Michael Von Korff, ScD, is associate director for external research, Center for Health Studies, Group Health Cooperative, Puget Sound, Washington. Von Korff and his colleagues have conducted numerous studies of depression treatment by primary care physicians and have explored ways to integrate behavioral techniques into that setting.

Q: How serious a problem is depression?

A: In the medical setting, it is a very common problem, affecting anywhere from 6 to 8 percent of patients up to 20 percent. In the general population, the estimates range from 4 percent up to 10 percent of all adults. It is twice as common in women as among men. And the burden on society is large. The cost of health care for people with depression is 1.5 to 2 times higher than for people of the same age and sex who are not depressed. Most of that increase is not due to patients seeking services for depression but for physical health problems related to depression, such as chronic disease, pain, and fatigue. Depression also is as disabling or more disabling than other common medical conditions such as arthritis, heart disease, and diabetes. People miss work, limit their activities, and have problems carrying out their social responsibilities. A big cost in terms of quality of life. And the other social cost you think most about is suicide. Depression is an important risk factor for suicide.

Q: Many experts now look at depression, not as a one-time, isolated event, but as a chronic condition that needs to be managed on an ongoing basis. Why has thinking changed?

A: We've learned that depression has fairly high relapse rates. About a third of primary care patients who recover from an episode of depression have a relapse over the following year. Among patients who come in for treatment of depression, about three-quarters have been treated for depression before. For some people, depression is chronic in the sense that it is always there. Fluctuations in depressive symptoms are more typical. Like having asthma or diabetes, there are times when you are better and times when you are not doing as well.

Q: What can be done to prevent the return of depression in these patients?

A: From randomized controlled trials we've learned that people who are at increased risk for relapse - those who have had multiple prior episodes or a family history of depression - can reduce their risk if they continue to take antidepressant medication at therapeutic dosage levels, what we call maintenance medication. Proven forms of psychotherapy have been shown to reduce relapse rates as well.

Q: When most people hear psychotherapy, they think they are going to have to talk about their relationship with their mother.

A: There are two forms of psychotherapy that have been proven effective for depression, and both concentrate on the here and now rather than the past. Cognitive behavioral therapy involves identifying negative, unrealistic thoughts you have about yourself and developing strategies to change them, as well as taking steps to do more things that are rewarding and pleasurable. In interpersonal therapy, you work to develop more effective ways of dealing with others that make you feel better. In studies by Ellen Frank (See Frank interview: "Preventing Depression's Return.") and colleagues at the University of Pittsburgh, interpersonal therapy was effective in preventing recurrence of depression in middle-aged and elderly adults.

Q: Are there other ways that behavioral techniques are useful in depression treatment -particularly in getting people to continue treatment over the long term?

A: This is a problem with almost every chronic condition you look at. People tend to be ambivalent about taking medications. In depression, we know that unless there is active follow-up, half or a little more than half of patients will quit taking their medicine before the end of the 4-6 month acute phase of treatment. [16] A similar problem exists in the maintenance phase. Behavioral techniques certainly can be very useful around medication issues. It's not a snap to stick with a medication regimen. You forget to do it. There are times when you don't feel like doing it. There are often side effects. We think that people frequently just stop taking their medications on their own for whatever reason and they never check back in with their physician, psychiatrist, or therapist. It is important to keep in touch and have good communication around these issues, make a plan, and work to stick with it. We know that patients that stick with their medications and work with their doctors to change their regimen, if necessary, are more likely to get better and stay better.

Q: For a majority of patients with depression, their primary care doctor is the point of departure for treatment. You've looked at ways to integrate medical and behavioral health care in primary care. What have you found?

A: We've done research and others have done research on how you can have mental health specialists and primary care specialists co-manage patients in ways that improve outcomes. [12] Some of the more recent approaches are not necessarily that hard to do, and they don't have to be expensive. It requires some organization to do it effectively - getting people organized so there is active follow-up, clearly defined roles, and people are managing the illness according to a protocol. In general, that is not happening in health care today, not for depression and not for other chronic diseases either.

Interview #2: 'Preventing Depression's Return'

Ellen Frank, PhD, is a professor of psychiatry and psychology and the director of the Depression and Manic Depression Prevention Clinic at The University of Pittsburgh School of Medicine. She and her colleagues have conducted a number of studies on the use of medication and psychotherapy to prevent recurrence among depressed patients.

Q: Many experts now view depression as a chronic, lifelong condition. How has the approach to treatment changed?

