The NationalDepressive and

Manic-Depressive Association
Consensus Statement on the
Undertreatment of Depression
Robert M. A. Hirschfeld, MD; Martin B. Keller, MD; Susan Panico; Bernard S. Arons, MD; David Barlow, PhD;
Frank Davidoff, MD; Jean Endicott, PhD; Jack Froom, MD; Michael Goldstein, MD; Jack M. Gorman, MD;
Don Guthrie, PhD; Richard G. Marek, MD; Theodore A. Maurer; Roger Meyer, MD; Katharine Phillips, MD;
Jerilyn Ross, MA, LCSW; Thomas L. Schwenk, MD; Steven S. Sharfstein, MD; Michael E. Thase, MD; Richard J. Wyatt, MD

Objective.\p=m-\Aconsensus conference on the reasons for the undertreatment of DEPEESSION is one of the most fre¬
depression was organized by the National Depressive and Manic Depressive As- quent of all medical illnesses. Depres¬
sociation (NDMDA) on January 17-18, 1996. The target audience included health sion is a pernicious illness associated
with episodes of long duration, high rates
policymakers, clinicians, patients and their families, and the public at large. Six key of chronicity, relapse, and recurrence,
questions were addressed: (1) Is depression undertreated in the community and in psychosocial and physical impairment,
the clinic? (2) What is the economic cost to society of depression? (3) What have and mortality and morbidity—with a
been the efforts in the past to redress undertreatment and how successful have they 15% risk of death from suicide in pa¬
been? (4) What are the reasons for the gap between our knowledge of the diagnosis tients with more severe forms of de¬
and treatment of depression and actual treatment received in this country? (5) What pression.1 Despite these facts, it has been
can we do to narrow this gap? (6) What can we do immediately to narrow this gap? extensively documented that patients
Participants.\p=m-\Consensus panel members were drawn from psychiatry, psy- with depression are being seriously un¬
chology, family practice, internal medicine, managed care and public health, con- dertreated, even though effective treat¬
sumers, and the general public. The panelists listened to a set of presentations with ments have been available for more than
35 years. Studies have also shown that
background papers from experts on diagnosis, epidemiology, treatment, and cost the vast majority of patients with chronic
of treatment.
Evidence.\p=m-\Expertssummarized relevant data from the world scientific literature major depression are misdiagnosed, re¬
ceive inappropriate or inadequate treat¬
on the 6 questions posed for the conference.
ment, or are given no treatment at all.2'5
Consensus Process.\p=m-\Panelmembers discussed openly all material present- Recent decades have witnessed an ex¬
ed to them in executive session. Selected panelists prepared first drafts of the con- traordinary expansion and refinement
sensus statements for each question. All of these drafts were read by all panelists of an array of treatment modalities for
and were edited and reedited until consensus was achieved. depression. The availability of effective
Conclusions.\p=m-\Thereis overwhelming evidence that individuals with depression pharmacological, other somatic, and psy¬
are being seriously undertreated. Safe, effective, and economical treatments are chosocial interventions greatly enhances
available. The cost to individuals and society of this undertreatment is substantial. the benefits of early identification and
treatment.
Long suffering, suicide, occupational impairment, and impairment in interpersonal In light of the prevalence and perni-
and family relationships exist. Efforts to redress this gap have included provider edu- ciousness of depression, the economic cost
cational programs and public educational programs. Reasons for the continuing gap of the illness, its treatability, and previ¬
include patient, provider, and health care system factors. Patient-based reasons in- ous public and professional educational
clude failure to recognize the symptoms, underestimating the severity, limited ac- efforts, why are so many people with
cess, reluctance to see a mental health care specialist due to stigma, noncompliance depression receiving inadequate treat¬
with treatment, and lack of health insurance. Provider factors include poor profes- ment or getting no treatment at all?
sional school education about depression, limited training in interpersonal skills, To help resolve questions surround¬
stigma, inadequate time to evaluate and treat depression, failure to consider psy- ing this issue, the National Depressive
and Manie-Depressive Association
chotherapeutic approaches, and prescription of inadequate doses of antidepressant (NDMDA) convened a Consensus Con¬
medication for inadequate durations. Mental health care systems create barriers to
ference on the Undertreatment of De-
receiving optimal treatment. Strategies to narrow the gap include enhancing the role
of patients and families as participants in care and advocates; developing perfor-
mance standards for behavioral health care systems, including incentives for posi- From the National Depressive and Manic-
tive identification, assessment, and treatment of depression; enhancing educational Depressive Association, Chicago, III. A complete list of
the consensus panel members' academic and profes-
programs for providers and the public; enhancing collaboration among provider sub- sional affiliations appears at the end of this article.
types (eg, primary care providers and mental health professionals); and conducting Reprints: Robert M. A. Hirschfeld, MD, Department
of Psychiatry and Behavioral Sciences, University of
research on development and testing of new treatments for depression. Texas Medical Branch, 1.200 Graves Bldg, Galveston,
JAMA. 1997;277:333-340 TX 77550-2774.

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 pression onJanuary 17-18, 1996. The
conference wascochaired by Martin B.
Keller, MD, chairman of the Department
of Psychiatry and Human Behavior at
Brown University, and Susan Panico,
executive director of the NDMDA. Rob¬
ert M. A. Hirschfeld, MD, chair of the
Department of Psychiatry and Behav¬
ioral Sciences at University of Texas
Medical Branch, chaired a consensus
panel including experts in psychiatry,
psychology, family practice, internal
medicine, managed care and public
health, as well as consumers and public
representatives. Following a day of pre¬
sentations by experts in the relevant
fields and discussion from the audience,
the panel considered the scientific and
historical evidence and formulated rec¬
ommendations and a consensus state¬
ment in response to the following
questions.
