Despite all the articles you read from us on biologics, biosimilars, specialty drugs… claims for antidepressant medications represent the largest spend for GSC’s block of business. We pay more claims for antidepressants—both in terms of number of claims and cost—than any other class of medication. It’s clear that plan sponsors are investing a lot of dollars in antidepressants—we reimbursed $45 million in antidepressants in 2015—but is this investment paying off in terms of having an equal downstream impact on plan member health?
Our loyal readers know we like to ask these hard questions, so we’re taking a closer look at the patterns associated with spending on antidepressants. However, as you also know, we don’t always have all the answers, but we make it our mission to keep digging. As a health benefits specialist, we do our best to determine whether concrete health outcomes result from our plan sponsors’ investment. So far, we’ve unearthed a lot for plan sponsors to consider…
$45 million in antidepressants
As you may recall from the June 2016 edition of The Inside Story when we reported on the GSC 2015 health study, a goal of all our studies is to identify costs driving up spending in your health plan. Specifically, as part of the 2015 analysis, we zeroed-in on 35,000 plan members who were “new starts” on an antidepressant over a three-year period to see what we could learn from the prescribing and claiming patterns.
Analysis revealed that of the “new starts” over the three years, 12-15% followed the typical treatment guidelines for depression. With the remaining 80-85% over three years, we saw a combination of dropouts who never started their prescription, “one and done’rs” who didn’t continue their prescription past the first fill, and those taking extremely low doses—so low that you wouldn’t expect any clinical outcome at all.
High medication non-adherence, low dosages, and usage that hints at overprescribing put our antennae on high alert: are some plan members needlessly taking antidepressants while others—those that could benefit most from antidepressants—aren’t necessarily getting all the support they need? Disturbing to say the least. As always, time to turn to the world of research to see if the GSC data is representative of what’s going on out there more broadly regarding depression.
What does the research show?
Over the last decade, the number of antidepressants prescribed in England has more than doubled1—a trend that many countries worldwide are also experiencing. For instance, in 2011, the last year for which comparative figures are available, Canada had the third highest level of consumption of antidepressants among the 23 countries surveyed by the OECD.2 However, there have been no changes in the annual prevalence of major depressive episodes in Canada.3
So on the one hand, if rates of depression haven’t significantly changed, why is there so much diagnosing of depression and prescribing antidepressants? And on the other hand, with such high prescribing of antidepressants, why aren’t the rates of depression going down?
Like the GSC study findings, the broader scientific research suggests that many people who need some level of support—but not necessarily antidepressants, are being prescribed antidepressants. They are incurring the risks of the medication (i.e., side-effects), without receiving the benefits. Whereas those that could benefit from an antidepressant may not be taking them. For instance, findings from a 2011 American study found that “just one-third of severely depressed people who really need antidepressant medication are taking it, while more than two-thirds who are taking antidepressants are not currently depressed.”4 To figure out why this is happening—and how to improve the situation—we tried to determine all the contributing factors.
What are the factors at play?
One of the biggest issues influencing the rising incidence of antidepressant use is that—both culturally and clinically—we seem to be casting the net increasingly widely.
For instance, society now labels someone experiencing mild symptoms of depression as having a disease; they are “ill.” And similarly, in the doctor’s office, patients who in the past would be considered as having mild symptoms of depression are now being diagnosed as depressed and are prescribed antidepressants. But to use our favourite word, why?
In terms of culture…
Increasingly North American society is influenced by a self-help culture that is focused on happiness, or as some caution, one that is happiness obsessed. However, many feel this idea—that at all times happiness is the goal—sets up unrealistic and potentially unhealthy expectations. As we experience life’s inevitable ups and downs, some people beat themselves up as they try to reach the unattainable goal of happiness at all times.9
Cultural influences also include society’s interest in reducing stigma surrounding mental health issues and encouraging people to seek help. For instance, over the last several years, we have seen an influx of mental health campaigns with the purpose of reducing stigma, raising awareness, and providing education. There is evidence that these programs are a having positive impact. For example, organizations that promote mental health awareness are seeing decreasing durations of absences due to mental health issues.
