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In the setting of major depressive disorder (MDD), and treatment-resistant depression (TRD) in particular, the clinical burden often becomes an economic one, with patients requiring significant healthcare resources. To examine this scenario in more detail, a new study explored the high demand in mental healthcare and corresponding costs among patients with depression in northwest London, tracking treatment dynamics and referral practices.¹

鈥淭o better understand how healthcare is accessed and used by patients with MDD and especially TRD across different settings (primary care, accident and emergency [A&E], hospital, outpatient, and secondary mental health services care), we used population-based, real-world linked healthcare data that tracks primary and secondary treatment pathways and referral practices,鈥� explained the authors, whose findings were published in the Journal of Psychiatric Research. 鈥淭herefore, the aim of this study was to evaluate and compare healthcare resource usage and associated costs in patients with MDD and TRD.鈥�¹

Identifying the greatest healthcare burden 

For this population-based, retrospective study, electronic health records were drawn from the Discover-NOW platform hosted by Imperial College Health Partners, one of the largest linked data sets in Europe, which covers more than 2.5 million patients.¹ Adults were eligible if they were diagnosed with MDD and had been prescribed at least 1 antidepressant between 2015 and 2020 (N=110,406). Of these, 92% (101,333) had a diagnosis of MDD and the remaining 8% (9073) had TRD. (The authors cited the large difference in sample sizes between cohorts as a potential study limitation.)

Most participants were between 20 and 59 years old (mean age 44.1 years), 62% were women, and the population tended to be overweight.

The mean duration of depression was 52.8 months for MDD and 70.8 months for TRD (P<.0001). Within the TRD group, 33.0% (2993) of patients had received more than 3 lines of antidepressants and 9.3% (845) had received more than 4 lines at the study鈥檚 inception.

A need for more resources in TRD patients

Patients with TRD incurred healthcare costs about 1.5 times higher on average than those with MDD, a finding that remained consistent throughout the study. As the duration of depression and the number of lines of treatment increased, so did the need for both primary care and emergency psychiatric services. Compared to the MDD group, the TRD cohort spent more time in emergency settings, with more frequent and longer hospitalizations.

Not surprisingly, such a high use of resources translated to greater expenses among patients with TRD versus those with MDD, with nonelective hospitalizations incurring the highest costs: mean 拢2518 (standard deviation [SD] 拢8064) versus 拢1909 (SD 拢6807) (P<.0001). Individuals with TRD were also more likely to be diagnosed with co-occurring diseases, including psychiatric comorbidities like anxiety, as well as somatic comorbidities like asthma or alcohol misuse (P<.0001 for all). 

Also, among those with TRD, the prescription of antipsychotics, lithium, or anticonvulsants was linked with a greater total burden in both primary and secondary care settings. The authors theorize that this group was clinically more resistant to treatment, supporting the study鈥檚 conclusion that nonresponsive depression is linked with a higher total healthcare burden. (Because the study used real-world data, nonpharmaceutical treatments were not documented.)

Primary care is popular . . . and expensive

The present study also sheds light on how patients managing depression access care across emergency and routine services. Seeing that depressed patients in the U.K. receive the bulk of their care from general practitioners, primary care stood out with the highest healthcare costs in this population.

Patients with TRD spent more time in primary care than any other setting (TRD mean 162 [SD 96] versus MDD 108 [76] visits per patient; P<.0001), with a cost per patient of 拢17,348 (SD 拢33,040) versus 拢12,011 (拢25,588) (P<.0001). Compared to patients with MDD, those with TRD visited primary care 1.5 to 1.7 times more frequently.

In the U.K., depression is generally diagnosed by primary care providers, who refer patients to secondary care as a step-up if they display risk or treatment resistance. But this study reveals that patients with depression often linger in primary care for a long time before their first contact with secondary mental health services, and many patients never receive specialist care at all: Less than a quarter of the entire study population made use of secondary mental health services (although the proportion rose to 53% among adults with TRD). The authors also pointed out that many patients with TRD may not have access to specialist care, a barrier documented in the literature.

Preventive, not secondary care, may reduce costs

Does the addition of secondary care for mental health narrow the economic burden of depression?

The present study suggests that contact with secondary services doesn鈥檛 unilaterally cut down on overall healthcare use and costs. In fact, among patients who did undergo secondary mental health services, the cost of nonelective hospital admissions was notable鈥攎uch higher than nonelective admissions by patients with any other type of secondary care. Accident and emergency visits were the most-used resources (TRD mean 5.5 [10.6] versus MDD mean 3.54 [SD 6.0] visits per patient; P<.0001).

Ultimately, the burden incurred by these secondary services underscores the importance of better pathways to depression remission.

鈥淓arlier proactive assessment and treatment of patients and timely access to specialist services could reduce unplanned secondary-care use and the high demand for primary care visits, which in turn might lessen the economic burden,鈥� the authors concluded.¹

Published: December 27, 2024