1. Is depression undertreated in the
community and in the clinic? How ex¬
tensive is the gap between current avail¬
able knowledge and actual treatment?
2. What is the economic cost to soci¬
ety of depression, including the cost of
lack of treatment, inappropriate treat¬
ment, and inadequate treatment?
3. What have been the efforts in the
past to redress undertreatment? How
successful have they been? What were
the problems associated with those
efforts?
4. What are the reasons for the gap
between our knowledge of the diagnosis
and treatment of depression and actual
treatment received in this country?
5. What can we do to narrow this gap?
(Propose research to better understand
the reasons for the gap.)
6. What can we do immediately to nar¬
row this gap? (Recommend programs to
narrow the gap now, while gaining more
knowledge about reasons for the gap.)
QUESTION 1
Is depression undertreated in the com¬
munity and in the clinic? How exten¬
sive is the gap between current avail¬
able knowledge and actual treatment?
Depressive disorders, including epi¬
sodic major depression and dysthymia,
are frequent conditions, with a lifetime
prevalence of up to 15% for men and
24% for women.6"8 Moreover, evidence
from several sources suggests that the
age of onset had decreased, and the over¬
all risk of suffering from a depressive
disorder has increased, over each of the
past several generations. Therefore, the
public health significance of depressive
disorders has increased.9·10
Data on the rates of recognition of
depression, the proportion of depressed
patients who are treated for depression,
and the adequacy of their treatment are
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available from research studies that have
wide variations in study design and popu¬
lation settings. Therefore, the response
to Question 1 is organized based on the
context in which the patients were as¬
sessed as to whether they were diag¬
nosed and treated for depression in 3
different settings: (1) the general popu¬
lation; (2) primary care settings; and
(3) mental health specialty settings.
Treatment of Depression
in the General Population
Epidemiologie studies document that
many people who suffer from depres¬
sion do not get adequate diagnosis and
treatment. In the Epidemiologie Catch¬
ment Area study, a nationwide commu¬
nity survey of psychiatric illness that
was conducted around 1980, approxi¬
mately one third of people suffering from
a major depressive disorder sought no
treatment for it. Of those who sought
treatment, few received adequate treat¬
ment. In fact, only about 1 in 10 of those
suffering from depression received ad¬
equate treatment.11
Treatment Received by Individuals
Before They Became Patients in Re¬
search Studies.—Even though these
data were collected on patients who
agreed to enter psychiatric research
studies, the information on treatment
represents a retrospective assessment
of the psychotropic medicine they re¬
ceived for their depression before en¬
tering their research studies, either for
the current episode of depression or at
any time in their lives. The treatment
they received may have been from any
type of health care provider. In most
instances the medical specialty or gradu¬
ate degree of the person who treated
the patient (perhaps in psychotherapy
or in a general medical office setting)
and the person who prescribed the treat¬
ment is not known, mainly because this
information was not requested. Simi¬
larly, there is usually not any informa¬
tion on the setting where the treatment
occurred. (It is not known where these
patients were seen and treated [if
treated] for their depression.) Thus,
these estimates of rates of treatment
are considered to be reflective of the
rate that occurs in the "general com¬
munity" for people who eventually en¬
ter psychiatric research studies for their
depression. These data are more restric¬
tive in generalizability than data col¬
lected in epidemiologie studies but are
informative of the treatment history of
people whose depression was severe
enough for them to seek and enter re¬
search studies on major depression.
A good example of data from natu¬
ralistic studies comes from a series of
articles from the National Institute of
Mental Health (NIMH) Collaborative
Depression Study. Undertreatment of
these patients with depression was first
described in 1982.12 Of the patients who
had moderate to severe depression for
at least 1 month before their entry into
the study,13 only 3% had been treated
with 250 mg of imipramine or the equiva¬
lent for 4 consecutive weeks and only
20% had received 150 mg of imipramine
or its equivalent for 4 consecutive weeks.
Treatment Received by Individuals
With Chronic Depression Prior to En¬
try Into Research Studies.—Data on
prior treatment received has also come
from randomized clinical trials (RCTs).
Among them are 4 RCTs of patients
with dysthymia, chronic major depres¬
sion, or double depression of a minimum
of 2 years' duration with median dura¬
tion of between 20 years and 30 years.
These studies2,3·5 had sample sizes of 635
patients, 416 patients, 76 patients, and
98 patients, respectively.
The lack of any prior antidepressant
treatment of patients5 is striking, rang¬
ing from 67% to 48%,3 who despite being
ill for a median of a minimum of 20 years
never received any antidepressant medi¬
cation. The range of patients who re¬
ceived adequate treatment is also so¬
bering: from a low of 5%5 to a high of
26.8%2 who had 1 course of adequate
antidepressant treatment, defined as 150
mg of imipramine or its equivalent for 4
consecutive weeks.
