglin, Stan N. Finkelstein M.D., and Ernst R. Berndt, who conducted the research, calculated the costs related to major depression, bipolar disorder, and dysthymia in their total figure. The approximate cost breakdown is as follows: [3]

* Direct costs--more than $12 billion. Of that amount, inpatient care accounts for $8.3 billion; outpatient and partial care programs account for about $2.9 billion; and pharmaceutical prescriptions add about $1.2 billion to the total;

* Mortality costs--about $7.5 billion. This figure reflects total earnings lost as a result of suicide. The figure is based on the assumption that 60% of suicides can be attributed to major depression, bipolar disorder, or dysthymia. Assigning relative values to lifetime earnings, the researchers calculated costs ranging from $4.3 billion to $11.2 billion;

* Morbidity costs--estimated to be about $23.8 billion--the largest indirect cost component in the study These are costs generated by absenteeism and reductions in worker productivity.

According to Paul E. Greenberg, one of the authors of the study, the researchers decided not to include comorbidity costs in the final report. These are the costs of substance abuse disorders that could possibly be eliminated if all depression cases were successfully treated. The reason, he says, is that it is difficult to identify those cases in which depression causes substance abuse and not the reverse.

Estimating that a total of almost 11 million people in the United States suffered from an affective illness during 1990, the MIT/Analysis Group study authors concluded that about 72% of depression sufferers, or 7.8 million individuals, are part of the nation's work force. [7]

The cost of depression to employers, therefore, is overwhelming. It is reflected in increased absenteeism, lowered productivity, and more frequent safety risks. Employers may also be subjected to some or all of the expenses related to inappropriate and often excessive utilization of medical services, including emergency room visits.

According to NIMH, patients with affective disorders make three times as many visits to medical doctors as do patients who don't suffer from psychiatric illness. Patients with moderate to severe depression also undergo more medical evaluations than do those patients without depressive illness. [8]

Related expenses

While the magnitude of expense associated specifically with depressive disorders is now being understood for the first time, overall costs related to mental health problems in general have long been familiar to employers.

Over the past decade, for example, employers saw their mental health and substance abuse claims grow from 5% to as much as 20% of all health care expenditures, says Saul Feldman, chairman of U.S. Behavioral Health (USBH), a managed mental health care company in Emeryville, Calif. [9]

According to A. Foster Higgins, benefits consultants in New York, in 1989, the cost of mental health and substance abuse benefits for employers with more than 5,000 employees rose by 47%, after a 27% increase the previous year. [6]

Despite the huge quantifiable costs associated with depression, monetary terms tell only part of the story. Depressive disorders can lead to job loss, interference with marital relationships and parenting ability, and in some cases, suicide, says Edward Shahady, M.D., professor of family medicine at the University of North Carolina in Chapel Hill. At work, depression also affects other employees. "Depressed people are more irritable. They can't concentrate as well. If their jobs require cooperation with others, the impact can be noticeable," he says.

Causes of depression

A number of factors appear to contribute to the onset of depression. Among them: genetic vulnerability; disturbances in brain biochemistry; and stressful life events.

Recently, gene mapping techniques have provided evidence of genetic involvement, according to NIMH. Children who have one depressed parent who has had several episodes of depressive illness have a one in seven chance of suffering from depression themselves, according to the Agency for Health Care Policy and Research (AHCPR) in Rockville, Md. [10]

An imbalance in the level of at least some of the brain's neurotransmitters--chemical messengers that transmit signals among brain cells--is also closely tied to depression. In many individuals, when the chemical imbalance is corrected and levels of these neurotransmitters increase, symptoms of depression decrease.

Finally, stress apparently plays a significant part in bringing about an episode of depression, according to NIMH. (For more information about the role of stress in depression, see "Helping to eliminate stress in the workplace," page 28.)

Groups at risk

According to NIMH, [8] there is an increased incidence of depression within certain groups. For example, clinical depression appears to be twice as common in women as it is in men. One explanation for this disparity is that depression may manifest differently in men than in women. Consequently, it may be harder to recognize in men.

Another explanation is that women are more likely to seek professional help than are men, who, because of cultural expectations, often hide their feelings.

In addition to women, groups that experience high rates of depression include individuals between the ages of 25 and 44, and those who are separated, divorced, or unhappily married, according to data from NIMH.

Among young children, the prevalence of depression can be hard to quantify since youngsters may exhibit symptoms of depression along with behavioral problems, such as difficulty getting along in school, or delinquency. These factors can make it more difficult to diagnose underlying depression in children.

At the other end of the age spectrum, the problems normally associated with aging can mask the onset of depression. For example, according to "Diagnosis and Treatment of Depression in Late Life," a report from the National Institutes of Health (NIH), in Bethesda, Md., elderly persons are more likely to report sleep disorders than they are depressed moods. [11] This can cause clinicians to focus on patients' medical conditions, rather than on depression, as the cause of their problems.

Treatment is essential

According to the AHCPR, [10] without treatment a major depressive disorder can last from six to as many as 12 months. Moreover, depression tends to recur. About half of the people who have one depressive episode will have a second. After three episodes, the chances of having a fourth episode rise to 90%. Therefore, depression remains a continuing health problem in the United States.

Yet the good news is that correct diagnosis and appropriate treatment can help between 80% and 90% of those suffering from depression, according to NIMH. [8] That's a positive message for the millions of individuals who now suffer from affective disorders. It should also be a source of encouragement for the employers who bear much of the economic brunt of untreated depression.

Some facts from a new guide for patients

The federal government is trying to help the public become aware of depression. One of its publications, "Depression Is A Treatable Illness," is aimed specifically at patients. The booklet is based on clinical guidelines developed under the sponsorship of the Agency for Health Care Policy and Research (AHCPR), in Rockville, Md.

Published in April 1993, the booklet describes the symptoms and treatments of depression and includes questions to ask doctors or other health care providers. Some of the more interesting facts included in the booklet are:

* Major depressive disorder is not caused by any one factor. It is probably caused by a combination of biological, genetic, psychological, and other factors.

* Drinking too much alcohol or using drugs can sametimes cause or worsen a depressive episode. It can also decrease the effectiveness of antidepressant medication that the patient may be taking.

* Depression is usually treated in two steps. The first, acute treatment, involves alleviating the symptoms of depression. Mare than half of all people treated with antidepressants feel significantly better after about six weeks. The second, continuation treatment, is aimed at helping to prevent relapse. After four to nine months of continuation treatment, a patient is usually considered to have recovered from an episode of depression.

Free copies of "Depression Is A Treatable Illness" can be obtained from AHCPR. The toll-free number to call: 800-358-9295.

Rita Shoor, a business writer from Blythewood, S.C., wrote all the articles in this Special Report.

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