While the number of people who sought out depression treatment in the past decade has seen a steady rise, use of psychotherapy as a treatment option has continued to experience a significant decline.
At the same time, researchers said depression treatment may have been hindered by 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.
Steven Marcus, Ph.D., of the Philadelphia Veterans Affairs Medical Center, and colleague Mark Olfson, M.D., M.P.H., of Columbia University, 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 older tricyclic antidepressants or SSRIs declined and the percentage receiving more recent antidepressants increased.
Of treated patients, the percentage receiving psychotherapy declined from 53.6 percent to 43.1 percent between 1998 and 2007. This reflects a continuing trend that has been occurring since the 1990s, when the use of psychotherapy decreased from 71.1 percent at the beginning of the decade to 60.2 percent in 1997.
“Of those who received psychotherapy, the average number of psychotherapy visits and expenditures for these visits also significantly decreased,” the authors wrote. “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 wrote. “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 concluded.“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.”
During the 1990s, among those who were treated for depression, the use of antidepressant medications increased from 37.3 percent to 74.5 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.
The authors noted that depression is a leading cause of disability, lost productivity and health care expenditures.
The study was published in the December issue of Archives of General Psychiatry, one of the JAMA/Archives journals.