This analysis of national Medical Expenditure Panel Survey data examines trends in outpatient treatment of depression in the United States from 1998 to 2015.
Key Points
Question
How did the trends in the prevalence of depression and spending for treatment in the US population shift from 1998 to 2007 and from 2007 to 2015?
Findings
In this analysis of 86 216 individuals from the 1998, 2007, and 2015 Medical Expenditure Panel Surveys, an absolute increase occurred in the prevalence of treated depression from 2.88 per 100 in 2007 to 3.47 per 100 in 2015, and an increasing proportion of this treatment was covered by insurance, particularly Medicaid (increase from 19% to 36%).
Meaning
These trends appear to be consistent with policies that were intended to increase insurance coverage of depression treatment.
Abstract
Context
After marked increases from 1987 to 1997, trends in depression treatment in the United States increased modestly from 1998 to 2007. However, multiple policy changes that expanded insurance coverage for mental health conditions may have shifted these trends again since 2007.
Objective
To examine national trends in outpatient treatment of depression from 1998 to 2015, with particular focus on 2007 to 2015.
Design, Setting, and Participants
This analysis of the use of health services and spending for treatment of depression in the United States assessed data from the 1998 (n = 22 953), 2007 (n = 29 370), and 2015 (n = 33 893) Medical Expenditure Panel Surveys (MEPSs). Participants included respondent households to the nationally representative survey. Data were analyzed from June 15 through December 18, 2018.
Main Outcomes and Measures
Rates of outpatient and pharmaceutical treatment of depression; counts of outpatient visits, psychotherapy visits, and prescriptions; and expenditures.
Results
The analysis included 86 216 individuals from the 1998, 2007, and 2015 MEPSs. Respondents’ mean (SD) age was 37.2 (22.7) years; 45 086 (52.3%) were female, 24 312 (28.2%) were Hispanic, 15 463 (17.9%) were black, and 62 926 (72.9%) were white. Rates of outpatient treatment of depression increased from 2.36 (95% CI, 2.12-2.61) per 100 population in 1998 to 3.47 (95% CI, 3.16-3.79) per 100 population in 2015. The proportion of respondents who were treated for depression using psychotherapy decreased from 53.7% (95% CI, 48.3%-59.1%) in 1998 to 43.2% (95% CI, 39.0%-47.4%) in 2007 and then increased to 50.4% (95% CI, 46.0%-54.9%) in 2015, whereas the proportion receiving pharmacotherapy remained steady at 81.9% (95% CI, 77.9%-85.9%) in 1998, 82.4% (95% CI, 79.3%-85.4%) in 2007, and 80.8% (95% CI, 77.9%-83.7%) in 2015. After adjusting for inflation using 2015 US dollars, prescription expenditures for these individuals decreased from $848 (95% CI, $713-$984) per year in 1998 to $603 (95% CI, $484-$722) per year in 2015, whereas the mean number of prescriptions decreased from 7.64 (95% CI, 6.61-8.67) in 1998 to 7.03 (95% CI, 6.51-7.56) in 2015. National expenditures for outpatient treatment of depression increased from $12 430 000 000 in 1997 to $15 554 000 000 in 2007 and then to $17 404 000 000 in 2015, consistent with a slowing growth in national outpatient expenditures for depression. The percentage of this spending that came from self-pay (uninsured) individuals decreased from 32% in 1998 to 29% in 2007 and then to 20% in 2015. This decrease was largely associated with increasing Medicaid coverage, because the percentage of this spending covered was 19% in 1998, 15% in 2007, and 36% in 2015.
Conclusions and Relevance
Recent policy changes that increased insurance coverage for depression may be associated with reduced uninsured burden and with modest increases in the prevalence of and overall spending for outpatient treatment of depression. The lower-than-expected rate of treatment suggests that substantial barriers remain to individuals receiving treatment for their depression.