A: Twenty years ago, we taught medical students that if patients had one episode of depression their chances of having a second were 50-50. Well, we now know that is not true. In most cases, depression is a recurrent condition. Perhaps 80 to 85 percent of individuals who have a first episode will probably have a second, and with subsequent episodes, the numbers just go up from there. How closely spaced those episodes are varies tremendously from person to person. We would consider a person to have recurrent depression if he or she had an episode every ten years. But there are others who are having new episodes every 18 to 20 months, and that is a very different clinical picture.

Q: You've studied "maintenance" treatments for depression to prevent symptoms from reappearing. What have you found?

A: In our studies with middle-aged patients and the elderly, we've found that monthly sessions of interpersonal psychotherapy seem to have a significant protective effect against new episodes of depression.[6] In the midlife study, the typical patient on placebo with no psychotherapy went 18 weeks before having a new episode of depression. The typical patient who underwent monthly psychotherapy either with or without a placebo tablet went 65 to 70 weeks without a new episode of depression. And among patients who received active medication with or without psychotherapy, 80 to 90 percent of them went the whole three years of the study without a new episode of depression.

Q: How does interpersonal psychotherapy work?

A: Interpersonal psychotherapy focuses on the patient's interpersonal and social roles. The theory is that depression always occurs in an interpersonal context; sometimes the interpersonal problems cause the depression and sometimes the depression causes the interpersonal problems. In either case, addressing the interpersonal problems seems to help the depression. Usually the problems are one of four specific types: an unresolved grief reaction; a dispute with a family member or other important person; an interpersonal role transition, such as going from being a married person to a divorced person; and interpersonal deficits, in which the person has no social relationships or only unsatisfying social relationships. The therapist takes a history, tries to assess which of these four problem areas seems most associated with the onset of depression, and then works with the patient to try to resolve the problem.

Q: So if it is somebody with a deficit in social relationships, what might the therapist do?

A: If it were the kind of deficit that results from the patient having disputes with all the people in his or her life, you might try to understand how the patient communicates his or her needs to other people. What are his expectations from other people and are there nonreciprocal expectations in multiple relationships? You try to help the patient to find a way of negotiating what he or she needs in the relationship without infuriating the other people.

Q: Cognitive behavioral therapy is also used to treat depression. How does it work?

A: Cognitive behavioral therapy is based on the rationale that depression arises when individuals have an unrealistically negative view of themselves, their world, or their future. These beliefs are not just negative - they also tend to have an overly generalized, exaggerated, spiraling quality to them. The treatment really consists of a kind of Socratic dialogue in which the therapist helps the patient see the irrationality of these negative beliefs and works with the patient to correct them.

Q: Can you give an example?

A: Let's say I walk out to my secretary and ask her in a relatively neutral tone to retype a letter because of an error. She thinks, "Oh, another mistake. I make mistakes every single day. I'm useless as a secretary, useless as a person, I might as well go home and kill myself." So the therapist would say, "When was the last time you really can remember making a mistake? Today is Friday; did you make any mistakes on Thursday? No. How about Wednesday? No. Oh, you remember making a mistake the week before? So what is this every day thing?" You teach patients how to monitor for these negative thoughts and how to combat them on their own.

Another component of cognitive behavioral therapy is helping patients to increase the frequency of activities that give them pleasure or a sense of accomplishment. The therapist helps the patient to identify these activities, and they draw up a contract that says, for example, today after work, you are going to visit your sister, and Friday you are going to a movie, and Saturday you are going to do a load of laundry. Some research suggests this "behavioral activation" component of the therapy alone may be as effective as the whole cognitive package.[8]

Q: We often think of depression treatment as an either/or situation: either medication or psychotherapy. Is there evidence that one can enhance the other?

A: Some. In the maintenance phase of our study with the elderly, those who got a combination of medication and psychotherapy did the best of any of the patients. In our midlife study, however, patients who received only drugs in the maintenance phase did just as well as patients who received drugs plus psychotherapy. Many studies exploring this question, like ours, have been completed in academic medical centers where both the medication and psychotherapy treatments have been done in the best way possible. Think of it this way: If 90 percent of patients on medication stay well for all three years of the maintenance treatment, there's not much room for psychotherapy to add to 90 percent. Out in the community where drug treatment may not be done in quite as sophisticated a manner, there may be much more room for psychotherapy to add to the effects of medication.

Treating Depression: "Good Value for the Money":

Depressed patients remain high users of all health services, leading some researchers to explore whether the cost of treating patients' depression might be offset by a reduction in their use of other medical care.

But asking whether treating depression produces a "cost offset" for other medical care is too limited a perspective, according to Michael Von Korff, ScD, associate director for external research, Center for Health Studies, Group Health Cooperative, Puget Sound, Washington.

