Brought to you by the Depression Is Real Coalition, The Down &
Up Show is dedicated to the reality of depression. Each week our
hosts will talk with some of the world's top experts on depression,
as well as people who have been impacted by this illness. The reality
of depression is that it is a debilitating and potentially deadly
medical condition that affects more than 15 million Americans every
year. The other reality of depression is that there is hope.
Down & Up Show #46: The Economic Burden of Depression in the
U.S.
DR. REEF KARIM:
Welcome to the Down and Up Show on depressionisreal.org. I'm your
host, Dr. Reef Karim, psychiatrist, addiction specialist and relationship
therapist. Our guest today is Dr. Ronald Kessler who is a professor
of healthcare policy at Harvard Medical School.
Dr. Kessler also sits on the scientific advisory boards of two depressionisreal
coalition member organizations--the Depression and Bipolar Support
Alliance and the National Alliance on Mental Illness.
We'll be speaking to Dr. Kessler about the economic burden of depression
in the United States. He's published several studies on this topic
as well as on the burden other mental illnesses have on the economy.
Welcome Dr. Kessler.
DR. RONALD KESSLER:
Thanks. It's nice to be here.
DR. REEF KARIM:
Let's start with can you briefly explain how depression impacts
the economy?
DR. RONALD KESSLER:
Well, the obvious thing one would think of in responding to that
question is that depression treatment costs a lot of money, and
employers of course for the last decade have been concerned about
the rising costs of depression treatment beginning with Prozac started
the revolution if you will of direct to consumer advertisement.
It's now grown over the course of time.
And with that a substantially higher proportion of people with depression
and other mental disorders have been getting into treatment in this
country as well as other developed countries.
So there is the impact on the economy of the treatment of the disorder.
But in fact if you look at the costs of not treating depression
those are actually substantially greater than the costs of treating
it.
Much of the work we've been doing in the past half dozen years has
been-has been collaborating with employers to have them think through
the implications of expanding or reducing kinds of benefits they
give to workers with mental disorders and depression the particular
focus to see what would be the impact on the workplace.
What we find in brief is that it's most employers cannot afford
not to treat depression. The impact of depression on sickness absence
from work, on reduced productivity while on the job, the risk of
disability because of depression, early retirement and with it hiring
and training costs of new employees.
There are enormous, enormous costs of depression to the workplace
in particular. Now these are costs to the employer and to society
as a whole in terms of human capital costs, and we're discovering
that those costs are so large that more and more enlightened employers
are coming to realize that it's actually a smart business move to
invest in an expansion of treatment, good quality treatment of depression,
because far from costing them money it makes them money.
It's a human capital investment as a positive return in terms of
value to the employer for increased productivity and decreased workplace
costs that far out shadow the cost of the treatment itself.
DR. REEF KARIM:
When we talk about the economic burden of depression how do we define
burden?
DR. RONALD KESSLER:
Well, it's a-it's really more a political than a scientific term.
It's we have-when we think of costs and if they're big costs you
say boy that's a burden to society. There's a famous book as you
know about the global burden of disease which was published in the
mid-1990s that was very influential.
People have picked up that word burden because of that. The Global
Burden of Disease Study, it's relevant to depression because they
went and on the basis of getting expert reviews and synthesis of
information about prevalence and impact of disorders all around
the world looking both at the risk of early death associated with
various kinds of illnesses and the impact on your functioning when
you're not alive-when you are alive calculated something called
disability adjusted life years which is if the typical person lives
to be seventy-eight in America if you have cancer you're gonna live
three years less on average and maybe for ten years you're gonna
be only functioning half speed.
So they say well that's three whole years and ten half years which
is five plus three. You'd have eight disability adjusted life years
lost to cancer. So they calculated that for each illness in America
and each other country around the world.
And then looked at the population prevalence and calculated how
many years of lost functional capacity were occurring in each country
in the world associated with each of the most commonly occurring
illnesses, and they found that out of the literally hundreds of
illnesses they looked at depression came out as number two in the
entire world.
Among people under the age of thirty-five it came out as number
one-the most burdensome illness in the entire world among people
who are in the young and middle age. It was that finding which was
a great surprise to these-to these people who had done research
who were not psychiatrists. They were public health people that
really started the interest in depression as a major source of societal
malaise.
The word burden just came along from that. But the original meaning
of the word burden to get back to your question was lost years of
productive life. In subsequent years as people have been looking
at that more carefully and trying to unpack why is it exactly that
this depression seems to have such an effect we find many component
pieces that seem to be important.
Depression is associated for example, early onset depression is
associated with doing poorly at school and not going on to higher
education among people who are depressed for example in high school.