Introduction
Depression is a major source of disability, and its treatment continues to be a source of significant health spending.1,2,3,4,5 This is true despite shifting trends in the prevalence of treated depression over time. From 1987 to 1997, the prevalence of treated depression increased more than 3-fold.6 This sharp uptick in the prevalence of treated depression leveled off to a slower increase of only 22% from 1998 to 2007.7
The dramatic increase in the rate of depression treatment from 1987 to 1997 was largely attributed to the increasing availability of pharmaceutical treatment, notably the increase in the use of selective serotonin reuptake inhibitors (SSRIs) and other pharmaceutical options.2,8 This increased medication availability occurred in the context of the publication of practice guidelines on depression diagnosis and treatment and dissemination of new screening tools.9,10 This increase in treatment was reinforced by expanding insurance coverage for pharmaceuticals in the 1990s and early 2000s, which contributed to shifting patterns of treatment after 1997.7 For example, rates of psychotherapy use declined in the subsequent years through 2007.7 These shifting patterns appear to have been associated with substitution toward medication-focused therapy combined with the potentially high expense of psychotherapy.11
Since 2007, multiple national policies have been implemented that may have further changed the prevalence and treatment patterns of depression. First, the Mental Health Parity and Addiction Equity Act (MHPAEA) was passed in 2008 and enacted in 2010,12 although full parity was only achieved by provisions in the Patient Protection and Affordable Care Act (ACA) of 2010 that mandated benefits for mental health services through the essential health benefits clauses of the ACA.13 Second, the Medicare Improvements for Patients and Providers Act of 2008 led to reduced cost sharing for outpatient mental health visits for individuals with Medicare.14 Before this legislation, outpatient treatment had a coinsurance rate of 50% under Medicare. The Medicare Improvements for Patients and Providers Act of 2008 decreased this from 2011 to 2014 so that outpatient mental health treatment cost sharing was on par with other outpatient services at a 20% coinsurance rate.14 Finally, Medicaid expansion under the ACA increased health insurance coverage in the 33 states that have expanded coverage to date for lower-income individuals, a group among whom the prevalence of untreated depression is potentially higher.15 In sum, these policies, by reducing the cost of depression care to the beneficiary, would be expected to increase the amount of care consumed through increasing the prevalence of care seeking as well as the quantity of care consumed among those already receiving care.
In this study, we examined the trends in the treated prevalence of depression in the US population from 2007 through 2015. We compared these trends with the earlier 1998-2007 period. We similarly examined whether discernible shifts in the patterns of treatment for depression occurred.
Methods
Data
We analyzed data from the Medical Expenditure Panel Survey (MEPS) household component for 1997, 2007, and 2015. The MEPS is a national survey of noninstitutionalized persons in the United States conducted by the Agency for Healthcare Research and Quality (AHRQ) to estimate national health care use and spending, and the data include weights to calculate national estimates. The publicly available MEPS data used for the analysis are deidentified and exempt from human participant review.
Study Samples
The sample consisted of 22 953 participants in 1998, 29 370 participants in 2007, and 33 893 participants in 2015. The MEPS has an overlapping cohort, multiple-round panel structure. The full-year response rates to the MEPS, as calculated by AHRQ, were 67.4% in 1998, 57.9% in 2007, and 47.7% in 2015.16 The AHRQ uses a weighting scheme to account for the complex survey design, and details on this and other technical issues are available in the agency’s documentation.17,18,19
Sociodemographic Characteristics
As in previous studies on the patterns of depression treatment in the MEPS, respondents were classified into groups based on self-reported age categories, sex, race/ethnicity, marital status (for those aged ≥21 years), highest educational attainment (for those aged ≥21 years), source of health insurance coverage, and current employment (for those aged 21-65 years).7
Depression and Use of Health Care Services
In conducting the MEPS, the AHRQ collects information on the use of health services and medication, health care professionals visited, charges and payments for care, and sources of payment (ie, insurance coverage and out-of-pocket cost).17,18,19 We used the same coding for depression, services, and medication as in previous studies of patterns of depression treatment in the MEPS population.7 Respondents to the MEPS report health care visits and the reason for the visits in the survey. This information is then used to gather information from health care professionals. The diagnosis for each visit to outpatient clinics, whether they are hospital or office based, is collected in the MEPS, and trained coders assign codes from the International Classification of Disease, Ninth Revision (ICD-9), to these visits (eAppendix in the Supplement). Patients were considered to be receiving depression treatment if they had outpatient visits or medication for major depressive disorder (single and recurrent episodes), DSM-IV dysthymic disorder, and/or depressive disorder not classified elsewhere. Those with bipolar depression were excluded. Self-responses to questions about psychotherapy use were used to identify psychotherapy visits.
Psychotropic medications were categorized by therapeutic class, including antidepressants, antipsychotics, anxiolytics and hypnotics, stimulants, and mood stabilizers. Antidepressants were further subclassified into new antidepressants (venlafaxine hydrochloride, duloxetine hydrochloride, mirtazapine, and bupropion hydrochloride), tricyclic antidepressants, older antidepressants, and SSRIs. The MEPS includes the type of health care professional seen for each health care visit, including social workers, psychologists, and physicians. As of 2007, physician specialty was also available in the MEPS, and psychiatrists could be separately identified in 2007 and 2015.18,19 Information for each health care service expenditure, including medication, office visits, and psychotherapy visits, was tabulated for outpatient depression care. These types of care were assigned sources of payment, including self-pay, private insurance, Medicaid, Medicare, other federal programs, and other categories.