These results are compelling for sev¬
eral reasons. First, the patients' depres¬
sion was diagnosed very carefully by
trained research diagnosticians using
structural clinical interviews and crite¬
rion-based diagnostic systems. Second,
the patients all had either moderate to
severe depression or very long-stand¬
ing chronic depression. By any reason¬
able standard all of these patients met
criteria to be treated with antidepres¬
sant medication for the depression be¬
fore study entry and for at least several
(if not many) years during their life¬
times. Third, each of these studies, ex¬
cept l,5 was conducted between 1989
and 1995. Therefore, most of these pa¬
tients were depressed before, during,
and after both the widespread use of the
serotonin selective reuptake inhibitors
(SSRIs) and after the nationwide public
education campaigns such as D/ART
(Depression/Awareness, Recognition,
and Treatment), the National Public
Education Campaign (NPEC), and Na¬
tional Depression Screening Day.
Primary Care Settings
More recent studies have shown im¬
provement in recognition and treatment
of depression. For example, in a 1995
study of nearly 2000 consecutive patients
 entering a primary care clinic, 6.6% were
found to have major depression.14 Of
these nearly two thirds were recognized
as psychologically distressed by their
primary care physician, and over half
were prescribed antidepressant medi¬
cation. This low prevalence of major de¬
pression may have been due to sampling
procedures or to a high threshold for
illness. In another primary care sample,
a prevalence rate of 13.5% was reported
for major depression.15
Two studies conducted in a general
medical setting were designed to mea¬
sure the recognition of depression by
general practitioners, the adequacy of
treatment of depression in these set¬
tings, and the effect of psychiatric con¬
sultation or educational programs on in¬
creasing the adequacy of pharmacologie
treatment of depression.
The first large sample carefully de¬
signed study of the treatment of de¬
pression in a general medical setting
was by Katon et al.16 In this study of
high utilizers of primary care services,
approximately half were depressed and
judged by a psychiatrist to need anti¬
depressant therapy. Of these, 55% had
received no antidepressants in the year
prior to evaluation, and only 10.7% had
received an adequate dose and duration
of antidepressants.
Wells and colleagues conducted a
study across different treatment set¬
tings, which include large group-prac¬
tice health maintenance organizations
(HMOs); multispecialty practices; mixed
prepaid and fee-for-services group prac¬
tices; and singe-specialty, small-group,
or solo practices. Within each system of
care, representative samples of inter¬
nists, family practitioners, cardiologists,
endocrinologists, diabetologists, psychia¬
trists, and psychologists were selected.
When patients treated by psychiatrists,
psychologists, or other nonphysician
therapists, and general medical clinicians
were grouped together, 11% of depressed
patients of low severity received an an¬
tidepressant, and 29% of patients of high
severity received an antidepressant.
Across all patients, psychiatrists were
most likely (34%) to prescribe an anti¬
depressant than the other groups of cli¬
nicians (16%), but even the rate of pre¬
scriptions by psychiatrists (34%) is rather
low. Of those who received an antide¬
pressant, approximately 41% received an
adequate dose.
Mental Health Specialty Settings
In 1986 the NIMH Collaborative De¬
pression Study (CDS) reported on treat¬
ment received by patients with major
depression after they were admitted as
inpatients or outpatients. These dates
therefore reflect the treatment provided
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in mental health procedures at univer¬
sity-based tertiary facilities under the
direction of psychiatrists.
Of the patients admitted to a major
medical center as hospital inpatients for
the treatment of depression, as many as
31% had been given no antidepressants
or very low amounts of antidepressants
during the 8 weeks of care. In addition,
53% of the subjects who began outpa¬
tient treatment at the start of the study
had not received adequate antidepres¬
sant therapy. After 8 weeks of care, as
many as 67% of all patients had not fully
recovered and 38% still had several de¬
bilitating symptoms. Therefore, the lack
of treatment was not because the pa¬
tients were well.17
A study in 198817 reports on the treat¬
ment of patients hospitalized for depres¬
sion for a median of 140 days with re¬
sults similar to the CDS. Only 45% of
patients received 1 trial of antidepres¬
sants of adequate dose and duration,
despite over 4 months of psychiatric hos-
pitalization. In the aforementioned stud¬
ies, adequacy of dose and duration var¬
ied somewhat, but were all on what
would generally considered to be the
low end, as approximately 4 consecutive
weeks of 150 mg of imipramine was con¬
sidered adequate, with the range of ad¬
equacy for dosage being as high as 200
mg a day of imipramine or its equivalent
and as low as 100 mg per day.18
The CDS also reports on patients fol¬
lowed up prospectively who did not re¬
cover for at least 2 years and who re¬
covered and had a recurrence of at least
1 year's duration.19 The findings rein¬
force the pattern of undertreatment as
follows: 50% of patients depressed for 2
years or longer after study received no
or minimal treatment; 50% of patients
who recovered from major depression
did not receive preventive treatment in
the month prior to the next episode,20
and 60% of patients with a recurrence of
major depression, who then remained
chronically depressed for longer than 1
year, received no or minimal treatment.21
In the above studies minimal treatment
was defined as 100 mg of imipramine (or
its equivalent) for 4 weeks.
In conclusion, it is unfortunate that
the vast majority of those treated with
antidepressant medication are not pre¬
scribed an adequate dose for a long
enough time. It is not yet clear if use of
the newer antidepressants will lessen
this problem because of their generally
more favorable adverse effects profiles.
Effective structured psychotherapies
for depression also exist. Unfortunately,
few patients with depression actually
receive these psychotherapies.13 When
they do, they may not receive them for
a long enough period of time.
QUESTION 2
What is the economic cost to society of
depression, including the cost of lack of
treatment, inappropriate treatment, and
inadequate treatment?
Depression imposes an enormous bur¬
den on society—resulting from its high
prevalence, underdiagnosis, and under¬
treatment. Depression has many costs
and consequences, including decreased
quality of life for patients and their fami¬
lies, high morbidity and mortality, and
substantial economic losses.