They're only about half as likely as other people to go on to college.
Among people who have a history of depression who go to college
they're twice as likely to flunk out as people who don't have depression.
People with depression are more likely to get married to people
who have other emotional problems that are not good earners. They
earn less money themselves than other people of the same educational
attainment because of various kinds of impairments in their work
performance.
So there are ripple effects throughout the life course, affects
on employment status and quality of employment, longevity on the
job and things that have big costs in real human terms to individuals
and their families independent of the pain and suffering that we
know to be associated with depression, real economic costs.
DR. REEF KARIM:
It's interesting. You have a-you have your Journal of Clinical Psychiatry
Study in 2003 that you published. Can you tell-can you tell us some
of your key findings from that study.
DR. RONALD KESSLER:
Well, um, we analyzed epidemiological data that were representative
of the United States to look at how many people in the population
had depression based on going out and doing really exhaustive surveys,
two-hour long interviews with people in their homes, thousands of
people around the country.
This was funded by National Institute of Mental Health to estimate
how many people had depression and get information about their educational
attainment and their employment and how many days they missed work
and their earnings on their job and so forth.
We also went to administrative claims databases to look at treatment
costs for depression and we looked at government mortality data
on causes of death and the association between depression and early
mortality.
We estimated that a substantial chunk of all those costs were associated
with lost productivity on the job, the biggest piece. It was a combination
of people not having a job more often if you were depressed and
if they did have a job having lower income and so from their point
of view having costs and doing a worse job from the employer's point
of view.
Having more workplace accidents, more disability, missing more days
of work and essentially being less productive from the employer's
point of view. So if we put all of that stuff together we estimated
that the total costs of depression were well over fifty billion
dollars a year in terms of financial implications to--to the society.
DR. REEF KARIM:
Wow.
DR. RONALD KESSLER:
That's in any one given year. You know given that you have depression
now and don't have it. So you extrapolate that over the life course
of people it's a substantial chunk of money. Now we have subsequently
based on that work done something else which I think is a little
more down to earth.
When you hear these numbers from the intrepid economists about fifty
billion and five trillion you know it's hard for you or me to get
our hands around what exactly that means. But in the life of an
individual we estimate that having a history of depression versus
not is associated with an average of well over $200,000 of lost
earnings over a life course.
So you know close to a quarter of a million dollars which is a substantial
amount of money from any one person's point of view. From the employer's
point of view having a worker who has depression as opposed to a
worker who is just like-I mean age and sex and occupation who does
not have depression costs the employer around $5,000 per year per
employee which as you know is substantially more than the cost of
treating that person and getting them undepressed.
So it would make sense that if you can do high quality treatment
and make sure the person gets back well again it would be a smart
business move for the employer. So with that though in mind a number
of years ago we approached a consortium of employers and worked
out with them a plan for developing an experiment where we would
screen in a health risk appraisal survey that's done every year
to the employers in many companies around America a little set of
screening questions to find out which workers were depressed and
which ones were not in treatment.
And of the workers we found who were depressed in these companies,
and we screened over 150,000 employees in a number of companies
around the country, we wrote a letter to half of them and said thanks
for doing the survey. It looks like you are possibly depressed from
what you said and as you probably know that's-your company has treatment
available for you and treatment can work to help this problem. If
you really have it you should go and see a doctor and talk about
this.
That was the control group. The experimental group, the random half,
we wrote them a letter and said well thanks for doing our survey.
It looks like you're depressed and we have some programs available
that are anonymous and confidential to your employer won't know
that many people find very effective, and we're gonna have one of
our nurses call you in the next day of two to see if you're interested
in them.
So we trained a corps of nurses to provide information and encouragement
to these people in the experimental groups to get them into treatment.
We helped them sign up because very often they were reluctant to
do so.
We kind of twisted their arm a little bit. Come on, you said you
were gonna do it. Give the doctor a call. We coached them so instead
of worrying about them getting the information on the internet we
gave them information about look, here's what you should tell the
doctor and here's the kind of things doctors should be doing.
At the end of the first visit we'll call you on the phone and debrief
about how it went and so forth. But we really held their hands all
the way through the process. Go them into treatment, made sure it
was good, quality treatment and then we followed them for two years.
And we found that the impact of this outreach and case management
and watching over the quality of care led to savings to the employer
that were so great that they quadrupled the cost of treatment. The
employer made a four to one return on his investment or her investment
as the case may be for expanding and improving this quality of care.
So it's a-it's something that many employers are very interested
in. Now this is a paper that was just published in JAMA about six
months ago, the first paper reporting the study, and it-there has
been a lot of attention to it since that time.