"Does an insurance company save money by treating depression? The answer to that question is probably no. But I don't know what other health problem we expect that of," Von Korff says. "Is there good value for the money? Absolutely. There are lots of things going on in health care today that are expensive with little evidence of effectiveness. Treatment of depression isn't one of them."

In his own study on the cost effectiveness of depression treatment, Von Korff and colleagues compared the costs and treatment outcomes over one year among patients who received usual treatment for depression from their primary care physician and those whose treatment was managed collaboratively by their primary care physician and a psychiatrist or psychologist. [25] The researchers found evidence that collaborative care was more cost effective. Among those whose care was coordinated by the physician-psychologist team, for example, the cost per patient of the collaborative care was higher than the usual care group ($1,182 vs. $968). But many more of the collaborative care patients were successfully treated (70 percent vs. 42 percent). The researchers calculated that the cost of successful treatment was actually lower for the collaborative-care patients ($1,679 vs. $2,170) than for those who received usual care.

"There is a difference between a 'cost offset' and 'cost effectiveness,'" Von Korff says. "It trivializes depression to say the primary justification for treating it is to save health care costs. The primary justification for treating it is that it ruins people's lives."

Improving Treatment of Depression in Primary Care:

While physicians treat almost half of all people who receive treatment for depression, some studies suggest they may fail to correctly identify 30 to 50 percent of depressed patients in their practices. [27] Physicians may face substantial barriers in recognizing and managing depressed patients seen in their practices. Many of these patients approach their physicians with physical health symptoms of depression rather than mental health complaints. Limited time and financial constraints present additional barriers to optimal care and suggest that a key function of primary care physicians is diagnosis and referral to mental health specialists.

Primary care physicians uniformly believe they are responsible for recognizing depression but not all believe it is their responsibility to treat it or feel competent to do so, according to a survey of 1350 physicians. Family physicians are most likely to welcome responsibility for treating depression and express confidence in their ability to do so, while obstetrician-gynecologists are least likely. General internists fall somewhere between the two. [27]

There have been a number of efforts in the last decade to improve diagnosis and treatment of depression in primary care, including the creation of clinical guidelines by the federal Agency for Health Care Policy and Research, [1] and the development of screening questionnaires, such as PRIME-MD, to aid primary care physicians in diagnosing mental illness. [24]

One of the latest attempts to improve depression care has been mounted by the MacArthur Foundation through its Initiative on Depression and Primary Care. Chaired by Allen Dietrich, MD, of Dartmouth Medical School, the multi-year effort supports research on current treatment practices in primary care, works to disseminate effective interventions in that setting, and focuses on improving communication surrounding referral.

Dietrich and colleagues found that communication barriers remain between primary care physicians and mental health specialists, according to a pilot study of referrals by five urban and suburban physicians. Primary care physicians feel a greater sense of urgency when referring patients for specialty treatment of depression than they do when making other referrals. But in nearly half the cases, physicians remained dissatisfied with the feedback they received from consultants, and in two-thirds of cases they viewed the consultation as still incomplete three months later. [17]

Research supported by the Initiative is addressing "skills training programs" for physicians, better ways to educate and monitor patients, and strategies to improve communications between primary care physicians and mental health specialists in patients they share.

What is Major Depression?:

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) [3] lists the following criteria for major depression. At least five must be present nearly every day during the same two-week period:
* Depressed mood most of the day
* Diminished interest or pleasure in all, or almost all, activities
* Significant weight loss or weight gain
* Insomnia or excessive sleeping
* Extreme restlessness or lethargy, observable by others
* Fatigue or loss of energy
* Feelings of worthlessness or guilt
* Diminished ability to think or concentrate
* Recurrent thoughts of death or suicide

Health Consequences of Depression:

Depression frequently accompanies a number of general medical conditions, including diabetes, cancer, heart attacks, and stroke. [1]

Recent research suggests depression can have profound effects on people's physical health. It can make it more difficult to manage certain chronic conditions, such as diabetes, and it can worsen the prognosis for people with cancer. It may even increase the risk of developing other serious disorders, including heart disease. Consider these findings:

* Diabetes: Among 33 adults with insulin-dependent diabetes, patients with a lifetime history of major depression scored significantly lower on physiologic measures of blood sugar control compared with those with no history of depression. [2] Children with insulin-dependant diabetes who were depressed were significantly more likely to develop diabetic retinopathy, a complication of diabetes affecting the eyes, compared with diabetic children who were not depressed. [15]