Traditionally, cost-of-illness estimates
are broken into direct and indirect costs.
Direct costs are all treatment costs, in¬
cluding inpatient and outpatient care,
medications, and other treatment costs.
Indirect costs are more difficult to mea¬
sure and include lost productivity while
at work and absenteeism. Indirect costs
also include those related to premature
death, primarily from suicide, which re¬
sults in reduced lifetime earnings.
A recent study22 estimates that the
annual cost of depression in the United
States is about $43 billion. Direct costs
are estimated to be $12 billion per year.
Indirect costs are estimated to be $31
billion per year, $8 billion of which is due
to premature death and $23 billion of
which is due to absenteeism and lost
productivity in the workplace. This es¬
timate includes costs for major depres¬
sion, bipolar disorder, and dysthymia,
with major depression accounting for
over 85% ofthe total cost.8·22"25 The model
used in this study (the human capital
approach) underestimates the true cost
to society because it does not include
the adverse effects of pain and suffering
and other quality-of-life issues.
Moreover, these estimates are con¬
servative because the study did not take
into account other important costs such
as additional out-of-pocket expenses for
families, excessive hospitalization for
nonpsychiatric conditions due to depres¬
sion, and excessive diagnostic tests look¬
ing for general medical diagnoses when
depression is the cause of a patient's
symptoms. This study also did not in¬
clude the additional costs associated with
individuals who have symptoms of de¬
pression but do not meet full criteria for
a diagnosis of major depression. Fur¬
thermore, depression can be as debili¬
tating asdiabetes, arthritis, gastroin¬
testinal disorders, back problems, or
hypertension, in terms of physical and
social functioning.
Depression is one of the 10 most costly
illnesses in the United States. The cost
of depression is comparable to a number
of other illnesses. For example, using
slightly different methods, the acquired
immunodeficiency syndrome (AIDS) has
 been estimated to cost $66 billion per
year, and coronary heart disease has
been estimated to cost $43 billion per
year. Depression also costs more than
many other illnesses, such as chronic
lung disease, which has been estimated
to cost $18 billion per year.22
Depression is costly to employers. The
annual economic cost of depression in
1995 was $6000 per depressed worker.
It has been estimated that employers
directly bear an annual cost of more than
$4200 per depressed worker, which
equals $250 per employee.26 Twenty-
eight percent of these costs are treat¬
ment costs, and 72% are costs related to
absenteeism and lost productivity at
work. Since most depressed individuals
are untreated, the majority of costs due
to absenteeism and productivity is dif¬
ficult to determine.27 In addition, depres¬
sion tends to affect people in their prime
working years and may last a lifetime if
untreated. Because of its chronicity, it
can remain costly for many years.
While further research is needed for
a fuller understanding of the economics
of depression, the available data sug¬
gest that it is cost-effective to treat de¬
pressive illness. There is evidence that
appropriate care for depression im¬
proves functioning.28 Although this ap¬
proach increased total costs of care, it
improved the cost-effectiveness, or
value, of care because each dollar spent
on care provided more health benefits.29
Other studies indicate that appropriate
care also improves impaired functioning
in the workplace, the most expensive
aspect of untreated depression.30
In addition, a recent cost-benefit
analysis estimated that the indirect cost
savings of appropriately treating depres¬
sion would outweigh the direct treat¬
ment costs by about $4 billion per year.31
These benefits would accrue to employ¬
ers, who bear the costs of untreated
depression.
QUESTION 3
What have been the efforts in the past
to redress undertreatment? How suc¬
cessful have they been? What were the
problems associated with those efforts?
Recent educational programs have sub¬
stantially improved knowledge and un¬
derstanding about depression. Programs
have been targeted toward public, pa¬
tient, and professional communities. In
general, the progress in dissemination of
information has been commendable, but
many efforts lack formal evaluation of
their effectiveness. Future efforts should
include careful measurement to determine
the extent of their impact and to identify
remaining information gaps.
The progress in provision of public
and professional support information has
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been steady and effective. We respect
the efforts needed to generate and dis¬
tribute these materials and programs,
and we encourage their continuation.
General Public Education
NIMH D/ART.—The D/ART (Depres¬
sion/Awareness, Recognition, and Treat¬
ment) program of the NIMH provides
broadly based outreach to patients, the
public, and professionals. Early efforts
focused on public awareness and encour¬
aged recognition and treatment. More re¬
cent themes have turned toward reach¬
ing families, coworkers, and friends. The
program has provided printed materials,
radio and television spots, a toll-free tele¬
phone number, special events, and con¬
sultation. The community and professional
partnership program has instituted model
collaborations with states and local enti¬
ties. D/ART also organizes special events,
such as health fairs. The National Work¬
site Program has established a structure
for mental health awareness and training
through contact with business and cor¬
porate organizations. The D/ART pro¬
gram appears to have been successful in
addressing its goals. It has not, however,
been subjected to formal evaluation which
would indicate the quantitative impact of
its initiatives. The program is a model of
government participation in provision of
support for public health needs.