That is good.
However, when we consider that the rates of diagnosing depression are rising with no significant increase in the actual rates of depression, it makes you think—what are the unintended consequences of society’s mental health awareness efforts? Are we casting the net so wide that we are inadvertently creating a culture where sadness and stress are labelled as “illness”? As one expert explains, “The line between the beneficial destigmatization of illness and the epidemic spread of an illness attribution is a thin one.”10 As a society, although we want to ensure that the right people get the help they need, at the same time, we need to ensure that we are not creating a culture that focuses on creating and treating “illness” rather than promoting healthy behaviours aimed at preventing illness.
These cultural influences may be resulting in the over diagnosis of depression, and as a result, overprescribing. For instance, medicalization in relation to unhappiness is described as “the increasing tendency, especially in primary care, to diagnose depression (commonly major depressive disorder) in patients presenting with sadness or distress and offering them antidepressant medication.”11 But (here we go again), why?
In terms of clinical diagnosis…
First, it’s important to note that diagnosing depression is no simple task. As we’ve learned while taking our deep dive into behaviour change and all things neurological, it’s clear that the brain is complex. And in fact, up until fairly recently, vast aspects of the brain were considered unchartered territory.
Although technology continues to make it possible for scientists to learn more than ever, there is very little (close to nothing) in the way of objective testing to help doctors definitively diagnose depression. Even when doctors use standardized screening tools for depression, research shows that screening has minimal impact on accurate detection, management, or outcome of depression.12
Adding to this situation is the diagnostic manual that most North American doctors consider the authoritative guide to diagnosing mental disorders. This manual, which has gone through multiple iterations over the years, has been criticized for its tendency to support over diagnosis. Traditional diagnostic categories have become even more inclusive and many new categories of diagnosis are introduced with each succeeding iteration of the manual. “It seemed that every kind of psychological problem, even those intrinsic to the human condition, could be described by a psychiatric diagnosis.”13
Another contributing factor is yet another challenge that doctors face—and it’s a biggie. In terms of mental health, doctors lack resources to draw on; essentially they don’t have a mental health toolkit at the ready. As a result, for example, although a doctor’s first instinct may be to refer a patient to counselling, the reality is that counselling is not widely available, can take months to access, and is usually high cost.
In addition, we are still very much a “pill-popping” society; patients typically expect a quick fix from their doctors—a cure-all in pill form. Accordingly, with patients who are not severely depressed but just going through temporary life problems and need support, doctors face a serious dilemma. Their choice is between not helping the patient at all versus providing them with a prescription—like a sub-therapeutic dose of an antidepressant. Basically, doctors are between a rock and a hard place; they are being pressured by cultural and clinical forces to effectively treat depression while not having a comprehensive toolkit to do so.
What are the consequences of overprescribing?
Labeling mild symptoms of depression as an illness and prescribing antidepressants—even if at sub-therapeutic doses—can have extremely negative implications for patients. For instance, labeling plan members with a psychiatric diagnosis can lead some to believe and behave as if they are ill. This in turn (for a whole number of other issues) can tend to limit ownership of their health issues and deter self-care efforts.
And in the bigger picture, a culture that is too quick to turn to medicalization of unhappiness and quick prescribing of antidepressants can result in draining scarce resources and diverting resources away from those who can truly benefit from them. For example, we spoke with a senior psychologist in Toronto who described many people with mild symptoms sitting on waiting lists to see him when they could be better managed in the community. This makes it difficult for him to provide treatment to those who are severely depressed.
A fresh perspective
As you can see from what we’ve learned so far, “depression” has come to mean even mild symptoms, and “treatment” for depression has come to largely mean drugs. From this we have come to a major conclusion: it’s time to take a fresh perspective on treating depression.
Peter Gove, GSC’s health innovation leader sums it up this way, “Not all antidepressant use is inappropriate, we’re not suggesting that at all. However, what we are strongly recommending is that we take a fresh perspective on treating depression—mild, moderate, and severe. On the one hand, we need to make sure that those with mild and moderate symptoms of depression get the help they need, which may or may not include antidepressants. And on the other hand, that we more effectively capture the more severely ill that are most likely to benefit from treatment by an antidepressant.”
