title: Cost of depression in Europe. Compliance in depressed patients treated with fluoxetine or amitriptyline Cost-effectiveness of treatments for major depression in primary care practice. Cost-effectiveness of systematic depression treatment for high utilizers of general medical care. Response, remission and relapse in relation to adherence in primary care treatment of depression: a 2-year outcome study Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice. Cost-effectiveness of practice-initiated quality improvement for depression: results of a randomized controlled trial. Telephone screening, outreach, and care management for depressed workers and impact on clinical and work productivity outcomes: a randomized controlled trial. Recovery from depression, work productivity, and health care costs among primary care patients. Depression, health-related quality of life, and medical cost outcomes of receiving recommended levels of antidepressant treatment. Impact of an antidepressant management program on medication adherence. Selective Serotonin Reuptake Inhibitor Discontinuation: Side Effects and Other Factors That Influence Medication Adherence Effects of major depression on moment-in-time work performance. Cost-effectiveness of a collaborative care program for primary care patients with persistent depression.
abstract: BACKGROUND Depression is one of the most disabling diseases , and causes a significant burden both to the individual and to society . WHO data suggests that depression causes 6 % of the burden of all diseases in Europe in terms of disability adjusted life years ( DALYs ) . Yet , the knowledge of the economic impact of depression has been relatively little research ed in Europe . AIMS OF THE STUDY The present study aims at estimating the total cost of depression  in Europe based on published epidemiologic and economic evidence . METHODS A model was developed to combine epidemiological and economic data on depression in Europe to estimate the cost . The model was populated with data collected from extensive literature review s of the epidemiology and economic burden of depression in Europe . The cost data was calculated as annual cost per patient , and epidemiologic data was reported as 12-month prevalence estimates . National and international statistics for the model were retrieved from the OECD and Eurostat data bases . The aggregated annual cost estimates were presented in Euro for 2004 . RESULTS In 28 countries with a population of 466 million , at least 21 million were affected by depression . The total annual cost of depression in Europe was estimated at Euro 118 billion in 2004 , which corresponds to a cost of Euro 253 per inhabitant . Direct costs alone totalled dollar 42 billion , comprised of outpatient care ( Euro 22 billion ) , drug cost ( Euro 9 billion ) and hospitalization ( Euro 10 billion ) . Indirect costs due to morbidity and mortality were estimated at Euro 76 billion . This makes depression the most costly brain disorder in Europe , accounting for 33 % of the total cost . The cost of depression corresponds to 1 % of the total economy of Europe ( GDP ) . DISCUSSION Our cost results are in good agreement with previous research findings . The cost estimates in the present study are based on model simulations for countries where no data was available . The predictability of our model is limited to the accuracy of the input data employed . As there is no earlier cost-of-illness study conducted on depression in Europe , it is , however , difficult to evaluate the validity of our results for individual countries and thus further research is needed . CONCLUSION The cost of depression poses a significant economic burden to European society . The simulation model employed shows good predictability of the cost of depression in Europe and is a novel approach to estimate the cost-of-illness in Europe . IMPLICATION S FOR HEALTH CARE PROVISION AND POLICIES : Health and social care policy and commissioning must be evidence -based . The empirical results from this study confirm previous findings , that depression is a major concern to the economic welfare in Europe which has consequences to both healthcare providers and policy makers . One important way to stop this explosion in cost is through increased research efforts in the field . Moreover , better detection , prevention , treatment and patient management are imperatives to reduce the burden of depression and its costs . Mental healthcare policies and better access to healthcare for mentally ill are other challenges to improve for Europe . IMPLICATION S FOR FURTHER RESEARCH This study has identified several research gaps which are of interest for future research . In order to better underst and the impact of depression to European society long-term prospect i ve epidemiology and cost-of-illness studies are needed . In particular data is lacking for Central European countries . On the basis of our findings , further economic evaluations of treatments for depression are necessary in order to ensure a cost-effective use of European healthcare budgets Two dimensions of compliance ( drop-outs and adherence ) were investigated in patients treated with antidepressant drugs .  