NPECCD.—The National Public Edu¬
cation Campaign on Clinical Depression
(NPECCD) is a national, private-sec¬
tor, nongovernmental program, spon¬
sored by the National Mental Health
Association and cosponsored by the
NDMDA, American Psychiatric Asso¬
ciation (APA), National Alliance for the
Mentally 111, D/ART, and a group of more
than 100 other organizations. The
NPECCD was launched in 1993 with
paid public service advertising about de¬
pression. Ninety-three percent of the
US population was reached an average
of 11 times each. Over 300000 people
responded to the ads over a 3-week pe¬
riod. In the intervening years many ac¬
tivities have been conducted by
NPECCD, including the distribution of
over 2.5 million brochures. In addition,
40 local campaigns have provided ex¬
tensive programs around the country.32
Community Programs.—National
Depression Screening Day and National
Mental Illness Awareness Week are
typical of large-scale community pro¬
grams. Each national program is orga¬
nized annually and leads to diagnoses
and referral to treatment.
Public Relations.—Similarly, public
relations efforts are widely based. Writ¬
ten and electronic media have given con¬
siderable exposure to mental health prob¬
lems in general, and depression in
particular. Full-length television pro¬
grams featuring known public figures and
analytic news articles have reached large
audiences. Shorter media spots have been
used to alert the public to issues in men¬
tal health; hundreds of millions of viewer
exposures have been generated.
Testimonials by celebrities have been
especially effective. Well-known and re¬
spected political and entertainment fig¬
ures have disclosed episodes of depres¬
sion experienced by themselves or family
members.
Press conferences featuring discover¬
ies in mental health research, public ser¬
vice announcements (including those of
D/ART), and mass literature distributions
constitute significant sources for public
information. Health newsletters, such as
those published by some major universi¬
ties, provide more technical information
for well-educated readers. The National
Alliance for Research on Schizophrenia
and Depression (NARSAD) has recently
launched a series of public service an¬
nouncements focused on reducing stigma.
Patient Information
Many pamphlets distributed through
physicians' offices, libraries, supermar¬
kets, and the like, are designed to reach
patients and families. Support and self-
help groups have been organized by pa¬
tient advocate organizations. Well-in¬
formed patients and their family
members can work with providers to
select among treatment options.
Professional Education
Mental health professionals receive
specialized training, continuing educa¬
tion, and distributions of diagnostic and
treatment guidelines. The APA has de¬
veloped practice guidelines for psychia¬
trists for the treatment of major de¬
pression and bipolar disorder. The
Agency for Health Care Policy and Re¬
search (AHCPR) has produced practice
guidelines for primary care providers;
and the APA, in collaboration with a
range of primary care organizations, has
developed a primary care version of the
Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition
(DSM-IV). A limited number of attempts
are under way to provide professional
education through contact with resi¬
dency training programs of primary care
specialties. Since these approaches have
been under way for a relatively short
time, it is too soon to determine what
impact they will have on these trainees.
In addition, some managed care compa¬
nies have developed and implemented
practice guidelines for depression.
Several pharmaceutical firms have de¬
veloped and implemented professional
education programs for psychiatrists and
 primary care providers on the diagnosis
and treatment of depression. In addition,
several depression screening and man¬
agement programs have been developed.
Workplace
In addition to those established in co¬
operation with D/ART, many organiza¬
tions, including private businesses, cor¬
porations, and public institutions, have
established employee assistance pro¬
grams (EAPs) for assisting with em¬
ployees' mental health issues and be¬
havioral problems. Properly established,
these programs can provide early evalu¬
ation of depression.
QUESTION 4
What are the reasons for the gap be¬
tween our knowledge of the diagnosis
and treatment ofdepression and actual
treatment received in this country?
Reasons for the gap between what we
know about the correct treatment ofde¬
pression and what actually gets deliv¬
ered have been attributed to patient,
provider, and health care system factors.
Patient Factors
At the most basic level, some patients
do not recognize that they have symp¬
toms of depression. They may focus in¬
stead on various somatic concerns, such
as gastrointestinal complaints, fatiga-
bility, and headaches. Others may rec¬
ognize that there is a problem, but fail
to identify it as depression.
There is evidence that patients and
their family members underestimate the
severity of depression and, therefore,
do not pursue treatment.33 The same
study concluded that individuals with
major depression who did not seek treat¬
ment thought they could handle or treat
the episode themselves. Furthermore,
they did not see the episode as serious
enough to seek treatment; they merely
thought it was an expected response to
a life situation.
People who do recognize or acknowl¬
edge that they need help may face lim¬
ited access to treatment. This is par¬
ticularly problematic in areas of the
country that are underserved by phy¬
sicians and mental health care providers.
There are also significant problems
with patient adherence, ie, one's will¬
ingness to stay with a recommended
medical regimen for the treatment of
depression. This may lead to poor treat¬
ment and often to demoralization of the
primary care physician.
Provider Factors
There are also many reasons for the
undertreatment of depression that rest
with the physician. Many medical schools
do not provide sufficient education about
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psychiatrie diagnosis, psychopharmacol-
ogy, or psychotherapy for depression.
Postgraduate education of primary care
providers may also lack sufficient infor¬
mation on the diagnosis and treatment
of depression.
The physician may be inadequately
prepared to use the most modern meth¬
ods. In addition, many providers have
limited training in the interpersonal
skills that enable them to manage emo¬
tional distress. This may lead to their
avoidance of addressing depression and
related disorders.
Some primary care providers may be¬
lieve that psychiatric disorders are not
"real" illnesses. This myth is supported
by the paucity of objective clinical mark¬
ers for psychiatric disorders. Other pro¬
viders may understand the reality and
severity of depression, but fear they would
alienate their patients by bringing it up.
Psychiatric disorders may take more
time to diagnose and treat than other
medical conditions. A survey reported
that primary care physicians had too
little time to treat psychiatric disorders
effectively.