Statistical Analysis
Data were analyzed from June 15 through December 18, 2018. Prevalence rates of outpatient depression treatment per 100 individuals for 1998, 2007, and 2015 are given in Table 1. These rates are stratified by sociodemographic characteristics, and we used logistic regression to compare the odds of treatment in 2007 relative to 1998 and 2015 relative to 2007 for individuals with each characteristic. The odds among those who received any outpatient treatment or medication for depression using a particular service or medication for 2007 relative to 1998 and 2015 relative to 2007 were calculated using logistic regression (Table 2). Annual expenditures for depression treatment and within each treatment modality among those who received treatment were compared across the 3 years using linear regression (Table 3). Also, trends in national spending on depression treatment for the noninstitutionalized populations in the United States were calculated and compared across years, within treatment modality and insurer type (Table 4 and Table 5). The analyses in Table 2 through Table 5 were conducted using the MEPS sample weights to create national representative estimates.17,18,19 All spending was adjusted for inflation to 2015 US dollars using the Consumer Price Index for Medical Care.20
Table 1. National Rates of Outpatient Treatment of Depression in 1998, 2007, and 2015 Stratified by Sociodemographic Characteristics.
| Characteristic | Treatment Rate per 100 Population (95% CI) | OR (95% CI)a | |||
|---|---|---|---|---|---|
| 1998 (n = 22 953) | 2007 (n = 29 370) | 2015 (n = 33 893) | 2007 vs 1998 (n = 52 323) | 2015 vs 2007 (n = 63 263) | |
| All respondents | 2.36 (2.12-2.61) | 2.88 (2.64-3.12) | 3.47 (3.16-3.79) | 1.16 (1.02-1.33) | 1.09 (0.96-1.24) |
| Sex | |||||
| Male | 1.47 (1.16-1.77) | 2.11 (1.81-2.41) | 2.21 (1.92-2.50) | 1.37 (1.06-1.76) | 0.91 (0.74-1.12) |
| Female | 3.22 (2.82-3.62) | 3.62 (3.29-3.94) | 4.68 (4.21-5.14) | 1.07 (0.91-1.26) | 1.19 (1.04-1.37) |
| Age, y | |||||
| <18 | 0.60 (0.41-0.80) | 0.57 (0.39-0.75) | 0.94 (0.60-1.27) | 0.86 (0.54-1.37) | 1.56 (0.97-2.51) |
| 18-34 | 2.35 (1.76-2.93) | 2.59 (2.09-3.08) | 3.83 (3.19-4.47) | 1.12 (0.80-1.55) | 1.35 (1.02-1.78) |
| 35-49 | 3.92 (3.28-4.57) | 4.05 (3.43-4.66) | 4.22 (3.47-4.97) | 0.97 (0.77-1.23) | 0.96 (0.76-1.23) |
| 50-64 | 3.50 (2.83-4.16) | 4.95 (4.32-5.59) | 5.48 (4.75-6.21) | 1.46 (1.14-1.87) | 0.94 (0.76-1.15) |
| ≥65 | 2.17 (1.56-2.78) | 3.28 (2.64-3.92) | 3.38 (2.58-4.18) | 1.55 (1.07-2.22) | 1.03 (0.74-1.43) |
| Race/ethnicity | |||||
| Hispanic | 1.68 (1.20-2.16) | 1.90 (1.48-2.32) | 2.44 (1.98-2.91) | 1.11 (0.77-1.60) | 1.05 (0.80-1.38) |
| Black | 1.00 (0.58-1.42) | 2.20 (1.71-2.69) | 1.91 (1.55-2.28) | 2.06 (1.27-3.34) | 0.74 (0.55-1.00) |
| White | 2.70 (2.39-3.00) | 3.20 (2.89-3.51) | 4.00 (3.58-4.43) | 1.12 (0.96-1.30) | 1.14 (0.98-1.32) |
| Marital statusb | |||||
| Married | 2.35 (1.99-2.72) | 2.95 (2.56-3.34) | 3.25 (2.84-3.66) | 1.24 (1.00-1.53) | 1.04 (0.86-1.27) |