Efficacy , compliance and its determinants were investigated in 66 patients suffering from major depressive disorder and treated in a double-blind manner with fluoxetine 20 mg/day or amitriptyline 150 mg/day for 9 weeks . Overall effectiveness [ 50 % decrease in the initial Hamilton Rating Scale for Depression ( HAM-D ) ] was similar in both groups ( 62.8 % for fluoxetine , 58.1 % for amitriptyline ) . The dropout rate due to side effects was 35.5 % for amitriptyline and 5.7 % for fluoxetine . A logistic regression analysis revealed that the initial HAM-D score was not predictive for dropping out , but this outcome was instead determined by sex ( increased risk for males ) , age ( increased risk for being younger ) and occurrence of severe side effects . Adherence was estimated using electronic Medication Event Monitoring System and defined as the percentage of days when the correct dose was taken out of the medication container . Of the patients studied 37 % had an adherence of less than 70 % . There was no relationship between adherence and efficacy and adherence was similar in patients on fluoxetine or amitriptyline .  Side effects were not predictive of being adherent or not , but a higher initial HAM-D score predicted a higher adherence to the medication regimen . The demographic variables bad no significant effect . The present study suggests that the link between efficacy , side effects and compliance or adherence is more complex than is generally believed and that early termination and non-adherence seem to be determined by different factors BACKGROUND This study augments a r and omized controlled trial to analyze the cost-effectiveness of 2 st and ardized treatments for major depression relative to each other and to the " usual care " provided by primary care physicians . METHODS A r and omized controlled trial was conducted in which primary care patients meeting DSM-III-R criteria for current major depression were assigned to pharmacotherapy ( where nortriptyline hydrochloride was given ) or interpersonal psychotherapy provided in a st and ardized framework or a primary physician 's usual care . Two outcome measures , depression-free days and quality -adjusted days , were developed using information on depressive symptoms over time . The costs of care were calculated . Cost-effectiveness ratios comparing the incremental outcomes with the incremental costs for the different treatments were estimated . Sensitivity analyses were performed . RESULTS In terms of both economic costs and quality -of-life outcomes , patients assigned to the pharmacotherapy group did slightly better than those assigned to interpersonal psychotherapy . Both st and ardized therapies provided better outcomes than primary physician 's usual care , but each consumed more re sources . No meaningful cost-offsets were found . The incremental direct cost per additional depression-free day for pharmacotherapy relative to usual care ranges from $ 12.66 to $ 16.87 which translates to direct cost per quality -adjusted year gained from $ 11270 to $ 19510 . CONCLUSIONS St and ardized treatments for depression lead to better outcomes than usual care but also lead to higher costs . However , the estimates of the cost per quality -of-life year gained for st and ardized pharmacotherapy are comparable with those found for other treatments provided in routine practice BACKGROUND Exp and ing access to high- quality depression treatment will depend on the balance of incremental benefits and costs . We examine the incremental cost-effectiveness of an organized depression management program for high utilizers of medical care . METHODS Computerized records at 3 health maintenance organizations were used to identify adult patients with outpatient medical visit rates above the 85th percentile for 2 consecutive years . A 2-step screening process identified patients with current depressive disorders , who were not in active treatment . Eligible patients were r and omly assigned to continued usual care ( n = 189 ) or to an organized depression management program ( n = 218 ) . The program included patient education , antidepressant pharmacotherapy initiated in primary care ( when appropriate ) , systematic