Just asthe patient avoids treatment
on account oflack of adequate reimburse¬
ment, physicians may also avoid treat¬
ing patients with depression because of
poor insurance coverage. There is an
urgent need to establish parity for in¬
surance coverage between psychiatric
disorders and other medical conditions,
particularly other chronic and relapsing
medical illnesses. In capitated systems,
the capitation rate must be adequate to
treat depression and prevent cost shift¬
ing to nonpsychiatric providers for de¬
pressionlike symptoms.
Patients are often treated with inad¬
equate doses of antidepressant medica¬
tion for inadequate lengths of time. In
addition, managed care and other health
care financing agencies (such as Medi¬
care) can often create barriers to pre¬
scribing the best antidepressant medi¬
cation for an individual patient with
depression.
Some managed care plans have made
it difficult for physicians to prescribe
newer antidepressant medications, even
though they are now widely regarded as
safer first-line treatments. These plans
may also have formularies that restrict
the kinds of antidepressants that can be
prescribed, thus limiting the patient's
and provider's options.
Even when treatment for depression
is readily available, patients are some¬
times reluctant to see a psychiatrist or
other mental health care specialist. Man¬
aged care procedures can also inhibit
appropriate referral. Part of the prob¬
lem for "referral noncompliance" may
be the fear of stigmatization. Cultural
and ethnic factors may also contribute
to the problem.
Health Care System Factors
Among the health care system-based
reasons for less than optimal treatment
of depression is the lack of adequate
insurance reimbursement. Many insur¬
ance and managed care companies ac¬
tively discourage patients from seeing
mental health care professionals. Fur¬
thermore, when care for mood disor¬
ders is rendered directly by a primary
care physician, there may still be diffi¬
culties in obtaining reimbursement.
Although brief structured psycho¬
therapies are effective for some types of
depression, therapists who have been
trained specifically in these modalities
are not readily found in some commu¬
nities. It is often impossible for primary
care physicians to offer structured psy¬
chotherapy in the course of a busy prac¬
tice. Hence, psychotherapeutic ap¬
proaches with demonstrated efficacy for
depression are commonly ignored.34
There is often poor collaboration
among the different types of providers
who may be helpful in treating depressed
patients. For example, physicians may
restrict their approach to medication and
fail to refer patients to other providers
for psychotherapy when it might be use¬
ful in addition to antidepressants. Psy¬
chotherapists may similarly fail to refer
depressed patients to a physician for
evaluation of the possible benefits from
taking medication.
Cost-saving plans in the managed care
system often discourage providers from
"sharing" patients or providing psycho¬
therapy. When 1 therapeutic approach
fails, another should be readily available.
The managed care and other health
financing systems can also discourage
the proper monitoring of patients once
an antidepressant regimen is started.
Patients need to be reevaluated at fre¬
quent intervals, to assess whether the
treatment is working in a reasonable
amount of time and to give the provider
the opportunity to make adjustments in
the treatment regimen.
Finally, many current health care sys¬
tems do not allow for the proper recog¬
nition of the chronic nature of depression
and the problem of recurrent depression.
Many (perhaps most) patients with de¬
pression need ongoing care to prevent
relapse and maintain adequate function¬
ing. Too many patients with depression
are treated for very brief periods of time
and then lost to the health care system.35
QUESTION 5
What can we do to narrow this gap?
(Propose research to better understand
the reasons for the gaps.)
 Based on our current understanding
of the reasons for the gap between
knowledge and practice, we propose the
following research questions:
What are the patient-related and gen¬
eral public-related factors that contrib¬
ute to the undertreatment of depres¬
sion? Pertinent areas of evaluation
include the following:
• attitudes and beliefs about
depres¬
sion—its diagnosis and treatment
• attitudes about barriers to treat¬
ment, including access and insurance
coverage
•
patient characteristics that predict
undertreatment—demographic, familial,
psychiatric, socioeconomic, cultural, and
religious
What is the cost of depressive illness,
untreated or undertreated? Available
data have shed useful light on this ques¬
tion, but further research is needed.
What are the provider-related factors
that contribute to the undertreatment
of depression? Pertinent areas of evalu¬
ation include the following:
•
provider attitudes and beliefs about
depression and its treatment
•
provider knowledge about diagno¬
sis and treatment
•
provider skill in assessment, diag¬
nosis and treatment
• attitudes about barriers to treat¬
ment (eg, lack of time, reimbursement,
patient complexity, fear of alienating pa¬
tients, self-efficacy)
•
potential incentives and rewards for
diagnosis and treatment
• the role of
professional collabora¬
tion in diagnosis and treatment
What is the effect of health care sys¬
tem factors on the diagnosis, treatment
and outcomes of depression? How do
differing disease management models
(eg, referral patterns, collaborative mod¬
els, chronic disease model, model of ser¬
vice delivery [HMO vs fee-for-service])
affect diagnosis, treatment and out¬
comes?
What interventions are effective in
changing patient attitudes about diag¬
nosis and treatment, increasing patient
acceptance of, satisfaction with, and ad¬
herence to treatment, and affecting clini¬
cal outcomes?
What interventions are effective in
changing provider knowledge, attitudes,
skills, and behaviors regarding the di¬
agnosis and treatment of depression?
