Summary
Depression is one of the costliest health issues for employers because of its high prevalence and co-morbidity with other conditions. It is estimated to cost U.S. employers $44 billion annually.

Most patients with depression are treated in primary care, yet according to an article in JAMA, less than 22% of patients diagnosed with depression receive adequate care.

This paper describes a collaborative care approach to treating depression that typically adds a care manager and consult with a psychiatrist to the primary care clinic to increase patient contact, coordinate care and actively motivate the patient with depression.

This team approach has shown a positive return on investment (ROI) in numerous trials. These trials have typically been funded through grants and research.

There is now a program called DIAMOND (Depression Improvement Across Minnesota, Offering a New Direction) that not only features a collaborative care model, but is funded by Minnesota health plans. Initially results show that patients recover from depression much faster with DIAMOND, providing a ROI that justifies providing coverage for employees.

The Problem
Depression is a common and debilitating illness. Individuals with untreated depression find it difficult to function in both their private and professional roles. A study published in 2003 by the Journal of the American Medical Association (JAMA) concluded that depression is treatable but less than 22% of affected people receive even minimally adequate treatment.

Depression contributes significantly to pain and suffering, reduced productivity and economic loss. A 2007 study by the World Health Organization (WHO) of more than 245,000 people across 60 countries showed depression decreased the quality of their health more than other chronic diseases such as diabetes, arthritis and asthma.

In their study, The Cost of Lost Productive Work Time Among U.S. Workers With Depression, researcher Walter F. Stewart and his colleagues said:

“Evidence consistently indicates that common conditions including migraine, low back pain, diabetes, allergic rhinitis, gastroesophageal influx and depression dominate health-related lost labor costs. Depression is among the most costly because it is highly prevalent and comorbid with other conditions. Furthermore, although workers with depression are usually present at work, their performance can be substantially reduced.”

The Cost to Employers
Study results continually find that workers with depression have a higher rate in absenteeism over workers without depression. Productivity lost on a yearly basis due to is also costly. In fact, according to another study published in JAMA in 2003:

“Because [depression] exacerbates physical illness, it is a significant factor in driving up the cost of care. Inversely, when depression is treated successfully, overall health improves and costs go down. The economic cost of traditional depression care has been estimated to be 8.4 hours lost per worker per week, a reduction in productivity estimated to cost U.S. employers $44 billion a year.

In 2001, the Minnesota Department of Health and the Minnesota Department of Human Services published a report titled Mental Health in the Workplace. It states, “In Minnesota alone, approximately 800,000 people have a diagnosable mental disorder, and 92,000 live with a serious and persistent mental illness. Though the cost per employee with depression in Minnesota varies, some studies show a cost range to employers from $3,000 to $4,000 per year.”

Usual Care
Primary care providers treat about 75% of the patients with depression. Their “usual care” consists of prescribing antidepressants, supportive counseling, and self- or physician-referral to specialty mental health care. With psychiatrists in limited supply, primary care physicians provide most antidepressant prescriptions but have little time for monitoring. Many patients stop taking antidepressants before they have a chance to help.

While primary care providers treat most of the patients with depression, a study published in the JAMA found that they detect only 35-50% of adult patients with major depression. Only about half of these patients get treated, and just 20-40% of treated patients show substantial improvement within 12 months of diagnosis. This is in part because more than 80% of them have an additional health condition or disease, and primary care physicians are usually better trained to address physical versus mental health problems.

Collaborative Care
With usual primary care proving less effective in helping patients with depression, new models of care have been explored. “Collaborative care” models soon proved that appropriately screening patients, patient self-management, and the use of a care manager to ensure persistent and coordinated therapy resulted in much better patients outcomes than achieved through usual care.

At least 37 randomized controlled trials involving 12,355 people treated for depression in primary care provide a solid base of evidence for the effectiveness of collaborative care versus usual care. The “Collaborative Care Model,” developed by Wayne Katon, MD, University of Washington, and put into practice in a depression study (known as IMPACT) conducted by Jürgen Unützer, MD, University of Washington, is the most comprehensive work in this area.

Unutzer’s work showed that under collaborative care, study participants had fewer suicidal thoughts, higher remission rates and improved function. They also reported 100 more depression-free days over a two-year period. In addition, Unützer’s four-year study, published in 2008 in the American Journal of Managed Care, showed potential overall health care savings of $3,300 per individual over a four-year span compared to individuals in usual treatment.

Much of these costs savings was attributed to patients not requiring more intensive medical care or hospitalization due to unmanaged depression. Also, since so many people with depression are plagued by another disease or illness, eliminating depression gave patients the energy and motivation to tackle it.

Financial Impact
According to JAMA, only one-third of the cost of depression falls on health care. The remaining two-thirds of its burden is in lost productivity and disability. The impact of various collaborative care approaches for depression on employee absenteeism and productivity are shown in Figure 1 (see attachment).

In her study, Dr. Rost noted that absenteeism is a very important business-relevant metric, reflecting that employers spend an average of 1.9% of payroll expenditures on sick leave benefits.