telephone monitoring of adherence and outcomes , and psychiatric consultation as needed . Clinical outcomes ( assessed using the Hamilton Depression Rating Scale on 4 occasions throughout 12 months ) were converted to measures of " depression-free days . " Health services utilization and costs were estimated using health plan-st and ardized cl aims . RESULTS The intervention program led to an adjusted increase of 47.7 depression-free days throughout 12 months ( 95 % confidence interval [ CI ] , 28.2 - 67.8 days ) . Estimated cost increases were $ 1008 per year ( 95 % CI , $ 534-$1383 ) for outpatient health services , $ 1974 per year for total health services costs ( 95 % CI , $ 848-$3171 ) , and $ 2475 for health services plus time-in-treatment costs ( 95 % CI , $ 880-$4138 ) . Including total health services and time-in-treatment costs , estimated incremental cost per depression-free day was $ 51.84 ( 95 % CI , $ 17.37-$108.47 ) . CONCLUSIONS Among high utilizers of medical care , systematic identification and treatment of depression produce significant and sustained improvements in clinical outcomes as well as significant increases in health services costs Non-adherence to antidepressant drug treatment is common . In a recent study in depressed primary care patients , we reported a strong relationship between adherence and response after 6 months . With the use of a naturalistic design , the patients in that study were prospect ively followed for 2 years . The purpose of the present study was to investigate the patients ' long-term outcome and , in particular , to examine the impact of patients ' treatment adherence on response , remission and relapse .  Of the 1031 patients in the intent-to-treat ( ITT ) sample , 835 completed the study . After 2 years , the overall remission rate defined as a Montgomery – Åsberg Depression Rating Scale score of nine or less was 68 % in the ITT sample analysed with the last observation carried forward ( LOCF ) technique , and 75 % in observed cases . In total , 34 % of the responders experienced at least one relapse . Response rates ( LOCF ) were significantly higher in adherent compared to non-adherent patients at week 24 [ 95 % confidence interval (CI)=21.4–32.1 ] , year 1 ( 95 % CI=12.3–22.2 ) and year 2 ( 95 % CI=9.2–19.0 ) . Remission rates ( LOCF ) were also significantly higher in the group of adherent patients at week 24 ( 95 % CI=9.6–21.5 ) , year 1 ( 95 % CI=10.0–21.5 ) and year 2 ( 95 % CI=11.0–22.0 ) . No relationship between adherence and relapse rate was observed , although the mean time from response to first sign of relapse was significantly longer in the adherent patients ( 95 % CI=9–97 days ) . In conclusion , this 2-year follow-up study showed superior long-term recovery in patients who were adherent to antidepressant medication compared to non-adherent patients OBJECTIVE Selective serotonin reuptake inhibitors ( SSRIs ) are widely used to treat depression , but the rates , timing , and baseline predictors of remission in " real world " patients are not established . The authors ' primary objectives in this study were to evaluate the effectiveness of citalopram , an SSRI , using measurement-based care in actual practice , and to identify predictors of symptom remission in out patients with major depressive disorder . METHOD This clinical study included out patients with major depressive disorder who were treated in 23 psychiatric and 18 primary care " real world " setting s. The patients received flexible doses of citalopram prescribed by clinicians for up to 14 weeks . The clinicians were assisted by a clinical research coordinator in the application of measurement-based care , which included the routine measurement of symptoms and side effects at each treatment visit and the use of a treatment manual that described when and how to modify medication doses based on these measures . Remission was defined as an exit score of < or=7 on the 17-item Hamilton Depression Rating Scale ( HAM-D ) ( primary outcome ) or a score of < or=5 on the 16-item Quick Inventory of Depressive Symptomatology , Self-Report ( QIDS-SR ) ( secondary outcome ) . Response was defined as a reduction of > or=50 % in baseline QIDS-SR score . RESULTS Nearly 80 % of the 2,876 out patients in the analyzed sample had chronic or recurrent major depression ; most also had a number of comorbid general medical and psychiatric conditions . The mean exit citalopram dose was 41.8 mg/day . Remission rates were 28 % ( HAM-D ) and 33 % ( QIDS-SR ) . The response rate was 47 % ( QIDS-SR ) . Patients in primary and psychiatric care setting s did not differ in remission or response rates . A substantial portion of participants who achieved