Interventions might include the follow¬
ing:
screening for depression (eg, using
• bers as effective advocates should be
aself-report inventory, such as the Beck
Depression Inventory36)
reminders to patients and providers
• ment requirements for depression. It is
outreach visits
• clear that this disorder must be treated
educational interventions (eg, tar¬
• as a chronic illness that requires treat¬
geted educational materials, continuing
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medical education sessions including skills
training in patient education and the ap¬
propriate administration of pharmaco¬
logical and psychosocial interventions,
academic detailing, direct supervision, at¬
titude revision, use of standardized pro¬
tocols and manuals)
•
provider audit with feedback
• financial incentives and
penalties
What system interventions enhance
the assessment, diagnosis, and treatment
of depression? Interventions to be stud¬
ied might include the following:
•
provider collaborative care models37
• service
delivery setting (eg, HMO,
fee-for-service)
• reimbursement
•
strategies to enhance access
•
patient involvement
•
monitoring of quality indicators (eg,
provider profiling, patient satisfaction)
What are the relative impacts, costs,
and benefits of the various intervention
strategies, or medical information sys¬
tems, for increasing the diagnosis and
treatment of depression and improving
outcomes?
One potentially fruitful research pro¬
tocol would apply different approaches
in different community settings. For ex¬
ample, patients in 3 different commu¬
nities or managed care organizations
would be screened for depression. One
site would receive care as usual. A sec¬
ond site would receive an intense public
and provider educational program us¬
ing local media, distribution of practice
guidelines, screening programs, and the
like. A third site would receive educa¬
tional interventions, as well as consul¬
tation and intervention by a mental
health professional located directly in
primary care settings.
QUESTION 6
What can we do immediately to nar¬
row this gap? (Recommend programs
to narrow the gap now, while gaining
more knowledge about reasons for the
gap.)
The time is ripe to apply lessons
learned from other areas of public health
to behavioral health services to improve
the quality of services to all patients
with depression. Each of the following
strategies will substantially advance this
goal.
Enhance the Role of Patients
and Their Families
The role of patients and family mem¬
enhanced by increasing their knowledge
of treatment options and essential treat¬
ment of the acute phase, continuation
treatment to sustain remission, and
maintenance treatment to reduce the
likelihood of recurrence. Treatment of
depression is cost-effective. Unfortu¬
nately, capitation rates in some carve-
outs are not sufficient to cover the real
treatment costs of the disorder.
Patients must be informed consum¬
ers. The NDMDA and other groups have
worked effectively to establish networks
of support and connectedness essential
for patient advocacy. These groups need
to work with managed care organiza¬
tions, other financing systems for health
care, and legislators to educate mem¬
bers and providers about the essential
requirements of diagnosis and treat¬
ment. The successes of the Breast Can¬
cer Alliance and Mothers Against Drunk
Driving are impressive examples of what
might be done in the next few years to
advance the care of all patients with
depression, through a well-informed pa¬
tient advocacy campaign with targeted
educational and political goals.
Guidelines for the treatment of de¬
pression in primary care and treatment
of depression and bipolar disorder in
psychiatric practice have been devel¬
oped by AHCPR and by the APA. Re¬
newed efforts should be made to make
these guidelines available to patients and
their families. In addition the guidelines
should be updated as new information
becomes available. Such knowledge will
help patients in their interaction with
providers regarding the evaluation and
selection of treatment options.
Develop Performance Standards
for Behavioral Health Care
Performance standards for behavioral
health care carve-outs and behavioral
health care in other organizations should
be developed. "Report cards" are be¬
coming increasingly important in many
areas of medicine (eg, the Health Plan
Employer Data Information Set).38 Man¬
aged behavioral health companies and
organizations need to be held account¬
able for their policies and practices. This
accountability should include the iden¬
tification of a standard for the percent¬
age of patients with depression who are
being treated, screened, diagnosed, re¬
ceiving antidepressants, and referred to
mental health specialists among the to¬
tal insured population covered under the
capitated arrangement. Deviations from
expected prevalence rates should be ac¬
tively investigated. Guidelines for spe¬
cialty referral, frequency of follow-up
after initiation of pharmacotherapy, and
frequency of visits in maintenance treat¬
ment should be developed. Other indi¬
cators might include the percentage of
patients diagnosed with depression who
have adequate pharmacotherapy (ie, the
 equivalent of 150 mg of imipramine for
at least 4weeks), the percentage who
have received psychotherapy, the num¬
ber of visits to mental health profes¬
sionals).
Managed care treatment protocols for
depression should be accessible to pa¬
tients and to providers in the network.
The protocols should be consistent with
the practice guidelines of the APA and
AHCPR and should offer a clear de¬
scription of approved treatments for the
acute, continuing, and maintenance
phases of treatment. If certain medica¬
tions are not on the approved treatment
list, a clear rationale should be provided
for their exclusion. For patients who
have not responded to treatment, op¬
tions should be offered that include medi¬
cations not normally available in the plan.
Payment mechanisms should provide in¬
centives for physicians to identify and
treat depression when it occurs with
other medical disorders. Payment
mechanisms to managed care providers
should not discourage adequate treat¬
ment of depression.
Increase Provider Knowledge
and Awareness About Depression
Barriers to provider recognition, di¬
agnosis, and screening of depression can
also be addressed by educational pro¬
grams for providers, aimed at increas¬
ing awareness and knowledge about de¬
pression and its effective treatment;
enhancing skills in screening and diag¬
nosis; and increasing the use of effective
pharmacological and psychosocial inter¬
ventions. Primary care physicians should
be targeted for training in these areas.
