Depression: A Misunderstood Companion to Chronic Illness

By: Edmund Pezalla, M.D., M.P.H.

An often under-diagnosed and under-treated condition, depression is prevalent in patients who are suffering from chronic illnesses. When depression is coupled with chronic illness and is not treated effectively, a patient's overall health status can decline significantly. This may lead to problems in the workplace, increased absenteeism and significant hikes in healthcare costs for both the employer and consumer. Understanding the relationship between depression and chronic disease is vital for employers in making informed decisions about healthcare delivery options.

Generally the risk of getting depression over a lifetime for healthy women is 10 to 25 percent and 5 to 12 percent for men. However, those with chronic illnesses face a much higher risk of between 25 and 33 percent for both women and men.^[1] As is often the case, people diagnosed with chronic illnesses must adjust to the demands and treatments of their illness. Often they experience loss of independence and mobility leading to despair and sadness. For some, pain can intensify, and fatigue can become even more pronounced than with the chronic condition alone.

While depression has become one of America's most costly illnesses by itself, when coupled with a chronic condition, the cost of depression rises even more. Employers feel the impact of depression in the form of higher treatment costs, increased absenteeism and lost worker productivity. Depression ranks among the top three workplace problems for employee assistance professionals, following only family crisis and
stress.^[2] Lost labor time due to depression is significant: A survey published in the Journal of the American Medical Association calculated that depression costs employers
$44 billion annually.^[3]

Looking at some of the most common chronic diseases, it is evident that depression is a serious threat for these patients. Nearly 50 percent of asthma patients may suffer from clinically significant depressive symptoms.^[4] Among cancer patients, 21 percent are reported to have depression.^[5] The same study found that depression is twice as prevalent in people with diabetes as it is among those without diabetes. In fact, total health expenditures for a person with diabetes and depression were 4.5 times higher than for those without depression.^[6]

Depression can make an already complex and expensive situation worse. In many cases, patients with complicated chronic illnesses, such as multiple sclerosis, rheumatoid arthritis, cancer and hemophilia already require expensive injectable drugs, called specialty pharmacy drugs, which can cost an average of $1,000 to $1,500 per month.^[7] While these new treatments can be extremely effective, they may cause serious side effects, and a depressed patient may decide to stop taking their medication. Non-compliance with therapies can lead to a worsening of their disease.

Detecting Depression: Hurdle #1

Detecting depression in chronically ill patients is often a challenge. In many cases, patients overlook their symptoms because they assume their feelings are a normal side effect of dealing with their chronic illness. Physicians may overlook depressive symptoms because they are frequently masked by other medical conditions, resulting in treatment for the symptoms, rather than the depression. Many employees may also choose not to seek treatment because of concerns that their condition will not be kept confidential and their employer may learn of their condition.

Often, chronically ill patients are dealing with a number of specialists as well as a primary care practitioner. The various physicians involved in care and treatment regimens can cause confusion to the patients because there can be a lack of communication and coordination among various physicians and treatments. This can lead to polypharmacy or unnecessary or excessive use of medications. The common result of polypharmacy is increased adverse drug reactions and higher costs.

Compliance with Treatment Regimens: Hurdle #2

For those who have been diagnosed with depression, non-compliance with antidepressant medications is high. As many as 60 percent of patients discontinue their antidepressant therapy before completing the recommended six to nine month treatment duration.^[8] Often, the side-effects of the medications can hamper a patient's willingness to continue drug therapy.

Addressing the Complexities of Chronic Illness and the Prevalence of Depression through Disease Therapy Management (DTM)

Employers can select a PBM that offers a DTM program to help employees suffering from chronic illness adhere to their treatment regimen and to identify additional issues, including the presence of depression. Through programs such as DTM, a PBM can identify patients with chronic conditions and reach out to them to provide extra support.

In particular, look for a PBM with DTM programs for patients on costly specialty pharmacy medications. In these programs, care managers work with patients, their families and their physicians to make sure patients understand their treatment regimens. Care managers provide strategies to help manage side effects, monitor patient compliance and ensure that refills are ordered on time.

Care managers can also help patients by offering a wide range of additional resources. These may include help to find counseling for depression, aid to connect with a community group for emotional support or even assistance to obtain a medication refill and delivery within 24 hours. Other resources may include help to find financial assistance to pay for prescription drug co-payments and even helpful strategies to discuss delicate subjects with physicians, such as incontinence. Patients enrolled in DTM programs may have the opportunity to receive the extra personal care they need to stay on their treatment regimen and fully benefit from their specialty pharmacy medications.

Benefits of such programs can be significant. Increased member medication adherence results in improved overall health status and the avoidance of more expensive healthcare interventions. For example, in one study involving multiple sclerosis patients who were enrolled in a DTM program, all participants fully complied with their therapy, while one in four not enrolled in the DTM program discontinued their medications.^[9]

Conclusion

A DTM program which integrates all of the elements of a chronically ill patients' healthcare needs and identifies depression when it exists, can impact the overall quality of life for a patient. While their chronic illness may continue to persist, a patient can live a more productive life because their overall healthcare needs are managed more effectively. For employers, this means less absenteeism, more productivity, and ultimately decreased healthcare costs.

1. Cleveland Clinic Health System, "Chronic Illness and Depression," 2004.
2. Employee Assistance Professionals Association 1996 Survey.
3. Stewart WF, Ricci JA, Hahn SR, Morganstein D. Cost of Lost Productive Work Time Among US Workers With Depression. JAMA, June 2003; 289: 3135-3144.
4. Chapman DP, Perry GS, Strine TW. The vital link between chronic disease and depressive disorders. Prev Chronic Dis [serial online] 2005 Jan.
5. ibid.
6. ibid.
7. AHIP Coverage, "Engineering New Strategies in Specialty Pharmacy Management," Oct./Nov. 2004.
8. Bull SA, Hu XH, Hunkeler EM, et al. Discontinuation of Use and Switching of Antidepressants. JAMA. 2002;288:1403-1409.
9. 2004 Prescription Solutions. Impact of a Disease Therapy Management Program on Medication Compliance in Patients with Multiple Sclerosis: A preliminary Analysis. Chung H.Lu, Pharm. D., Russell L. Knoth, Ph.D.