| Separated, divorced, or widowed | 5.06 (4.17-5.95) | 5.89 (5.12-6.66) | 6.88 (5.90-7.86) | 1.18 (0.92-1.51) | 1.02 (0.83-1.25) |
| Not married | 3.26 (2.36-4.16) | 3.93 (3.20-4.67) | 4.70 (3.96-5.44) | 1.13 (0.80-1.61) | 1.08 (0.82-1.41) |
| Educational level, highest gradeb | |||||
| 0-11 | 2.63 (2.08-3.19) | 4.17 (3.44-4.90) | 4.16 (3.08-5.23) | 1.63 (1.23-2.17) | 0.80 (0.57-1.11) |
| 12 | 2.84 (2.31-3.37) | 3.41 (2.91-3.90) | 3.73 (2.99-4.46) | 1.16 (0.91-1.48) | 1.01 (0.78-1.31) |
| 13-16 | 3.55 (2.99-4.11) | 3.79 (3.30-4.28) | 4.32 (3.63-5.01) | 1.00 (0.80-1.24) | 1.08 (0.87-1.34) |
| ≥17 | 3.43 (2.17-4.69) | 4.26 (3.05-5.46) | 3.65 (2.34-4.96) | 1.22 (0.76-1.97) | 0.78 (0.45-1.35) |
| Health insurance | |||||
| Any private | 2.21 (1.93-2.48) | 2.62 (2.34-2.89) | 2.88 (2.55-3.20) | 1.16 (0.98-1.36) | 1.10 (0.93-1.29) |
| Any Medicare | 3.18 (2.52-3.84) | 5.46 (4.70-6.21) | 5.73 (4.89-6.57) | 1.65 (1.26-2.16) | 1.02 (0.81-1.27) |
| Any Medicaid | 4.02 (3.19-4.84) | 4.31 (3.70-4.92) | 5.35 (4.67-6.03) | 1.16 (0.90-1.51) | 1.09 (0.89-1.34) |
| None | 1.57 (1.08-2.06) | 1.86 (1.34-2.37) | 1.76 (1.09-2.43) | 1.15 (0.74-1.78) | 0.90 (0.57-1.44) |
| Employment statusc | |||||
| Not employed | 6.98 (5.72-8.25) | 8.85 (7.76-9.94) | 10.29 (9.05-11.53) | 1.29 (1.01-1.64) | 1.01 (0.83-1.22) |
| Employed | 2.58 (2.16-3.00) | 2.80 (2.47-3.14) | 3.17 (2.78-3.56) | 1.11 (0.91-1.37) | 1.07 (0.90-1.27) |
Abbreviation: OR, odds ratio.
Adjusted for age, sex, race/ethnicity, and health insurance status.
Includes those 21 years and older.
Includes those aged 21 to 64 years.
Table 2. Treatment Characteristics of Persons Diagnosed and Receiving Outpatient Treatment for Depression in the United States.
| Treatment Characteristic | Proportion of Respondents, % (95% CI) | OR (95% CI)a | |||
|---|---|---|---|---|---|
| 1998 | 2007 | 2015 | 2007 vs 1998 | 2015 vs 2007 | |
| Unweighted No. | 549 | 841 | 1048 | 1390 | 1889 |
| Weighted No. | 6 465 783 | 8 672 781 | 11 155 628 | NA | NA |
| Treatment | |||||
| Psychotherapy | 53.7 (48.3-59.1) | 43.2 (39.0-47.4) | 50.4 (46.0-54.9) | 0.70 (0.52-0.93) | 1.33 (1.05-1.69) |
| Pharmacotherapy | 81.9 (77.9-85.9) | 82.4 (79.3-85.4) | 80.8 (77.9-83.7) | 1.03 (0.75-1.43) | 0.90 (0.67-1.20) |
| Antidepressants | 77.3 (72.9-81.6) | 76.2 (72.6-79.7) | 74.9 (71.5-78.3) | 0.96 (0.71-1.30) | 0.93 (0.71-1.22) |
| SSRIs | 60.7 (56.2-65.3) | 50.0 (45.6-54.3) | 47.9 (44.0-51.8) | 0.67 (0.52-0.86) | 0.90 (0.71-1.14) |
| Other newer antidepressants | 16.3 (12.2-20.4) | 35.6 (31.5-39.6) | 31.9 (28.4-35.5) | 2.97 (2.07-4.24) | 0.89 (0.70-1.14) |
| Tricyclic antidepressants | 12.6 (9.2-15.9) | 2.6 (1.5-3.7) | 3.1 (1.8-4.4) | 0.17 (0.10-0.29) | 1.18 (0.62-2.25) |
| Anxiolytics | 9.8 (6.8-12.7) | 12.1 (9.6-14.6) | 11.5 (8.8-14.2) | 1.17 (0.77-1.79) | 0.94 (0.64-1.38) |
| Antipsychotics | 11.7 (8.2-15.2) | 9.9 (7.6-12.2) | 12.5 (9.9-15.2) | 0.77 (0.50-1.20) | 1.19 (0.82-1.74) |
| Mood stabilizers | 6.4 (4.1-8.7) | 6.9 (4.9-8.9) | 6.2 (4.1-8.2) | 1.10 (0.66-1.83) | 0.88 (0.56-1.40) |
| Stimulants | 1.9 (0.5-3.3) | 2.6 (1.0-4.1) | 2.2 (1.1-3.3) | 1.54 (0.59-4.02) | 0.86 (0.38-1.93) |