either response or remission at study exit did so at or after 8 weeks of treatment . Participants who were Caucasian , female , employed , or had higher levels of education or income had higher HAM-D remission rates ; longer index episodes , more concurrent psychiatric disorders ( especially anxiety disorders or drug abuse ) , more general medical disorders , and lower baseline function and quality of life were associated with lower HAM-D remission rates . CONCLUSIONS The response and remission rates in this highly generalizable sample with substantial axis I and axis III comorbidity closely resemble those seen in 8-week efficacy trials . The systematic use of easily implemented measurement-based care procedures may have assisted in achieving these results CONTEXT Depression is a leading cause of disability worldwide , but treatment rates in primary care are low . OBJECTIVE To determine the cost-effectiveness from a societal perspective of 2 quality improvement ( QI ) interventions to improve treatment of depression in primary care and their effects on patient employment . DESIGN Group-level r and omized controlled trial conducted June 1996 to July 1999 . SETTING Forty-six primary care clinics in 6 community-based managed care organizations . PARTICIPANTS One hundred eighty-one primary care clinicians and 1356 patients with positive screening results for current depression . INTERVENTIONS Matched practice s were r and omly assigned to provide usual care ( n = 443 patients ) or to 1 of 2 QI interventions offering training to practice leaders and nurses , enhanced educational and assessment re sources , and either nurses for medication follow-up ( QI-meds ; n = 424 patients ) or trained local psychotherapists ( QI-therapy ; n = 489 ) . Practice s could flexibly implement the interventions , which did not assign type of treatment . MAIN OUTCOME MEASURES Total health care costs , costs per quality -adjusted life-year ( QALY ) , days with depression burden , and employment over 24 months , compared between usual care and the 2 interventions . RESULTS Relative to usual care , average health care costs increased $ 419 ( 11 % ) in QI-meds ( P = .35 ) and $ 485 ( 13 % ) in QI-therapy ( P = .28 ) ; estimated costs per QALY gained were between $ 15 331 and $ 36 467 for QI-meds and $ 9478 and $ 21 478 for QI-therapy ; and patients had 25 ( P = .19 ) and 47 ( P = .01 ) fewer days with depression burden and were employed 17.9 ( P = .07 ) and 20.9 ( P = .03 ) more days during the study period . CONCLUSIONS Societal cost-effectiveness of practice -initiated QI efforts for depression is comparable with that of accepted medical interventions . The intervention effects on employment may be of particular interest to employers and other stakeholders CONTEXT Although guideline -concordant depression treatment is clearly effective , treatment often falls short of evidence -based recommendations . Organized depression care programs significantly improve treatment quality , but employer purchasers have been slow to adopt these programs based on lack of evidence for cost-effectiveness from their perspective . OBJECTIVE To evaluate the effects of a depression outreach-treatment program on workplace outcomes , a concern to employers . DESIGN , SETTING , AND PARTICIPANTS A r and omized controlled trial involving 604 employees covered by a managed behavioral health plan were identified in a 2-stage screening process as having significant depression . Patient treatment allocation was concealed and assessment of depression severity and work performance at months 6 and 12 was blinded . Employees with lifetime bipolar disorder , substance disorder , recent mental health specialty care , or suicidality were excluded . INTERVENTION A telephonic outreach and care management program encouraged workers to enter outpatient treatment ( psychotherapy and /or antidepressant medication ) , monitored treatment quality continuity , and attempted to improve treatment by giving recommendations to providers . Participants reluctant to enter treatment were offered a structured telephone cognitive behavioral psychotherapy . MAIN OUTCOME MEASURES Depression severity ( Quick Inventory of Depressive Symptomatology , QIDS ) and work performance ( World Health Organization Health and Productivity Question naire [ HPQ ] , a vali date d self-report instrument assessing job retention , time missed from work , work performance , and critical workplace incidents ) . RESULTS Combining data across 6- and 12-month assessment s , the intervention group had significantly lower QIDS self-report scores ( relative odds of recovery , 1.4 ; 95 % confidence interval , 1.1 - 2.0 ; P = .009 ) , significantly higher job retention ( relative odds , 1.7 ; 95 % confidence interval , 1.1 - 3.3 ; P = .02 ) , and significantly more hours worked among the intervention ( beta=2.0 ; P=.02 ; equivalent to an annualized effect of 2 weeks of work ) than the usual care groups that were employed . CONCLUSIONS A systematic program to identify depression and promote effective treatment significantly improves not only clinical outcomes but also workplace outcomes . The financial value of the latter to employers in terms of recovered hiring , training , and salary costs suggests that many employers would experience a positive return on investment from outreach and enhanced treatment of depressed workers . