Soc Psychiatry Psychiatr Epidemiol (2007) 42:740–746
DOI 10.1007/s00127-007-0225-9
ORIGINAL PAPER
Anke Bramesfeld Æ Thomas Grobe Æ Friedrich Wilhelm Schwartz
Who is treated, and how, for depression? An analysis of statutory health insurance data in Germany
Accepted: 31 May 2007 / Published online: 27 June 2007
j Abstract Background Studies on the treatment of depression using epidemiological survey methods suggest a high level of under-treatment. Little is known about the characteristics of those people receiving treatment and indeed what kind of treatment they are likely to receive. Method Analysis of the data of a statutory health insurance company in Germany. Results In middle-aged groups, about 50% of those diagnosed as being depressed in outpatient care are prescribed antidepressants and/or psychotherapy in the course of a year. There is more pharmacologic treatment provided in rural areas and more psychotherapy in cities, suggesting that treatment is dependent upon service availability rather than evidence-based treatment decisions. Treatment rates are considerably lower in the very young and the very old and show gender bias. Young females receive less pharmacologic treatment than young males, and elderly men are, in general, treated less than women, suggesting under-treatment at least for these groups. Conclusions The low treatment rates following the diagnosis of depression in the young and the old require attention, in particular with respect to gender aspect. j Key words treatment of depression – sociodemographic characteristics – health insurance data – epidemiology – health service research
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Dr. A. Bramesfeld (&) Æ F.W. Schwartz Dept. for Epidemiology Social Medicine, and Health System Research Medical School Hannover, OE 5410 Carl Neunberg Straße 1 30625 Hannover, Germany Tel.: +49-511/532-4459 Fax: +49-511/532-5347 E-Mail:
[email protected] T. Grobe Institute for Social Medicine, Epidemiology and Health System Research (ISEG) Hannover, Germany
Background Depression is increasingly recognised as a major public health problem in industrialized countries because of its high prevalence [28], high costs of treatment [11] and the disability associated with it [18]. To tackle the burden of depressive disease much is expected from improving service provision [3]. Therefore timely and cost-efficient accessible information on the epidemiology of disease and the status of health care provision is needed [4]. Such information can be provided through health insurance data. However, the data needs to include information on outpatient care and be derived in a health system providing population wide coverage and a relatively low threshold access to health care. This study takes such an approach and explores the chances of people diagnosed with depression in outpatient care actually receiving treatment in Germany. It aims to investigate the characteristics that might be related to the likelihood of a patient receiving treatment and explores what kind of treatment is given to what kind of people. In practice, only half the clinically depressed population seeks any medical help for their symptoms [11]. At the same time, according to cross-sectional studies in primary health care, quite a number of depression-related illnesses are not diagnosed as such. Of those patients who are correctly diagnosed as being depressed, about 60% have adequate treatment prescribed [17, 27]. Across European countries there is the perception that depression is under-diagnosed and under-treated [2]. Little is known about the characteristics of those people receiving treatment (and indeed the characteristics of those who do not receive treatment). Also, there is little known about the likelihood of someone being treated for depression in relation to age and gender, place of residence or social status [20].
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Method We analysed the data of a German statutory health insurance company. About 88% of the German population are insured in one of the country’s 253 statutory health insurance companies, while approximately 10% are covered by private health insurance [6]. Analysing the data of statutory heath insurance companies has the advantage over epidemiological survey data in that—beyond availability—it covers a wide section of the population, including those people who are usually exempt from epidemiological studies, such as the institutionalised. Furthermore, health insurance data is available longitudinally and thus not subject to recall bias. Compared to population surveys, however, health insurance data has the disadvantage that it is restricted to specific information and that diagnoses are not made by standardised instruments but rather in clinical practice (thus is subject to under-diagnosis, misdiagnosis or over-diagnosis). In addition, people who do not seek medical help, will not appear in health insurance data. For this study, the data of a major statutory health insurance company, the Gmu¨nder Ersatzkasse (GEK), was used. In 2004, approximately 1.4 million people were covered by the GEK, i.e., 1.7% of the German population. Historically, predominantly bluecollar workers were insured with the GEK, with a focus on craftsmen and the metal-processing industry. Thus, a relatively high number of men of a working age are represented in the clientele of the GEK. Although the population represented here with the GEK cannot be considered representative of the German population in respect to its occupation mix, prior studies have found that results from analyses of data provided by the GEK can be transferred to the German population as a whole without major distortions. For example, an analysis of GEK data on hospital-made diagnoses corresponded well with the official data provided on diagnosis at the time of hospital discharge by the federal