| Psychotherapy and pharmacotherapy | 42.9 (37.8-48.0) | 35.1 (31.3-38.8) | 39.1 (34.7-43.5) | 0.75 (0.57-0.99) | 1.17 (0.92-1.49) |
| Psychotherapy and antidepressants | 41.0 (35.8-46.1) | 33.2 (29.5-36.8) | 35.9 (31.3-40.4) | 0.75 (0.57-0.99) | 1.11 (0.86-1.43) |
| Health care professional at mental health visits | |||||
| Physician | 85.6 (82.0-89.2) | 84.6 (81.7-87.4) | 76.5 (73.0-79.9) | 0.81 (0.56-1.17) | 0.59 (0.44-0.80) |
| Psychiatristb | NA | 42.0 (38.1-45.8) | 42.6 (37.7-47.4) | NA | 2.30 (1.80-2.95) |
| Psychologist | 21.5 (17.3-25.7) | 19.4 (16.0-22.8) | 22.9 (19.4-26.4) | 0.98 (0.70-1.37) | 1.25 (0.93-1.68) |
| Social worker | 6.8 (4.1-9.5) | 6.8 (5.0-8.5) | 10.7 (8.3-13.2) | 1.06 (0.64-1.75) | 1.56 (1.06-2.30) |
| Acute psychiatric services | |||||
| Inpatient treatment | 4.9 (2.7-7.0) | 2.8 (1.5-4.1) | 2.8 (1.3-4.2) | 0.53 (0.26-1.09) | 0.98 (0.49-1.95) |
| Emergency department | 1.6 (0.7-2.5) | 2.6 (1.1-4.2) | 2.5 (1.2-3.9) | 1.64 (0.70-3.86) | 0.87 (0.42-1.80) |
Abbreviations: NA, not applicable; OR, odds ratio; SSRI, selective serotonin reuptake inhibitor.
Adjusted for age, sex, race/ethnicity, and health insurance status.
Specialist information was not collected in the 1998 Medical Expenditure Panel Survey data.
Table 3. Trends in Use and Cost of Depression Treatment Among Those Using Outpatient Depression Care.
| Treatment Variable | 1998 | 2007 | 2015 |
|---|---|---|---|
| Unweighted No. | 549 | 841 | 1048 |
| Weighted No. | 6 465 783 | 8 672 781 | 11 155 628 |
| Depression visits | |||
| Expenditure, $ (95% CI)a | 1074 (829-1320) | 859 (717-1001) | 957 (823-1092) |
| No. of visits, mean (95% CI) | 7.37 (6.21-8.52) | 6.36 (5.43-7.30) | 6.79 (5.97-7.61) |
| Psychotherapy | |||
| Expenditure, $ (95% CI)a,b | 1585 (1176-1995) | 1230 (1005-1455) | 1558 (1314-1802) |
| No. of visits, mean (95% CI)b | 9.17 (7.71-10.64) | 8.16 (6.51-9.81) | 9.05 (7.63-10.47) |
| Psychotropic prescriptions | |||
| Expenditure, $ (95% CI)a | 848 (713-984) | 933 (813-1054) | 603 (484-722) |
| No. of prescriptions, mean (95% CI) | 7.64 (6.61-8.67) | 6.87 (6.30-7.45) | 7.03 (6.51-7.56) |
Adjusted for inflation to 2015 US dollars using the Consumer Price Index for Medical Care.
Analysis limited to persons with 1 or more psychotherapy visits for depression.
Table 4. Trends in Total Estimated Expenditures for Depression Treatment.
| Treatment for Depression | Annual Expenditure, $a | Change, % | ||||
|---|---|---|---|---|---|---|
| 1998 | 2007 | 2015 | 1998 to 2007 | 1998 to 2015 | 2007 to 2015 | |
| Total outpatient treatment | 12 430 000 000 | 15 540 000 000 | 17 404 000 000 | 25.0 | 40.0 | 12.0 |
| Mental health visits | 6 945 000 000 | 7 446 000 000 | 10 680 000 000 | 7.2 | 53.8 | 43.4 |
| Psychotherapy | 5 503 000 000 | 4 604 000 000 | 8 769 000 000 | −16.3 | 59.3 | 90.4 |
| Medications | 5 484 000 000 | 8 094 000 000 | 6 724 000 000 | 47.6 | 22.6 | −16.9 |
The 1998 and 2007 expenditures have been inflated to 2015 US dollars using the Consumer Price Index for Medical Care.