The dissemination of clinical practice
guidelines for the assessment and treat¬
ment of depression will help providers
deliver effective care. However, dissemi¬
nation must be paired with other inter¬
ventions in order to change physician
practices. The use of opinion leaders and
innovative education strategies (such as
office-based training or interactive com¬
puter-assisted learning), the provision
of feedback about effectiveness, and the
use of incentives would all enhance
change in provider behavior.
Medical schools and primary care resi¬
dencies should review their curricula re¬
garding depression. In addition, the As¬
sociation of American Medical Colleges
should review guidelines for medical
schools regarding depression education.
The Accreditation Council for Graduate
Medical Education might review the
Residency Review Committee require¬
ments for depression education in resi¬
dencies. And the National Board of Medi¬
cal Examiners should continue to include
and update examination questions about
depression.
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Enhance Collaboration Among
Providers for Disease Management
More effective collaboration among
primary care providers, psychiatrists,
and other mental health professionals is
needed. Patients needing structured
psychotherapy should have access to
psychotherapies that have proven effi¬
cacy. Depressed patients with coexist¬
ing disorders should have access to ap¬
propriate treatments for both disorders
(eg, depression and substance abuse).
The primary care provider should be
fully knowledgeable about the diagno¬
sis and treatment of depression and able
to intervene in effective ways to assure
patient compliance and follow-through.
Primary care physicians, psychiatrists,
and other mental health providers need
to develop collaborative practice ar¬
rangements that will meet the needs of
patients with depression.37
Educational programs, especially
those designed for trainees, should be
attended by both primary care and spe¬
cialty providers. This type of effort needs
to have the support of relevant accred¬
iting entities.
Conduct Research
for New Treatments
There is a compelling need to conduct
research on the development and test¬
ing of new treatments for depression,
especially in patients with multiple ill¬
nesses(for example, alcoholism, cancer,
AIDS), and for patients who have not
responded to other treatments. More
attention should be given to special popu¬
lations, such as children, adolescents,
and the elderly.
CONCLUSION
Individuals with depression are being
seriously undertreated, even though ef¬
fective treatments have been available
for more than 35 years. Depression is a
pernicious illness associated with long
duration of episodes, high rates of chro-
nicity, relapse, and recurrence, psycho-
social and physical impairment, and mor¬
tality and morbidity—with a 15% risk of
death from suicide in patients who have
ever been hospitalized for depression.
Despite these facts, the vast majority of
patients with chronic depression are mis-
diagnosed, receive inappropriate or in¬
adequate treatment, or are given no
treatment at all.
It is disturbing that dramatic advances
in the diagnosis and treatment of de¬
pression have not revolutionized treat¬
ment practice. Recent educational pro¬
grams have been of value in increasing
knowledge and understanding about de¬
pression. However, there is still an enor¬
mous gap between our knowledge about
the correct diagnosis and treatment of
depression and the actual treatment that
is being received in this country.
Reasons for the gap have been at¬
tributed to patient, provider, and health
care system factors. Patient-based rea¬
sons include: failure to recognize the
symptoms, under-estimating the sever¬
ity of depression, limited access to treat¬
ment, reluctance to see a mental health
care specialist due to stigma, non-com¬
pliance with prescribed medical regi¬
mens, and lack of adequate insurance
reimbursement. Reasons that rest with
the physician include: failure of medical
schools in providing sufficient education
about psychiatric diagnosis, limited pro¬
vider training in interpersonal skills, be¬
lief in the myth that psychiatric disor¬
ders are not "real" illnesses, inadequate
time to evaluate and treat depression,
failure to consider psychotherapeutic ap¬
proaches, avoidance of treating patients
with depression because of poor insur¬
ance coverage, poor collaberation among
providers, prescribing inadequate doses
of antidepressant medication for inad¬
equate durations, and the fact that psy¬
chiatric disorders may take more time
to diagnose and treat than many other
medical conditions.
In addition, some primary care phy¬
sicians are reluctant to use the mental
health care system because of financial
constraints, a lack of qualified providers
to refer to, or a fear of offending the
patient. Finally, many managed health
care systems create barriers to prescrib¬
ing the best antidepressant medication,
discourage the proper monitoring of pa¬
tients, and do not allow for the proper
recognition of the chronic and recurrent
nature of depression. Too many patients
with depression are treated for very
brief periods of time and then lost to the
health care system.
The time is ripe to apply lessons
learned from other areas of public health
to behavioral health services in order to
improve the quality of services to all
patients with depression.
The panel proposed the following
strategies to advance this goal.
1. Enhance the role of patients and
their families by increasing their knowl¬
edge of treatment options and essential
treatment requirements for depression.
Patients must be informed consumers and
advocates. The NDMD A and other groups
have worked effectively to establish net¬
works of support and connectedness es¬
sential for patient advocacy.
2. Develop performance standards for
behavioral health care carve-outs and
behavioral health care in other organi¬
zations. Managed care treatment guide¬
lines and protocols for depression should
be accessible to patients and providers
 in the network. Payment mechanisms
should provide incentives for physicians
to identify and treat depression when it
occurs with other medical disorders.
3. Barriers to provider recognition,
diagnosis, and screening of depression
can also be addressed by educational
programs that increase provider aware¬
ness and knowledge about depression
and its effective treatment, enhance
skills in screening and diagnosis, and
increase the use of effective pharmaco¬
logical and psychosocial interventions.
4. More effective collaboration among
primary care physicians, psychiatrists,
and other mental health professionals is
needed. The primary care provider
should be fully knowledgeable about the
diagnosis and treatment of depression
and able to intervene in effective ways
to assure patient compliance and follow-
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