Our findings do not show a statistically significant difference in total expenditures or out-of-pocket expenditures between those who are depressed and those who are non-depressed but have another chronic condition. This study establishes these findings using the methodologically strong platform of a systematic assessment of depression in contrast to assessment based on utilization, a national sample, and the use of a matched control group to account for potential confounders.
The greatest contributor to out-of-pocket expenses is prescription medications, which have similar but very high co-payments relative to other services for both depressed and not depressed persons with other chronic conditions. Ambulatory/ physician visits also shows large total expenditures, but these services play a much smaller role in the total out-of-pocket expenditures because of lower co-payments for those services relative to prescription medication. For most services, persons with depression generally pay similar proportions out-of-pocket as their not depressed peers with another chronic condition. There is a difference in inpatient out-of-pocket cost in this group with chronic disease for persons with and without depression. However, we cannot tell if this result is meaningful because of the small sample of individuals with inpatient stays.
Because prescription medication plays a large role in the treatment of depression, [25
] the high co-payment rate for prescription medication may serve as a barrier to adhering to appropriate care for depression. High out-of-pocket costs for prescription medication are the largest contributor to the substantially greater economic burden (out-of-pocket expenditures relative to income) that individuals with depression face compared to those without depression [26
]. High out-of-pocket costs may cause depressed persons to forgo medication treatment or depression treatment as a whole which can contribute to poor adherence [27
]. Ambulatory/ physician visits services, although important for depression treatment, are less of a barrier for treatment in terms of expenditures because of the low contribution to the economic burden it provides relative to prescription medication.
Further, in the general population a larger proportion of depressed individuals reported income below 200% of the poverty level, compared to those with another chronic disease, but without depression (). Therefore, this higher out-of-pocket expenditure represents an even greater percent of their income, resulting in a higher financial burden.
This study is limited by the modest number of cases of depression in the sample. The modest number is due to the administration of the CIDI-SF to only a subsample of NHIS respondents. However, the use a systematic assessment of depression using the CIDI-SF is valuable for a valid epidemiologic assessment because it provides a systematic ascertainment of depression that is unrelated to utilization of medical services. The major area where the small sample size is problematic is the estimate of hospital expenditures, where it is not clear whether the observed out-of-pocket differences (not statistically significant) reflect true differences (not significant due to a lack of power) or simply represent random variation.
Other limitations of the study should be noted. The presence of depression and other diseases are ascertained in 1999 while expenditures are taken from 2000. It is possible that some people will no longer have a disease in the following year, though the focus on chronic depression assessed by the CIDI-SF and chronic conditions should limit this problem. Because the other chronic diseases are measured by patient response as to the their presence while depression is systematically measured,, our comparison group may include people with more severe forms of the other diseases – those with less symptoms may not have been diagnosed. This will tend to overstate costs of the other chronic diseases relative to depression. Finally, the data this study is based on is now almost ten years old and it is possible that expenditures today have a different pattern than in 2000.
] found that for those over age 65, mean out-of-pocket expenditures of people with a diagnosis of depression were greater than for people with arthritis or hypertension but similar to individuals with diabetes and heart disease. This paper compares out-of-pocket costs for those under age 65 and also finds them similar. Zuvekas [11
] found that out-of-pocket expenditures represented 23 percent of the total mental health cost, similar to our finding that the share of all medical expenditures for those that are paid out-of-pocket is 27.8% for individuals with depression. Ringel and Sturm [10
] found out-of-pocket expenditures were less than 10% of overall income for most people either reporting psychological distress or using mental health services in the last year. While we do not have a comparable data, we do find that at the 75th
percentile () out-of-pocket expenditures are just $477 for those with depression. However, 28.5% of those with depression under age 65 had income less than twice the poverty level and mean out-of-pocket expenditures were $665, suggesting the out-of-pocket costs are extremely skewed with a low percentage of people with very high out-of-pocket expenditures (maximum amount = $11,028).
In summary, high out-of-pocket expenditures appear to be an equally large concern for individuals with depression and for non-depressed individuals with other chronic diseases. Because prescription medications play a large role in the treatment of depression and other chronic diseases, and because those with depression, on average, have lower income, this high co-payment rate may serve as a barrier to appropriate care of depression, at least for a small subset of those with depression.