Table 5. Sources of Payment for Depression Treatment.
| Sources of Payment | Annual Expenditures, $ (Share, %)a | Change, % | ||||
|---|---|---|---|---|---|---|
| 1998 | 2007 | 2015 | 1998 to 2007 | 1998 to 2015 | 2007 to 2015 | |
| Self-payment | 3 964 000 000 (32) | 3 586 000 000 (29) | 2 471 000 000 (20) | −9.5 | −37.7 | −31.1 |
| Private insurance | 4 755 000 000 (38) | 6 126 000 000 (49) | 5 296 000 000 (43) | 28.8 | 11.4 | −13.5 |
| Medicare | 654 000 000 (5) | 2 684 000 000 (22) | 3 115 000 000 (25) | 310.2 | 376.1 | 16.1 |
| Medicaid | 2 329 000 000 (19) | 1 835 000 000 (15) | 4 494 000 000 (36) | −21.2 | 93.0 | 144.9 |
| Other public sources | 219 000 000 (2) | 290 000 000(2) | 256 000 000 (2) | 32.8 | 17.0 | −11.9 |
| Other | 509 000 000 (4) | 1 019 000 000(8) | 1 772 000 000 (14) | 100.1 | 247.9 | 73.9 |
The 1998 and 2007 expenditures have been inflated to 2015 US dollars using the Consumer Price Index for Medical Care.
Results
The analysis included 86 216 individuals from the 1998, 2007, and 2015 MEPSs. Respondents’ mean (SD) age was 37.2 (22.7) years, 45 086 (52.3%) were female, 24 312 (28.2%) were Hispanic, 15 463 (17.9%) were black, and 62 926 (72.9%) were white. From 1998 to 2015, the treated prevalence of depression increased from 2.36 (95% CI, 2.12-2.61) per 100 population to 3.47 (95% CI, 3.16-3.79) per 100 population, representing a 46.8% relative increase (Table 1). The relative growth in prevalence from 1998 to 2007 was 21.8%, and from 2007 to 2015, it was 20.6%. With respect to sociodemographic characteristics, marked departures from the general increase in the treated prevalence occurred from 1998 to 2007. From 1998 to 2007, the treated prevalence among the group aged 50 to 64 years increased from 3.50 (95% CI, 2.83-4.16) per 100 population to 4.95 (95% CI, 4.32-5.59) per 100 population (relative increase, 41.7%), and among those 65 years and older, the treated prevalence increased from 2.17 (95% CI, 1.56-2.78) per 100 population to 3.28 (95% CI, 2.64-3.92) per 100 population (relative increase, 50.5%). In contrast, the treated prevalence among those younger than 18 years decreased slightly from 0.60 (95% CI, 0.41-0.80) per 100 population to 0.57 (95% CI, 0.39-0.75) per 100 population, and those aged 18 to 34 years only increased from 2.35 (95% CI, 1.76-2.93) per 100 population to 2.59 (95% CI, 2.09-3.08) per 100 population (relative increase, 10.2%). In the period from 2007 to 2015, this pattern reversed, with the group aged 50 to 64 years having a 10.6% increase and the group 65 years and older only having a 3.1% increase in treated prevalence, whereas the group younger than 18 years had a 64.9% increase in treated prevalence and the group aged 18 to 34 years had a 48.0% increase in treated prevalence.
The treated prevalence among black respondents increased between 1998 and 2007 from 1.00 (95% CI, 0.58-1.42) per 100 population to 2.20 (95% CI, 1.71-2.69) per 100 population (relative increase, 120%) but then decreased to 1.91 (95% CI, 1.55-2.28) per 100 by 2015 (−13.0%). The prevalence among white respondents was still more than double that of black respondents in 2015 at 4.00 (95% CI, 3.58-4.43) per 100. From 1998 to 2007, a higher relative increase occurred among those with less than 12 years of completed education from 2.63 (95% CI, 2.08-3.19) per 100 to 4.17 (95% CI, 3.44-4.90) per 100 (58.2%), which leveled off and remained at 4.16 (95% CI, 3.08-5.23) per 100 by 2015.