Employers who pay replacement workers overtime, hire temporary workers, or incur productivity losses from coworkers when depressed workers are absent may realize additional benefits.

Cost-Benefit
Research shows that not only do collaborative care models for managing depression reduce absenteeism and boost employee productivity, they also show a good return on investment. Lo Sasso’s study, Modeling the Impact of Enhanced Depression Treatment on Workplace Functioning and Costs: A Cost-Benefit Approach, found the treatment costs and benefits displayed in Tables 1 and 2 (see attachment).

Table 1 shows the two-year costs of enhanced depression treatment to cover provider training, the program itself, and outpatient costs attributable to the program (e.g., care manager services). The right two columns show the aggregated costs for the enhanced treatment for a hypothetical employer with 1,000 employees, 5% of which are assumed to have sought primary care during a depression episode. Table 2 shows the incremental benefits from improved absenteeism and productivity, valued in terms of the average full wage ($24,174 plus 0.5 fringe benefits. Note: fringe benefits in Minnesota are closer to 0.35). It shows the average benefit per employee who visits primary care during a depression episode, and extrapolates those savings over two years based on an employer with 1,000 workers, 5% of which seek primary care during a depression episode. This is a cost savings of $286,600 for a company with 1,000 employees.

Employer Obstacles in Funding Depression Treatment
Based on the magnitude of depression-related absenteeism and lost productivity, one might expect employers to invest in enhanced depression screening-treatment programs or other collaborative care models. However, in a study by Philip Wang, MD, and colleagues, they noted that widespread uptake has not occurred due in part to employers’ uncertainty over the return-on-investment.

While more and more employers are contemplating and paying for treatment of depression for their employees, they likely have not paid for collaborative care models to date because they have been research projects funded through grants and other unsustainable means.

DIAMOND
ICSI—the Institute for Clinical Systems
Improvement, a non-profit organization dedicated to improving the quality and lowering the cost of health care, set out to establish a sustainable collaborative care model for managing depression. It brought together providers, psychiatrists, employers, health plans and patients to develop a program called DIAMOND (Depression Improvement Across Minnesota, Offering a New Direction).

DIAMOND changes how care for the patient with depression is delivered and paid for in primary care. Its scope is “to assist primary care in developing systems that support effective assessment, diagnosis and ongoing management of new or existing diagnosis of major depression in adults age 18 and over, and to assist individuals to achieve remission of symptoms, reduce relapse and return to previous level of functioning.”

The Katon/Unützer model became the foundation for DIAMOND, and the program uses six key components of the IMPACT model to treat depression:

1. The use of PHQ-9 (Patient Health Questionnaire), a validated screening tool for primary care providers to detect and monitor a patient’s symptoms of depression
   
2. Systematic patient follow-up tracking and monitoring (based on repeat PHQ-9 measurements and use of a patient registry) to help the provider monitor a patient’s status
   
3. Use of evidence-based guidelines and a stepped-care approach for the provider to know how to best change or intensify treatment if needed
   
4. Addition of a care manager to staff to educate, coordinate, and troubleshoot services for patients
   
5. Addition of a consulting psychiatrist to review patient case load with the care manager and offer assistance for patients with depression that is severe or not improving
   
6. Tools to help the provider prevent a patient who is getting better from falling back into major depression.

The DIAMOND model involves collaboration between the primary care physician, a care manager and a consulting psychiatrist. It allows medical groups to provide more education, more frequent patient follow-up, better monitoring of outcomes, and timelier referrals to mental health specialists when necessary.

DIAMOND is most unique because of its reimbursement model. Nine Minnesota health plans agreed to make a monthly payment to participating DIAMOND clinics for a bundle of services that included the roles of care manager and consulting psychiatrist, and not for a “visit.” Only clinics trained and certified to deliver the DIAMOND program are reimbursed, and all clinics use a single, established billing code. Each medical group and health plan has negotiated a care management fee, which may in the future increase or decrease depending on the medical group’s results with patients.

DIAMOND Results
In March 2008, DIAMOND was launched in 10 primary care medical clinics in Minnesota. Another 20 clinics made DIAMOND available in September 2008, and 18 more added the program in March 2009. Additional groups are being introduced at six-month intervals until about 90 clinics are expected to be offering DIAMOND in 2010.

More than 1,600 patients have been enrolled in DIAMOND to date. Of 213 patients contacted who have been activated in the program for at least six months, 43% are in remission—they have recovered from their depression. Another 10% of these patients have seen at least a 50% reduction in the severity of their depression. These results are 5-10 times better than recovery and improvement noted under usual primary care treatment of patients with depression.

DIAMOND patient outcomes are matching or exceeding the outcomes reported in the collaborative care research studies proven to lower health care costs, and provide financial benefits by getting employees with depression back to productive work faster.

Major corporations in Minnesota are providing DIAMOND coverage to their employees, and more are supporting it as the program is spread across the state through more primary care clinics. Based on its novel care delivery and payment models, it is being hailed as the possible model for managing depression in the primary care clinic not only in Minnesota, but nationwide.