statistic bureau that covered the whole country [13]. In the analysis presented here, persons suffering from depression were identified through the diagnosis of depression made in the outpatient setting. It is only since 2004 that data on individual patient diagnoses in ambulatory care has been transferred by the physicians treating the patients in outpatient care to the health insurance companies. Diagnoses are coded according to ICD-10. For the analysis we focused on ICD-10 depressive episode (F32) and recurrent depressive episode (F33). These diagnoses are most used for coding depression in clinical life. Diagnoses such as adjustment disorders (F43.2) are also given to patients suffering from depression, however, rarely, and mostly by mental health specialists. Brief analysis of the data showed that diagnosis adjustment disorders accounted for less than 2% of the total number of depression diagnoses and were, thus, excluded from further analysis. Since on a four digit level the unspecific ICD-10 codes F32.9 and F33.9 represented 64% of all diagnoses of depressions, we only considered ICD codes up to three digits, thus there is no information of disease severity. Persons identified as having been diagnosed with depression (e.g., ICD10 F32, F33) in an outpatient setting within the first quarter of 2004 were further analysed for the treatment that they received. Treatment was defined as follows:
• Having been prescribed antidepressants. Only data on medication that the health insurance has to pay for is available. Herbal medication for adults, such as St. John’s Wort, mostly has to be paid out of the patient’s own pocket and thus, no information about its use is available in the health insurance data. • Having consulted a psychotherapist (either psychologists or medical doctors with an additional training) or a physician specialised in psychosomatics. This data contains only information about visits to psychotherapists who are registered with the Regional Association of Statutory Health Insurance Physicians. Only visits to these registered psychotherapists are reimbursed by the heath insurance companies and thus, information is available in the health insurance data.
• Having had a hospital admission with the primary diagnosis of depression (F32/F33) either in an acute hospital or a rehabilitation clinic. We analysed the data with simple descriptive statistics for age, gender and place of residence using SAS statistical software package.
Results j Prevalence of depression diagnosis In the course of one year, approximately 91% of all insured persons visited a medical outpatient facility—either an office-based physician or an outpatient clinic—at least once. Approximately 4.8% of all insured were thereby diagnosed as suffering from depression within the first quarter of the year 2004; during the whole year 2004, it was 8.7% (rates are standardized for sex and age distribution of the German population as at the end of 2003). Rates of depression diagnosed in outpatient care in 2004, stratified for age and gender, are presented in Fig. 1. In all age groups, women are approximately twice as often affected as men. Standardised for age, 4.9% of all males insured and 12.4% of all females are diagnosed as being depressed in the course of one year. After the age of 55, at least 18% of all women are diagnosed as being depressed. Depression diagnosis rates for men older than 55 vary between 9 and 12%. It is remarkable, that at around the age of 65, which is the official retirement age, diagnosis rates decrease, in particular amongst men.
j Treatment rates Antidepressants About 29% of all those insured who were diagnosed as suffering from depression in outpatient care within the first quarter of the year were already prescribed antidepressants in the same quarter. This rate increases to 40% when considering prescriptions for antidepressants during the entire year.
Psychotherapy About 11.7% of those diagnosed with depression consulted a psychotherapist; 3.9% consulted a physician specialised in psychosomatic medicine (these doctors are additional to psychotherapists and also mostly provide psychotherapy). Together, 15.1% received treatment from a psychotherapist and/or physicians specialised in psychosomatic medicine in the course of a year.
Inpatient treatment About 4.9% of all persons diagnosed with depression in the first quarter of the year 2004 were treated in
742 24%
proportion of insured with diagnosis of depression in ambulatory care 2004
Fig. 1 Proportion of insured with diagnosis of depression during 1 year
male female
22% 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 1
5
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25
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acute hospitals and 2.5% in rehabilitation clinics for any main diagnosis,1 which was not necessarily a psychiatric diagnosis. About 2% of those diagnosed as depressed in outpatient care received inpatient treatment under the main diagnosis depression in acute hospitals and 1% in rehabilitation clinics.
j Treatment according to age and gender Figures 2 and 3 show treatment rates in women and men stratified for age. The following modes of treatment are considered in the calculations: • consulting at least a psychotherapist once within the year; • being prescribed antidepressants at least once a year; • being both prescribed antidepressants and consulting a psychotherapist; • being prescribed either antidepressants or consulting a psychotherapist or both. • being prescribed antidepressants or consulting a psychotherapist or receiving inpatient treatment with the main diagnosis of mental disorder (ICD10 Chapter V) or any combination of these treatments. A rate of 100% would have been reached, if every men or women diagnosed as depressed in outpatient care would have received at least one of these therapeutic options within the year.