Psychotherapy use declined between 1998 and 2007, from 53.7% (95% CI, 48.3%-59.1%) to 43.2% (95% CI, 39.0%-47.4%) of those with treated depression, but then increased to 50.4% (95% CI, 46.0%-54.9%) in 2015 (Table 2). Use of pharmacotherapy remained high and relatively constant across years at 81.9% (95% CI, 77.9%-85.9%) in 1998, 82.4% (95% CI, 79.3%-85.4%) in 2007, and 80.8% (95% CI, 77.9%-83.7%) in 2015. The proportion of patients with combined use of psychotherapy and pharmacotherapy followed a similar pattern to that of psychotherapy use, with a decline from 1998 to 2007 (42.9% [95% CI, 37.8%-48.0%] to 35.1% [95% CI, 31.3%-38.8%]) and then an increase in 2015 (39.1% [95% CI, 34.7%-43.5%]), which was still below the 1998 level. The proportion of those being treated for depression using newer antidepressants increased between 1998 and 2007, from 16.3% (95% CI, 12.2%-20.4%) to 35.6% (95% CI, 31.5%-39.6%), which abated by 2015 to 31.9% (95% CI, 28.4%-35.5%). Use of SSRIs among those treated for depression declined significantly from 60.7% (95% CI, 56.2%-65.3%) in 1998 to 47.9% (95% CI, 44.0%-51.8%) in 2015; however, SSRIs remained the most frequently used pharmacotherapy. Although no change occurred in the proportion of those with treated depression seeing social workers from 1998 to 2007, there was a marked increase from 6.8% (95% CI, 5.0%-8.5%) in 2007 to 10.7% (95% CI, 8.3%-13.2%) in 2015.
Annual per capita expenditures on depression visits ranged from $1074 (95% CI, $829-$1320) in 1998 to $859 (95% CI, $717-$1001) in 2007 and $957 (95% CI, $823-$1092) in 2015, with a mean number of visits of 7.37 (95% CI, 6.21-8.52) in 1998, 6.36 (95% CI, 5.43-7.30) in 2007, and 6.79 (95% CI, 5.97-7.61) in 2015 (Table 3). Although the mean number of psychotherapy visits declined among those using psychotherapy from 9.17 (95% CI, 7.71-10.64) in 1998 to 8.16 (95% CI, 6.51-9.81) in 2007, by 2015 the mean number of psychotherapy visits had increased to 9.05 (95% CI, 7.63-10.47), and expenditures on psychotherapy among those who used it were almost identical to those in 1998. In contrast, pharmaceutical spending on depression increased from $848 (95% CI, $713-$984) per year in 1998 to $933 (95% CI, $813-$1054) per year in 2007, but then declined to $603 (95% CI, $484-$722) per year by 2015. The mean number of prescriptions decreased from 7.64 (95% CI, 6.61-8.67) in 1998 to 7.03 (95% CI, 6.51-7.56) in 2015.
Total expenditures on depression treatment increased 40% from $12 430 000 000 in 1998 to $15 554 000 000 in 2007 and $17 404 000 000 in 2015 (Table 4). This increase represents an annual growth rate of 2%. During that period the total expenditures on medications for depression increased by 22.6%. The share of total depression treatment covered by self-pay declined from 32% in 1998 to 29% in 2007 and 20% in 2015 (Table 5). Conversely, the Medicare-covered share increased from 5% in 1998 to 22% in 2007 to 25% in 2015, whereas the Medicaid-covered share of spending declined from 19% in 1998 to 15% in 2007 and then increased to 36% in 2015.
Discussion
From 1998 to 2015, substantial changes in treatment availability and recommendations occurred, as well as policy changes that increased the coverage of mental health services and generosity of coverage in many cases. Most notable was the passage of the MHPAEA, the essential benefits under the ACA, and expansion of Medicaid under the ACA.12,13,15 Despite this increased coverage, total spending on depression increased at about 2% per year from 1998 to 2015, below the annual growth rate in overall health spending over that period.21 Despite recent concerns about drug costs, in the case of depression, spending on drugs has decreased since 2007, despite a notable increase in the prevalence of treated depression. This decrease was likely attributable in part to the multiple blockbuster antidepressants coming off patent in recent years and becoming available as low-cost generics.22,23
The overall rate of treatment for depression remains below the 4.8% to 12.8% reported rate of depression in various age subgroups in the population.1 This finding is consistent with those of studies that suggest that many individuals with depressive symptoms are not receiving treatment and a meaningful proportion of those who are receiving depression treatment do not currently have symptoms of depression.24 However, a recent study examining changes in general psychological distress using the MEPS25 suggests that these reductions in general psychological distress are not likely solely driven by increases in outpatient treatment. In addition, a substantial gap remains in treatment prevalence among white, black, and Hispanic patients, as well as between male and female patients. Although recent insurance expansions should have addressed one of the major stated barriers to receiving mental health care, other psychosocial factors that sustain these differences are likely involved.26
Although rates of psychotherapy use fell from 1998 through 2007, rates increased through 2015 and were approaching those observed in 1998. This pattern may reflect changes in how and where psychotherapy is delivered, including treatment in primary care and teletherapy. The MEPS does not allow us to distinguish such changes. In the MEPS, we observed notable increases in the use of psychologists and social workers but decreases in physician visits. If the decreases in physician visits occur because respondents in the survey do not recognize these newer types of visits as physician care or as psychotherapy, then the observed rates underestimate treatment prevalence.
