Policy Changes Reduce Spending Burden in Outpatient Depression Treatment

Researchers found data that showed in the United States, due to an increase in Medicaid coverage, the percentage of spending for uninsured patients in outpatient depression treatment decreased from 32% in 1998 to 20% in 2015.

Over time, policy changes aimed at increasing insurance coverage for mental health conditions have improved the financial burden on patients undergoing outpatient depression treatment, according to research published in JAMA Psychiatry.

Researchers examined the national trends in outpatient treatment of depression in the United States between 1998 and 2015, focusing particularly on the 2007 to 2015 time period. Data from the Medical Expenditure Panel Survey, which has an overlapping cohort, multiple-round panel structure, for 1998, 2007, and 2015 were analyzed.

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A total of 86,216 people (mean age 37.2±22.7, 52.3% women, 72.9% white) were included in the analysis. Investigators found that between 1998 and 2015, the treated prevalence of depression increased from 2.36 (95% CI, 2.12-2.61) to 3.47 (95% CI, 3.16-3.79) per 100 population; this represented a 46.8% relative increase. Broken down by time period, the relative growth was 21.8% between 1998 and 2007 and 20.6% between 2007 and 2015.

Between 1998 and 2007, the proportion of respondents treated for depression via psycho therapy decreased from 53.7% (95% CI, 48.3%-59.1%) to 43.2% (95% CI, 39.0%-47.4%); between 2007 and 2015, that number increased to 50.4% (95% CI, 46.0%-54.9%).

The proportion of patients receiving pharmacotherapy remained steady over time: 81.9% (95% CI, 77.9%-85.9%) in 1998, 82.4% (95% CI, 79.3%-85.4%) in 2007, and 80.8% (95% CI, 77.9%-83.7%) in 2015. Following an adjustment for inflation, prescription expenditures in 2015 US dollars decreased from $848 (95% CI, $713-$984) in 1998 to $603 (95% CI, $484-$722) in 2015. During this time period, the number of prescriptions also decreased, from 7.64 (95% CI, 6.61-8.67) in 1998 to 7.03 (95% CI, 6.51-7.56) per year in 2015.

National expenditures for outpatient depression treatment increased from 1998 to 2007 to 2015 — $12,430,000 to $15,554,000 to $17,404,000 — which was “consistent with a slowing growth in national outpatient expenditures for depression.” The percentage of this spending associated with uninsured patients decreased from 32% to 29% to 20% from 1998 to 2007 to 2015 and was primarily associated with an increase in Medicaid coverage.

The researchers noted that between 1998 and 2015, “substantial changes in treatment availability and recommendations occurred, as well as policy changes that increased the coverage of mental health services,” citing the passage of the Mental Health Parity and Addiction Equity Act, the Affordable Care Act (ACA), and the ACA expansion of Medicaid.

One study limitation is the effect of “a multitude of policies” that may influence trend analyses conducted using national surveys over long periods of time. Another limitation is the Medical Expenditure Panel Survey reliance on self-reported participant data.

“Taken together, the reductions in the amount spent by those who were uninsured, the trends in costs, and the apparent stability in prices of pharmacotherapy suggest that policies enacted in recent years to expand insurance coverage for mental health services … have had an association with increased prevalence of treatment for depression without increasing prices or total spending,” the researchers of the study concluded.


Hockenberry JM, Joski P, Yarborough C, Druss BG. Trends in treatment and spending for patients receiving outpatient treatment of depression in the United States, 1998-2015 [published online April 24, 2019]. JAMA Psychiatry. doi: 10.1001/jamapsychiatry.2019.0633