While the lowest treatment rates can be found for very young patients (mainly treatment by psychotherapists), the highest overall treatment rates were found for those of a working age. Approximately 50% of patients in that age group received either psychotherapy 1
Only one main diagnosis can be coded for patients admitted to hospital. It usually indicates the main reason for admission. Beyond this, numerous secondary diagnosis can be added, indicating comorbidity
and/or a prescription for antidepressants in the course of a year. However, treatment rates for men aged 60 and older were found to be considerably lower. Different treatments show different age preferences: Psychotherapy is more often provided to younger persons. Under the age of 20, more psychotherapy is provided than antidepressants prescribed. The highest rates of psychotherapy treatment are found in men aged between 20 and 24-year-old (27.5%) and in women between the ages of 25 and 29 (31.7%). After that, rates decrease sharply for women, and somewhat slower for men. After the age of 60, psychotherapy is very rarely provided. Psychotherapy and antidepressants as a combined treatment are prescribed predominantly to persons of a working age. This amounts to approximately 10%. Prescriptions for antidepressants for women increase steadily up until the age of 50 at a level of between 40 and 45% and then stay at this same level in the higher age groups. Rates for men show a steeper rise in the younger age group, reaching somewhat higher maximum levels of about 46% between the ages of 50 and 59 years. After that, they decrease to 35% and stay at a level below the treatment rate for female patients. When inpatient treatment is considered additionally, the rates for receiving any kind of treatment do not change substantially. As can be seen in Figs. 2 and 3, rates for prescriptions of antidepressants only resemble those for prescriptions for any kind of treatment in the higher age groups.
j Treatment according to place of residence The rate of persons diagnosed with depression and prescribed antidepressants was calculated for sub-
743 Fig. 2 Proportion of males diagnosed with depression within the first quarter of the year receiving different kinds of treatments within 2004 proportion of patients with depressions receiving treatment
60%
50%
40%
30%
any inpatient/outpatient treatment drugs or psych. therapy drugs
20%
psych. therapy drugs and psych. therapie 10%
0% 10-
15-
20-
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age (male)
Fig. 3 Proportion of females diagnosed with depression within the first quarter of the year receiving different kinds of treatments within 2004 proportion of patients with depressions receiving treatment
60%
50%
40%
any inpatient/outpatient treatment drugs or psych. therapy
30%
drugs psych. therapy drugs and psych. therapie
20%
10%
0%
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age (female)
groups according to the density of population in their place of residence. In order to have more homogeneous groups, the calculation was restricted to those aged between 15 and 65 (n = 37,020). The same calculation was repeated with a focus on psychotherapy treatment. Figure 4 reveals differences in prescription rates for psychotherapy and for antidepressants between regions: In rural areas with less than 100 inhabitants per square kilometre, 42.6% of persons diagnosed with depression were prescribed an antidepressant in the course of 12 months. In densely populated regions, only 36.7% of patients were prescribed antidepressants. However, they were provided with psychotherapy more often (21.5%), while in rural areas this was the case in only 15% of patients. In different population density areas, between 48 and
51% of all persons diagnosed as depressed were prescribed antidepressants and/or psychotherapy (results not shown in figure).
Discussion j Prevalence of depression diagnosis Despite methodological differences between the sampling of routine data and data in epidemiological surveys, there are remarkable parallels in the findings with respect to the prevalence rate, gender differences in prevalence and increase of prevalence rates until the fifth decade [23, 29].
744 50%
prolportion of patients with depressions receiving treatment
Fig. 4 Proportion of insured (15–65 years of age) who were diagnosed with depression and who received either antidepressants or psychotherapy stratified for density of population at place of residence
drugs psych. Therapy
42,6% 41,1%
41,0%
40,1%
39,9%
40% 36,7%
30%
21,5% 19,0%
20%
19,8%
20,0%
17,6% 15,0%
10%
0% <100
100-
250-
550-
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population density (persons per km2)
Prior analysis of the health insurance data has revealed similar patterns in the diagnosis of depression described above, and also in the pharmacologic and inpatient data [12]. This consistency in the findings across health insurance data and its similarity with epidemiological findings point to its reliability and validity on a population level. However, unlike in most epidemiological surveys, the rate of depression diagnosis in the health insurance data continues to rise after the age of 70. It reaches its peak in the very old. This discrepancy is most likely caused by an increase in sub-syndromal and atypical depression in later life. Epidemiological surveys that include atypical and sub-syndromal depression syndromes also reveal a steady increase into old age [21, 25]. As discussed above, although diagnosed by standardised instruments, atypical and sub-syndromal depressions are not classified as depressive episodes. However, in real clinical life, clinicians seem to understand them as such [12].
