The federal Agency for Health Care Policy and Research estimates that one in five individuals is affected by a mood disorder in their lifetime. Depression symptoms can include "...a persistent sad mood; loss of interest or pleasure in activities that were once enjoyed; significant change in appetite or body weight; difficulty sleeping or over sleeping; physical slowing or agitation; loss of energy; feelings of worthlessness or inappropriate guilt; difficulty thinking or concentrating; and recurrent thoughts of death or suicide." (NIMH Depression Research 1999). A patient is diagnosed with major depression if he or she has five or more symptoms during a two-week period.

Approximately 10 percent of the U.S. population meet the criteria for major depression at some time during a 12-month period (Kessler et. al. 1994). Most return to their normal level of functioning. Approximately 50 percent of those having depressive episodes may be expected to have a recurrence (American Psychiatric Association 1993). If a patient has a second episode, there is a 70 percent chance for a third. Somewhere between 20 and 35 percent of patients experience chronic symptoms. It is this latter patient that usually qualifies as an SMI patient.

Manic-depressive illness, also referred to as bipolar disorder, is characterized by alternating episodes of serious mania and serious depression. Mood swings interspersed with normal periods take the patient from being "high" and irritable to sad and hopeless, and back again. The episodes can vary in severity and the time it takes to develop (Hendrix 1999). Bipolar disorder is often not diagnosed, but when it is, the illness is usually identified in adolescence or early adulthood. It is a lifetime condition that can be treated. If left untreated, the condition will worsen with the episodes of mania and depression becoming more severe. Patients are treated according to whichever symptoms are predominant.

Antidepressants

Newer antidepressive medications called SSRIs (selective serotonin reuptake inhibitors) have been available for the last 10 years. Other antidepressant drugs which act on more than just serotonin in the brain have been developed and they, too, are gaining acceptance, meaning the array of available drugs effective against depression is extensive. What characterizes all of these newer medications are side effects that are less bothersome than the older groups of antidepressants represented by tricyclic antidepressants (TCAs) and Monoamine oxidase (MAO) inhibitors. All of them, however, are effective in treating depression.

TCAs cause side effects like seizures, weight gain, drowsiness, dry mouth, and impaired ability to concentrate (NIH 1995, No. 95:3929). MAO inhibitors are used less frequently and most often when a patient cannot use other medications. They can cause dizziness and other side effects, but the most serious one is their interaction with many other drugs, foods and red wines. Interactions can cause such things as nausea, vomiting, high blood pressure and other symptoms that can result in seizures, stroke and coma (NIH 1995, No. 95:3929).

SSRIs have names recognizable to the general public as Prozac, Luvox, Paxil, Zoloft, and Celexa. They are included in the state's formularies, or lists of drugs available to treat SMI patients. Side effects usually relate to gastrointestinal problems, headaches, and sexual inhibition, all of which may cause patients to stop taking the drugs. There is, however, a lower risk of overdose and improved tolerance of the drugs over the older medications (NIH 1995, No.95:3929). "For these reasons, SSRIs are the most widely prescribed antidepressants in use today." (Gelenberg 1999, p.8).

SSRIs cost between $60 and $100 per person/per month while older antidepressants average $25 per person, per month (Value Options 1999). The price difference is evident, but the SSRIs represent a significant improvement in the ability to treat depression and therefore are the drugs of choice. Hospital admissions and length of stay for patients using SSRIs are less than for patients taking TCAs and MAO inhibitors and result in significant decreases in direct care costs (McCollum 1997; Wulkan 1999). In the Nevada study (Wulkan 1999), the number of hospital admissions for patients using SSRIs fell 37.5 percent, while the number of days in hospital fell 31.9 percent. When in the hospital, patient length of stay fell 9.1 percent. The number of housing days increased (6.2 percent) as did costs (6.3 percent) for patients using SSRIs. Ambulatory crisis services decreased by 36 percent while counseling services increased 8.1 percent. All services costs (not related to hospital and medication costs) increased by 10.3 percent, or $2 per day.

Although this paper focuses on the seriously mentally ill receiving state mental health services, SSRI antidepressants are being widely used outside the mental health setting as well. Physicians in general medical practices prescribe nearly 75 percent of the antidepressants in use today (Hylan et. al. 1998). The widespread nature of depressive illnesses, and improved access to effective medications outside of the mental health setting, has resulted in significant depression related research in the primary care or general medical care setting. Since so many depressed patients recover from the acute phase of their illness, remain at home, and continue to work, a review of the research is useful.

The findings are that the treatment of depression in a primary care setting is expensive, but that the bulk of the costs are for care of accompanying medical illnesses rather than the psychiatric condition itself (Croghan, et. al 1998; Thompson 1998; Henk 1996). Thompson et. al. (1998) suggests medical care cost savings may occur for patients with selected medical conditions who receive treatment for an accompanying depression for at least six months. Croghan et. al. (1998) found there was reduced cost for direct mental health care of a depressed patient and improved quality in the care when using the new treatments available. He did not find as significant a cost savings in the use of other types of medical services as some other researchers. The higher costs for using medications may again reflect a shifting of costs from provider driven services to pharmaceutical costs (Frank & Berndt 1997). Differences in how studies define their patient populations, duration of illnesses, diagnoses, treatment approaches, and effects make direct comparisons difficult.
Here are a few selected findings:

• Depressed patients consume two to four times more medical health services than patients without metal illness (Croghan et. al. 1998; Simon et. al. 1995).
  

• In a twelve month study by Von Korf (1992), patients treated for severe depression experienced a 36 percent reduction in the number of days of functional disability, going from 79 days per year to 51 days. No reductions were noted in patients with unimproved depression.
  

• Employed depressed patients report greater absenteeism from work. The national cost of absenteeism due to depression is estimated at $24 billion annually (Greenberg, et. al, 1997).