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00057590 We describe a secondary analysis of data from a r and omized trial conducted at seven primary care clinics of a Seattle area HMO . Adults with major depression ( n=290 ) beginning antidepressant treatment completed structured interviews at baseline , 1 , 3 , 6 , 9 , 12 , 18 , and 24 months . Interviews examined clinical outcomes ( Hamilton Depression Rating Scale and depression module of the Structured Clinical Interview for DSM-IIIR ) , employment status , and work days missed due to illness . Medical comorbidity was assessed using computerized pharmacy data , and medical costs were assessed using the HMO 's computerized accounting data . Using data from the 12-month assessment , patients were classified as remitted ( 41 % ) , improved but not remitted ( 47 % ) , and persistently depressed ( 12 % ) . After adjustment for depression severity and medical comorbidity at baseline , patients with greater clinical improvement were more likely to maintain paid employment ( P=.007 ) and reported fewer days missed from work due to illness ( P<.001 ) . Patients with better 12-month clinical outcomes had marginally lower health care costs during the second year of follow-up ( P=.06 ) . We conclude that recovery from depression is associated with significant reductions in work disability and possible reductions in health care costs . Although observational data can not definitively prove any causal relationships , these longitudinal results strengthen previous findings regarding the economic burden of depression on employers and health insurers BACKGROUND We evaluated depression severity , health-related quality of life ( HRQL ) , and medical cost outcomes of primary care patients receiving recommended and less-than-recommended levels of antidepressant treatment .  METHODS We performed a secondary analysis of clinical trial data from primary care clinics in a staff-model managed care organization . The trial included patients with Diagnostic and Statistical Manual of Mental Disorders , Third Edition , Revised ( DSM-III-R ) criteria for major depression who were starting antidepressant treatment .  The primary outcomes measures used were the 17-item Hamilton Depression Rating Scale ( HDRS ) , Hopkins Symptom Checklist depression scores , the Medical Outcomes Study 36-Item Short-Form Health Survey ( SF-36 ) mental and physical component summary scores , and the total outpatient and inpatient medical costs . RESULTS Of 358 patients starting antidepressant treatment , 195 ( 54.5 % ) received doses recommended by the Agency for Health Care Policy and Research for 90 days or more . Mean HDRS score decreased from 14.1 to 8.8 in patients receiving less-than-recommended treatment and decreased from 13.8 to 8.9 in patients with minimum recommended treatment ( P = .761 ) . No significant differences in improvement of HRQL outcomes during 6 months were observed between patients receiving recommended or less-than-recommended antidepressant therapy .  Mean total medical costs over 6 months for patients taking the recommended levels of antidepressant treatment were $ 1872 + /- 140 compared with $ 2622 + /- 413 for patients taking less-than-recommended treatment ( P = .032 ) . The differences in total medical costs were attributable to significantly lower nonmental health-related inpatient costs in the recommended antidepressant treatment group ( $ 104 vs $ 785 , P = .004 ) . CONCLUSIONS Patients receiving minimum recommended levels of antidepressant therapy for 3 months showed improvement in depression severity and HRQL comparable with patients receiving less-than-recommended treatment . Patients receiving minimum recommended treatment had lower total costs and nonmental health-related inpatient costs .  