Care for Depression in a Changing Environment

Prologue: Psychologist Martin Seligman has referred to depression as “the common cold of mental illness.” The incidence of depression has continued to climb, ranking it among the leading causes of chronic illness among Americans. As such, depression was one of five “tracer conditions' that were part of the Medical Outcomes Study (MOS), conducted longitudinally over four years beginning in 1986. The authors of this paper were investigators in the MOS; here they use their findings as a test case to discuss the effects of various payment strategies and managed care on the treatment of mental health conditions. The paper places their clinical findings in a policy context. The authors found that the cost-effectiveness of care can be improved, although this does not necessarily mean that treatment costs are lowered. In fact, often the opposite is true. “Much dis-cussion about [mental health care coverage] reflects an implicit hope that higher-quality care is the magic bullet that miraculously lowers health care costs,” the authors write. “This wishful thinking appears to be so ingrained that our simulation of the effects of quality improvement is regularly misquoted as evidence for it, even though we explicitly say that quality improvement by itself raises treatment costs.” Kenneth Wells, a psychiatrist, holds a medical degree from the University of California, San Francisco, and a master of public health degree from the University of California, Los Angeles (UCLA). Since 1980 he has been a professor in the Department of Psychiatry, Neuropsychiatric Institute, at UCLA; a senior research analyst in the Systems Science Department of RAND; and director of mental health research for the National Study of Medical Care Outcomes. Roland Sturm is an associate economist at RAND in Santa Monica, California, and is a visiting assistant professor in the UCLA Department of Economics. He holds a doctorate in economics from Stanford University. Abstract: The U.S. health care system is quickly changing, but is it moving in the right direction? Focusing on care for clinical depression as a test case, this paper summarizes our previously published findings on the effects of various payment strategies, managed care, and primary care gatekeepers on the outcomes and costs for the treatment of mental health conditions. We then synthesize the policy implications of these findings for achieving value of care, lower costs, and good health outcomes.