How can care for depression become more cost-effective?

Objective. —To determine the cost and health effects of changes in the content and quality of care for depressed patients treated in prepaid general medical practices (internal and family medicine) and mental health specialty practices and shifts in the proportion of patients treated in general medicine. Methods. —Cost-effectiveness analysis and simulations, which are empirically based on data from the Medical Outcomes Study. Outcome Measures. —Change in serious functional limitations, annual treatment costs per patient, and costs per reduction in one functional limitation. Results. —More appropriate care for depression (increased counseling, use of appropriate antidepressant medications, or avoidance of regular minor tranquilizer use) improves functioning outcomes. Although this approach increases total costs of care, it also improves the value of care because each dollar spent on care now provides more benefits in terms of health improvements. In contrast with the effects of more appropriate care for depression, the trend away from mental health specialty care and toward general medical provider care under current treatment patterns reduces costs, worsens outcomes, and does not increase the value of health care spending in terms of health improvement per dollar. Conclusion. —Quality improvement measures that roughly follow practice guidelines for depression can improve outcomes and the value or cost-effectiveness of care, but at increased treatment costs; shifting patients away from mental health specialists decreases costs but worsens functioning outcomes. The best strategy for making care for depression more cost-effective is through quality improvement, not through changing specialty mix. Yet combining these strategies may achieve better outcomes, lower treatment costs, and better value of care compared with current practice patterns. To realize this potential, however, substantial quality improvement of care for depression is necessary in general medical practice. (JAMA. 1995;273:51-58)