* Cancer: In a study of 68 adults with malignant melanoma, those who learned stress management, problem solving, and other coping skills in addition to receiving usual care reported lower levels of depression six months after surgery and a mortality rate after six years of 8.8% compared with a rate of 29.4% for those who received usual care alone. Improvement in depression was accompanied by a number of indicators of improved immune function, including increased numbers of cancer-destroying natural killer (NK) cells and greater NK activity. [4]

* Heart disease: Among 1,557 healthy adults followed for 12 years, those who were depressed at baseline had more than twice the number of heart attacks as people who were not depressed. [22] Among 218 hospitalized heart attack patients followed for 18 months, those with mild, moderate, or severe symptoms of depression were approximately three to eight times more likely to die over the course of the study. [7]

Depressed at Work:

The cost to employers of treating depressed workers may be offset in whole or in part by decreases in short-term disability and increases in productivity, a number of studies suggest.

For example, Ronald Kessler, PhD, Harvard University, and colleagues examined short-term disability rates attributable to depression among more than 11,000 workers interviewed in two national studies. [13] They found that depressed workers had between 1.5 and 3.2 more short-term disability days in any given month than did non-depressed workers. That was equivalent to between $182 and $395 in wages, or about 45 percent to 98 percent of the estimated cost of successfully treating depression with the drug Nortriptyline for 30 days, Kessler and colleagues say.

In another study, Kathryn M. Rost, PhD, University of Arkansas for Medical Sciences, Little Rock, followed a group of 435 workers with depression or depressive symptoms for one year. [28] Of these workers, 171 received treatment for depression. When the researchers compared estimates of the workers' lost earnings due to depression with treatment costs, they found that the cost of depression treatment was fully offset by savings realized from fewer lost work days. In fact, assuming workers paid for their own treatment, those who received treatment came out $448 ahead, on average.

"Employers who bear the cost from lost work days should encourage their employees with depressive disorders to seek treatment, even if it means paying for the entire treatment cost," Rost and colleagues say. "Self-employed individuals with depression also will benefit even if they pay for the treatment costs themselves."

Steps to Collaborative Management of Chronic Conditions:

Once a chronic condition has been identified, patients do best if there is on-going commitment by patients, their families, and their health care providers to work together over time. There is strong evidence that the following simple steps taken by providers and patients can significantly improve health and well-being.

1. Define the problem jointly: Providers often define problems in terms of medical diagnoses and treatments, while patients define them in terms of the impact that symptoms have on their lives. Patients are more likely to benefit when these two perspectives are harmonized in a shared definition of the problem.

2. Develop common action plan: Managing chronic conditions is more successful when providers and patients focus on a few specific concerns, identify realistic goals, and commit to a joint plan of action in which the responsibilities of both parties are clear.

3. Explore possible programs and services: Many chronic conditions are better managed when patients are referred by providers to special support services or behavior change programs tailored to their priorities, needs, and preferences.

4. Track progress and anticipate course corrections: Scheduled, on-going communication between providers and patients is critical to tracking progress in achieving goals, identifying potential barriers and complications, and making needed adjustments in the joint plan of action.

For more information on the Behavior Change in Managed Care Settings project, visit our Web site http://www.cfah.org

The Research:

1. Clinical Guideline Panel. (1993). "Depression in Primary Care: Volume 1, Detection and Diagnosis; Volume 2, Treatment of Major Depression." Agency for Health Care Policy and Research, Rockville, MD. http://www.ahcpr.gov.

2. DeGroot M, et al. (1999). "Glycemic Control and Major Depression in Patients with Type 1 and Type 2 Diabetes Mellitus." Journal of Psychosomatic Research, 46(5): 425-435.

3. Diagnostic and Statistical Manual of Mental Disorders IV. (1994) American Psychiatric Association, Washington, DC. http://www.psych.org.

4. Fawzy FI, et al. (1993). "Malignant Melanoma: Effects of an Early Structured Psychiatric Intervention, Coping, and Affective State on Recurrence and Survival 6 Years Later." Archives of General Psychiatry, 50: 681-689.

5. Frank E and Thase ME. (1999). "Natural History and Preventative Treatment of Recurrent Mood Disorders." Annual Review of Medicine, 50: 453-468.

6. Frank E, et al. (1990). "Three-Year Outcomes for Maintenance Therapies in Recurrent Depression." Archives of General Psychiatry, 47: 1093-1099.

7. Frasure-Smith N, et al. (1995). "Depression and 18-month Prognosis after Myocardial Infarction." Circulation, 91(4): 999-1005.