As a plan sponsor, this means recognizing that casting the widest net possible and assuming a medicalized approach may have very limited value regarding overall plan member health. Accordingly, ensure that your mental health programs promote health rather than focus on identifying illness.
What does this mean? That it’s important that plan sponsors understand—and in turn, educate plan members—that good mental health involves a lot more than just drugs. Promote healthy behaviours that are shown in the research to help prevent and improve mental health like regular exercise, healthy eating, smoking cessation, and moderate alcohol consumption. Also, consider increasing your plan’s annual maximum for counselling services because approaches like cognitive behavioural therapy are well documented in the scientific evidence as beneficial.
…And now for the big newsflash…
To address the accessibility and affordability of other approaches beyond drugs, GSC will be piloting some new ideas in 2017 to help provide doctors (and plan members) with a different set of tools that are not entirely medication based. Now that really is a fresh perspective!
1“Prescriptions Dispensed in the Community, England 2005-2015,” Prescribing and Medicines Team Health and Social Care Information Centre, July 5, 2016. Retrieved December 2016: http://content.digital.nhs.uk/catalogue/PUB20664/pres-disp-com-eng-2005-15-rep.pdf.
2“Psychiatrist warns against trying to cure ordinary sadness as Canadians among top users of antidepressants,” Sharon Kirkey, National Post, January 19, 2014. Retrieved December 2016: http://news.nationalpost.com/news/canada/psychiatrist-warns-against-trying-to-cure-ordinary-sadness-as-canadians-among-top-users-of-antidepressants.
3“Descriptive epidemiology of major depressive disorder in Canada in 2012,” S.B. Patten, J. Williams, D.H. Lavorato, et al, Canadian Journal of Psychiatry, 2015; 60:23-30.
4“Antidepressant Use Has Gone Crazy: Bad News from the CDC,” Allen Frances, Psychiatric Times, October 28, 2011. Retrieved December 2016: http://www.psychiatrictimes.com/blogs/antidepressant-use-has-gone-crazy-bad-news-cdc.
5“Medicalising unhappiness: new classification of depression risks more patients being put on drug treatment from which they will not benefit,” Christopher Dowrick, Allen Frances, BMJ, 2013;347:f7140. Retrieved December 2016: http://www.bmj.com/content/347/bmj.f7140.
6“Antidepressant Drug Effects and Depression Severity: A Patient-Level Meta-Analysis,” Jay Fournier, Robert DeRubeis, Steven Hollon, Sona Dimidjian, Jay Amsterdam, Richard Shelton, Jan Fawcett, JAMA, January 6, 2010. Retrieved December 2016: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3712503/.
7“Treatment of Adult Depression in the United States,” Mark Olfson, Carlos Blanco, Steven Marcus, JAMA Internal Medicine, 2016;176(10):1482-1491. Retrieved December 2016: http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2546155.
8“Suicidality and aggression during antidepressant treatment: systematic review and meta analyses based on clinical study reports,” Tarang Sharma, Louise Schow Guski, Nanna Freund, Peter C Gøtzsche, BMJ, 2016;352:i65. Retrieved December 2016: http://dx.doi.org/10.1136/bmj.i65.
9, 11“Medicalising and medicating unhappiness,” Christopher Dowrick, Allen Frances, BMJ Volume 347, December 14, 2013. Retrieved December 2016: http://www.bmj.com/bmj/section-pdf/750417?path=/bmj/347/7937/Analysis.full.pdf.
10How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown, Edward Shorter, Oxford University Press, January 13, 2013.
12“Screening and case finding instruments for depression,” S. Gilbody, A. House, T. Sheldon. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD002792. DOI: 10.1002/14651858.CD002792.pub2. Retrieved December 2016: http://www.cochrane.org/CD002792/DEPRESSN_screening-and-case-finding-instruments-for-depression.
13Overdiagnosis in Psychiatry – How Modern Psychiatry Lost Its Way While Creating a Diagnosis for Almost All of Life’s Misfortunes, Joel Paris, Oxford University Press, 2015.