j Treatment rates Overall, 48% of all persons diagnosed with depression by clinicians in the outpatient setting in the first quarter of the year are either treated with antidepressants or psychotherapy or both during the course of 1 year. Of those diagnosed with depression, 40% were prescribed antidepressants. This rate is slightly higher than the mean treatment rate with antidepressants identified by six European countries [1]. From our data we are unable to tell to what extent patients have been treated with regard to effective dosage, duration of medication and mode of psychotherapy. We are also not able to say whether the treatment provided conformed to guidelines and evidence, nor do we know about the outcome of the treatment. However, it has to be assumed that not all prescriptions were collected, that not all patients complied with the intended treatment, and that not all those diagnosed
with depression who visited a psychotherapist actually went into psychotherapy. Therefore, lower de-facto treatment rates have to be assumed. Also, there is no information on what happened to those who were diagnosed with depression but did not receive any treatment. Did they remit spontaneously or were they helped by herbal medicines or other sources outside the official health care system? The rate of treatment prescribed does not differ according to the density of population in different regions. Taken density of population as a proxy for differences between rural and urban areas, this indicates more or less homogenous service provision. This is consistent with results from the ESEMED study, surveying six European countries including Germany [8]. However, in our data there are differences in the mode of treatment that is provided. More psychotherapy is given in cities, whereas the rate of those treated with antidepressants is found to be higher in rural areas. These differences most likely reflect service availability (psychotherapists are less available in rural areas [24]) than evidence-based treatment decisions. Overall, we found gender specific lower prescription and treatment rates in young adults and in the elderly. Prescription rates for middle-aged people were more or less equal for men and women. This result is confirmed by other studies using survey methods [22]. Treatment rates for young women aged 15–25 years are lower than those for men in the same age group. These results do not conform to a recent analysis of data provided by the same health insurance on the prescription of antidepressants to adolescents (15 to 19-year-old) [7]. This study revealed a prescription rate for antidepressants that was twice as high in young females compared to males. However, firstly this study did not distinguish between diagnoses, thus it could be that more antidepressants were given to females for syndromes other than depressive episodes. Secondly, the study included St. John’s Wort as an
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antidepressant (which is reimbursed by statutory health insurance companies for children and adolescents, but not generally for adults), whereas our analysis did not. St. John’s Wort accounted for more than half the prescriptions for antidepressants in adolescents. Thus, it is possible that the differences between the two studies might all be due to the high rate of St. John’s Wort prescribed to young women. As such, there seems to be a need for more research into the practice of treatment for depression in adolescents and young people when considering gender aspects. Low treatment rates in younger people were also found in another survey which revealed that, in Germany, only 8–23% of depressed adolescents are treated [19]. Looking at the low prescription rates for antidepressants in the young, their questionable effect on this age group has to be considered as a reason for physicians not prescribing them [15, 26]. On the other hand, the evidence for the effectiveness of psychotherapy in adolescent depression is available [14], but—as our data shows—psychotherapy is also not applied much to this age group. Also, the low treatment rates in the elderly require attention. Diagnosis rates are particularly high in the elderly. However, these people have the lowest treatment rates. Even if it is assumed that a large number of depression diagnoses in the elderly refer to subsyndromal and atypical depression, to clinicians these syndromes presented severe enough symptoms to be coded as depressive episodes. Treatment for depression in later life is available, however it has to be noted that the evidence base for its effectiveness in the primary care setting is scarce, in particular with respect to sub-threshold cases [10]. However, collaborative care approaches have shown to be effective in primary care in the long-term [16]. Considering that rates for completed suicides are the highest in elderly men [9], action with respect to increasing treatment rates among this population group is urgently needed and should also have a specific gender focus.
Conclusions Antidepressant prescription rates show to be considerably low in young people and in the old and show gender differences. In particular in old men notable low rates in pharmacological and psychotherapy prescriptions are found. Also among young people psychotherapy rates are remarkably low. More attention should therefore be paid to the young and the elderly depressed, to assure that they get the care they need. This study can only point to certain groups at risk for under-treatment. To learn more about the quality of care provided, more research is needed into the fate and outcome of those diagnosed as depressed but not receiving treatment. Also the quality of care of those that are being prescribed treatment should be analysed more in depth under considering demographic
and socioeconomic parameters. Future health service research in its aim to improve treatment for depression, should pay more attention to sociodemographic characteristics including gender and age of those receiving treatment and those that do not [5].
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