8. Gortner ET, et al. (1998). "Cognitive Behavioral Treatment for Depression: Relapse Prevention." Journal of Consulting and Clinical Psychology, 66(2): 377-384.

9. Greenberg PE, et al. (1993). "The Economic Burden of Depression in 1990." Journal of Clinical Psychiatry, 54(11): 405-417.

10. Jarrett RB, et al. (1998). "Is There a Role for Continuation Phase Cognitive Therapy for Depressed Outpatients?" Journal of Consulting and Clinical Psychology, 66:1036-1040.

11. Judd LL. (1997). "The Clinical Course of Unipolar Major Depressive Disorders." Archives of General Psychiatry, 54: 989-991.

12. Katon W, et al. (1995). "Collaborative Management to Achieve Treatment Guidelines. Impact on Depression in Primary Care." Journal of the American Medical Association, 273(13): 1026-1031.

13. Kessler RC, et al. (1994). "Lifetime and 12-month Prevalence of DSM-III-R Psychiatric Disorders in the United States. Results from the National Comorbidity Survey." Archives of General Psychiatry, 51: 8-19.

14. Kessler RC, et al. (1999). "Depression in the Workplace: Effects on Short-term Disability." Health Affairs, 18(5): 163-171.

15. Kovacs M, et al. (1995). "Biomedical and Psychiatric Risk Factors for Retinopathy among Children with IDDM." Diabetes Care, 15: 1592-1599.

16. Lin EHB, et al. (1995). "The Role of the Primary Care Physician in Patients' Adherence to Antidepressant Therapy." Medical Care, 33(1): 67-74.

17. Little DN, et al. (1998). "Referrals for Depression by Primary Care Physicians," Journal of Family Practice, 47(5): 375-377.

18. Narrow WE, et al. (1993). Use of Services by Persons with Mental and Addictive Disorders. Findings from the National Institute of Mental Health Epidemiological Catchment Area Program." Archives of General Psychiatry, 50: 95-107.

19. National Alliance for the Mentally Ill. (1999). "Depression." Arlington, VA. http://www.nami.org.

20. National Depressive and Manic-Depressive Association. (1999). "Overview of Depressive Illnesses and it Symptoms." Chicago, IL. http://www.ndma.org.

21. National Institute of Mental Health. (1999). "Depression: Treat It. Defeat It." Bethesda, MD. http://www.nimh.nih.gov.

22. Pratt LA, et al. (1996). "Depression, Psychotropic Medication, and Risk of Myocardial Infarction. Prospective Data from the Baltimore ECA Follow-up." Circulation, 94: 3123-3129.

23. Simon GE, et al. (1995). "Health Care Costs of Primary Care Patients with Recognized Depression." Archives of General Psychiatry, 52: 850-856.

24. Spitzer RL, et al. (1994). "Utility of a New Procedure for Diagnosing Mental Disorder in Primary Care. The PRIME-MD 1000 Study." Journal of the American Medical Association, 272(22): 1749-56.

25. Von Korff M, et al. (1998). "Treatment Costs, Cost Offset, and Cost-Effectiveness of Collaborative Management of Depression." Psychosomatic Medicine, 60: 143-149.

26. Wells KB, et al. (1989). "The Functioning and Well-Being of Depressed Patients. Results from the Medical Outcomes Study." Journal of the American Medical Association, 262(7): 914-919.

27. Williams JW, et al. (1999). "Primary Care Physicians' Approach to Depressive Disorder." Archives of Family Medicine, 8: 58-67.

28. Zhang M, et al. (1999). "A Community Study of Depression Treatment and Employment Earnings." Psychiatric Services, 50(9): 1209-171.

Facts of Life is prepared with assistance from:

Academy of Behavioral Medicine Research
Academy of Psychosomatic Medicine
American College of Neuropsychopharmacology
American Psychiatric Association
American Psychological Association
American Psychological Association-Division 38
American Psychosomatic Society
American Society of Psychiatric Oncology
College on Problems of Drug Dependence
International Psycho-Oncology Society
International Society for Traumatic Stress Studies
Society of Behavioral Medicine
Society for Developmental and Behavioral Pediatrics
Society for Public Health Education
Society for Research on Nicotine and Tobacco

The Center for the Advancement of Health, , a nonprofit institute, promotes the science that explores health as a complex and dynamic system of relationships among biology, behavior, psychology, and social context and works to integrate this knowledge into public awareness, health care policy, and health care practice. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding.

Funding for this series was provided by the Robert Wood Johnson Foundation.

For more information contact:
Petrina Chong Director of Communications
phone: 202.387.2829
To e-mail Petrina Chong