I'm net week as a matter of fact going to New York to give a talk
to a big national employers group who are interested in this, recognizing
the importance of depression. Our hope is that this is not only
going to increase employer's awareness that there is something you
can do about this problem.
They're all aware now that depression is a big problem and they're
kind of casting about for what should we do. But this tells them
there is something productive you can do that's a smart business
move as well as the right thing from an ethical point of view to
do.
We just gotta get the treatment systems in place to be able to do
that. So I think that's where the rubber hits the road in this kind
of thing for the employed population. It's a whole separate matter
about what to do with kids in school, retired people, homemakers
who are in their home and it's hard to get them out.
But at least for that segment of the population that's easiest to
touch, the people who get up and go to work every day, I think this
has been a very valuable first step that we're hoping to build on.
DR. REEF KARIM:
How does the economic burden of other chronic illnesses say heart
disease, diabetes, how do they compare with depression?
DR. RONALD KESSLER:
Well, there've never been systematic comparative studies that use
the same methodology across-across illnesses to do this kind of
stuff, but we know from the workplace studies where we've gone in
and done these surveys I mentioned that they ask not just about
depression but they ask about a whole range of common physical and
mental disorders.
These have now been done in national samples and in samples of big
employers, and rank orderings have been made to look at which are
the conditions that are associated with the most sickness absence
days on the job, which conditions are associated with the most lost
productivity when people are at work and associated with the combination
of those things.
As you can imagine there's some conditions that are more important
for one than another. Migraine headache for example. People miss
a lot of days of work if they have migraines. On the days they are
at work though they don't have any impairment in function at all.
The reason is that migraines are often so serious and also migraines-a
typical migraine starts early in the morning.
So when they're having a migraine they just don't come to work.
But on the days they're there they function quite well. So migraine's
important for sickness absence days but not for quality of performance.
There are other things that are associated with quality of performance
and not sickness absence and so forth. Depression is associated
with both. When we do rank ordering so that the David Letterman
top ten list of if you were an employer what you would least like
your employee to have the number one thing from a societal perspective
is probably one that you wouldn't think of and it's consistently
and time and again low back pain.
And it's because we have an overweight, middle age population in
America. But musculo-skeletal problems are number one. Number two,
depression. So-but musculo-skeletal disorders and emotional disorders
are the number one and number two most common, seriously impairing
conditions.
And you think well gee cancer is terrible and heart disease is terrible
and AIDS is terrible and diabetes is terrible, it is. But a lot
of the people who have those conditions it doesn't happen until
later in life.
The typical age of depression is twenty-five years earlier than
the typical age of heart disease. Half-way through your productive
years of life depression is there influencing people before some
of these things that you typically think of as the major illnesses
that play a part.
As a result some of those things that you common sensibly think
of as should be at the top of the list are not really at the top
of the list. Depression is number two.
DR. REEF KARIM:
What advice can you give our listeners who may have depression and
are struggling in their workplaces right now?
DR. RONALD KESSLER:
Well unfortunately I can't give any advice. I mean I could but it
would be useless. I'm an epidemiologist and so I'm in the happy
position of being able to say to clinicians like yourself by God
there's a problem here. You guys should do something about that.
I have to say I don't have any great solutions but it's quite clear
that there's so many health problems out there in the world. Not
even the richest society can tackle all of them in an aggressive
way.
Some kind of triage rules are needed, and the stuff that my colleagues
and I do try as best we can to help people who are decision makers
both at the local-the clinical level like you and employers and
governments to try to sort through all the information that's available
to try and help them make informed decisions about what are the
biggest problems and the smallest problems, where are the levers
where one could go and attack a problem in a certain way and do
the most good?
It's quite clear to us that being even-handed about it I'm not a
person who is a depression-depression is my only thing I care about.
I look at illness generally and I can say in an even-handed way
that I find myself drawn to the study of depression because the
data tell me so clearly that this is of vital importance from a
public health point of view.
DR. REEF KARIM:
I think what you're doing is great because you're looking at it-I
mean obviously it's a universal theme. But from the employer's standpoint
there's so much more change that can be created by showing the employer's
how great it is to treat depression.
DR. RONALD KESSLER:
Yep, that's right.
DR. REEF KARIM:
I think that's a great statement. So I want to thank you so much
Dr. Kessler for joining us and really enlightening us on the subject.
DR. RONALD KESSLER:
É.a great topic here.
DR. REEF KARIM:
Indeed.
DR. RONALD KESSLER:
Bye-bye.
DR. REEF KARIM:
Okay, take care. Thank you for speaking with us today. Join us next
week for another segment of the Down and Up Show on depressionisreal.org.
I'm Dr. Reef Karim.