Although SSRI use declined substantially from 1998 through 2007, the decline leveled off somewhat by 2015, as did the increase in the use of newer antidepressants. Concomitant use of pharmacotherapy and psychotherapy has increased since 2007, which may reflect expanded insurance coverage. Based on the data, the quantity and inflation-adjusted price of psychotherapy visits in 2015 were nearly identical to those in 1998.
The increase in treated depression among individuals who were unemployed continued to increase faster than the rate among those who were employed. Coupled with the increasing proportion of individuals with depression who visited a social worker and the earlier rapid growth in depression among those with lower levels of education between 1998 and 2007, this increase was consistent with expanding insurance coverage that reduced barriers to access for depression treatment. This increase appears to be associated with Medicaid expansion under the ACA, which had resulted in almost 11 million newly eligible enrollees by the end of 2015. Medicaid spending on depression increased by 144.9%, more than any other insurance type, during the period from 2007 through 2015.27 In contrast, the spending on depression among those covered by private insurance decreased by 13.5%, and spending on depression for the uninsured decreased by 31.1%. Although Medicaid expansion may have been associated with increased Medicaid spending on depression, the effects of the MHPAEA on private spending is less clear.
Medicaid can reduce the burden on many people with depression, a burden that weakens their ability to work. That said, states spent an additional $4.3 billion on overall health care for newly eligible Medicaid enrollees in 2015, which restricts their abilities to deal with other social factors that are intertwined with depression and its care.28,29 Furthermore, work requirements proposed by the Department of Health and Human Services may exacerbate access to depression treatment if these requirements fail to consider the role of mental health in being able to maintain a steady job and vice versa.29
Limitations
Trends analyses using national surveys across long periods can be affected by a multitude of policies and other factors that influence the practice and seeking of medical care, as well as changing patterns of responses to surveys. The changes in the prevalence and financing of depression care observed in the MEPS are consistent with the a priori arguments of the potential increases in coverage that would accompany Medicaid expansion. This observation is less relevant for the MHPAEA because private spending decreased during the period. However, observed differences could have been augmented or mitigated by other factors that also occurred during the period.
Further, the MEPS relies on the respondents’ calendars and diaries or their ability to recall health care visits, although these are supplemented with surveys of health care professionals to verify the information provided. The approach relies on probabilistic matches between respondent reports and health care professional information, resulting in uncertainty around a specific diagnosis, which is pronounced in the case of mental health.30 In addition, the MEPS response rate was 47.7% in 2015, and as with any survey, there is a threat of nonresponse bias. This bias could influence the observed increases in treatment if those not using health care were less likely to respond to the MEPS but still responded to the National Health Interview Survey, of which the MEPS is a subsample.
National surveys that assess major depression, particularly the 2016 National Survey on Drug Use and Health (NSDUH), have found similar proportions of treated depression to what we find in the 2015 MEPS.31 According to the NSDUH, the proportion of the population that experienced a major depressive episode in a given year is higher than what we observed in the MEPS in 2015.31 However, the proportion of those who received treatment from a health professional or used medication for their major depression was similar to what we observed in the MEPS. In particular, among the proportion of individuals in the NSDUH using any care for depression, the proportion that used medication to treat their depression was nearly identical to that in the MEPS, and slight differences in visits to health care professionals were likely driven by differences in how the information was assessed.
Conclusions
Taken together, the reductions in the amount spent by those who were uninsured, the trends in costs, and the apparent stability in prices of pharmacotherapy suggest that policies enacted in recent years to expand insurance coverage for mental health services, in particular the MHPAEA and ACA, have had an association with increased prevalence of treatment for depression without increasing prices or total spending. These findings still need to be balanced against the fact that the lower-than-expected rate of treatment suggests that substantial barriers remain to individuals receiving treatment for their depression. These factors may prove to be more difficult to address from a policy perspective because clinical inertia, community stigma, and other constraints are not as easily addressed as mandating parity in insurance coverage and level of generosity.
eAppendix. ICD-9 Codes Assigned for Depression
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Associated Data
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Supplementary Materials
eAppendix. ICD-9 Codes Assigned for Depression