Studies reveal significant levels of depression, inadequate care in the US

By Joanne Laurier
12 July 2003

More than 16 percent of the adult population in the US, or as many as 35 million people, suffer from depression severe enough to warrant treatment at some point in their lives, according to the National Comorbidity Study. The study, sponsored by the National Institutes of Health and published in a special June issue on depression of the Journal of the American Medical Association (JAMA), asserts that in any given one-year period, 13 to 14 million people, about 6.6 percent of the country, experience the condition. (Comorbidity means having two or more diagnosable conditions at the same time.)

The study found that more than 14 million people were depressed in the US during the past year and that women continued to have a higher risk for depression than men, although the gap is narrowing. Investigators concluded that African-Americans were 40 percent less likely to experience depression than Latinos or whites, although blacks who develop the disorder are 30 percent more likely to suffer lasting or recurring depression. People living in poverty are four times as likely to suffer chronic depression as those living in affluence. Young people aged 18 to 29 are three times more likely to suffer depression, as are adults 60 years and older.

A companion piece in JAMA entitled “Research on Major Depression” states: “Depression is an illness that frequently starts early in life, tends to run a chronic course, and produces substantial disability. According to the World Health Organization, depression is the leading global cause of years of life lived with disability and the fourth leading cause of disability-adjusted life years, a measure that takes premature mortality into account.

“Depression is not only widespread and common, it may be fatal; an estimated 90 percent of suicides are associated with mental illness, most commonly depression. There were nearly 30,000 suicides in the United States in 1999, almost twice the number of homicides. Suicide has become the third leading cause of death in individuals aged 15 to 24 years.”

The article goes on to state that only 25 percent of patients with depression receive appropriate psychopharmacological or psychosocial treatment. It cites one study indicating that almost half of those young people who commit suicide have previously attempted to take their lives, most within the previous year. Yet, the article observes, less than 25 percent of these youth had been receiving specialty mental health care. As many as 75 percent of adults who died by suicide had visited a primary care physician within a month of their suicide.

“We’re not doing a good job of treating these people,” said Dr. Ronald Kessler of Harvard University, an investigator of the study and co-author of the JAMA article, “The Epidemiology of Major Depressive Disorder.” He described current responses to the disease as “halfway treatments” that are often ineffective and wasteful. Dr. Kessler was quoted in the New York Times as saying: “Family doctors are apparently not yet up to speed enough to give good quality care.” He also said that the fact that depression strikes so early in life is a significant factor in the global burden of the disease.

“Patients with depression feel hopeless, helpless, and worthless,” states the JAMA article, “Research on Major Depression.” “These symptoms of the disorder preclude seeking treatment, because many patients with depression believe they are not worthy of anything better. Many patients may feel the stigma of seeking treatment is greater than the stigma of living with the disorder.”

The article describes “depression as currently diagnosed” as likely representing “a heterogeneous set of disorders, usually characterized by sad mood and anhedonia (inability to experience pleasure), but often including abnormalities in cognition and neurovegetative, or physiological, function... Depression is now recognized as a multisystem disorder affecting brain and body.”

Another study published in the special June JAMA issue focuses on the cost of depression in the workplace. Entitled “Cost of Lost Productive Work Time Among US Workers With Depression,” it concludes that depression accounts for $44 billion per year in lost work time as well as another $31 billion in related costs from non-depressed workers. The study’s authors point out that the costs enumerated do not include those associated with disability leave.

Depressed workers reported an average of about 5.6 hours per week of lost productivity or absenteeism, compared with 1.5 weekly hours among non-depressed workers.

Dr. Walter Stewart, lead author of the workplace study and a research director at Geisinger Health System, said that depression is probably the most expensive illness for employers because it is often associated with other ailments such as back pain, headaches and stomach problems, and undermines people’s ability to work.

“People are making it to work,” commented Dr. Stewart. “They’re just not engaged in work. They’re getting to the door, but then closing it and just not functioning. People have called this ‘presenteeism,’ and it is often invisible to employers.”

A third paper in the journal discusses the high rate of suicides among physicians. Although there have been no recent evaluations of doctor suicide rates in the United States, international studies have found that physicians are significantly more likely to commit suicide than other people in similar age and sex groupings.

One in four people who have had heart attacks, JAMA reports, develop depression, increasing the risk of dying by 3.5 times over heart attack victims who do not experience the disorder. This represents as great a risk factor as smoking.

An unprecedented study in Uganda was also reported in the JAMA issue, revealing that the effects of depression are particularly severe in underdeveloped countries given that antidepressant medication, like drugs for so many other afflictions, are generally unavailable.

“The burden of mental illness on health and productivity in the United States and throughout the world has long been underestimated. Data developed by the massive ‘Global Burden of Disease’ study conducted by the World Health Organization, the World Bank, and Harvard University, reveal that mental illness, including suicide, accounts for over 15 percent of the burden of disease in established market economies, such as the United States. This is more than the disease burden caused by all cancer,” states the National Institute of Mental Health (NIMH) web site.

The NIMH’s Kathleen Merkangas commented that “Major depression is the number one, the leading cause of disability in the general population across the world. It has now surpassed heart disease, which was the leading cause of disability as recently as 1996.”

Neither the JAMA pieces nor any of the investigators cared to draw any social conclusions about the research results, which one suspects, if anything, probably underestimate the numbers of people suffering from depression to one degree or another.

It might be suggestive to correlate the findings on increased levels of psychological depression with surveys revealing growing pessimism about the state of social and economic life. The Pew Research Center global survey, What the World Thinks in 2002, released last December 4, for example, found that “almost all national publics view the fortunes of the world as drifting downward.” The study’s authors wrote, “As 2002 draws to a close, the world is not a happy place.”

The report’s authors stated bluntly that the more than 38,000 people interviewed were “overwhelmingly dissatisfied with the way things are going in their countries today. Solid majorities in nearly every country in every region surveyed say they are unhappy with the state of their nation... If any single attitude unites people of different nations and varied personal circumstances, it is their very strong dissatisfaction with the way things are going in the world.”