Antidepressant treatment in primary care patients may have the greatest impact on the frequency of health care visits and on costs for medical conditions and impairments OBJECTIVE To evaluate the impact of mail-based physician and member educational interventions on  patient adherence  to antidepressant medications . STUDY DESIGN The r and omized controlled prospect i ve design included patients followed for 6 months after filling a new prescription for an antidepressant . A pharmacy cl aims data base was used to identify patients and track medication adherence . PATIENTS AND METHODS Patients receiving a new prescription for an antidepressant and their prescribers were included . Prescribers were r and omly assigned to the intervention and control groups . Patient assignment was linked to their physician 's assignment . The control group received no intervention . The educational intervention consisted of monthly letters to patients and prescribers regarding the Health Plan Employer Data and Information Set ( HEDIS ) st and ards or educational information regarding the importance of medication adherence . The primary outcome was adherence as measured by the medication possession ratio and measurement as specified by HEDIS . The Student 's ttest , the chi2 test , and a logistic regression model were used to compare groups and the variables that affect adherence . Other secondary measurements of adherence were performed . RESULTS A total of 9564 patients were included . Patients in the intervention group demonstrated greater adherence compared with the control group at 90 and 180 days ( P < .05 ) . After adjusting for variables , the intervention variable stood alone in its significant impact on adherence ( P < .01 ; confidence interval , 1.003 - 1.197 ) . Adherence in the total population was significantly higher for selective serotonin reuptake inhibitors than for other agents ( P < .001 ) . CONCLUSION A monthly mail-based educational intervention program regarding antidepressant medications can positively influence patient adherence to therapy Objective : Patients with major depression discontinue taking their antidepressants for many reasons . Although side effects are often cited as the reason for discontinuation , few prospect i ve studies have addressed this question , and none has specifically examined discontinuation in patients with severe depression . Method : In patients and out patients treated with a selective serotonin reuptake inhibitor for major depressive disorder were identified after admission . Three months later , patients were contacted and interviewed to determine antidepressant usage and the side effects experienced , including when these were experienced and their severity . Results : Between October 2001 and April 2003 , 406 English- or Spanish-speaking patients aged 18 to 75 years were followed up . One in 4 patients discontinued the index antidepressant . Among specific side effects noted , only " change in weight " and " anxiety " were significant predictors of discontinuation after controlling for confounders . Experiencing 1 or more " extremely " bothersome side effects was associated with more than a doubling of the risk of discontinuation , but the presence of side effects and side effects less severe than " extremely " bothersome were not significant predictors . There were no differences among selective serotonin reuptake inhibitor antidepressants in either the presence/absence of side effects or in the discontinuation rates . Conclusion : The results suggest that the contribution of side effects to antidepressant discontinuation is more complex than previously suggested . Disparate findings from earlier studies may reflect aspects of study design , such as examining population s whose severity of depression varied widely or not controlling for important confounding factors . Future research should separately examine high-risk groups ( or control for severity of depression ) and carefully rule out other potential contributors to discontinuation OBJECTIVE Although major depression is thought to have substantial negative effects on work performance , the possibility of recall bias limits self-report studies of these effects . The authors used the experience sampling method to address this problem by collecting comparative data on moment-in-time work performance among service workers who were depressed and those who were not depressed . METHOD The group studied included 105 airline reservation agents and 181 telephone customer service representatives selected from a larger baseline sample ; depressed workers were deliberately over sample d. Respondents were given pagers and experience sampling method diaries for each day of the study . A computerized autodialer paged respondents at r and om time points . When paged , respondents reported on their work performance in the diary . Moment-in-time work performance was assessed at five r and om times each day over a 7-day data collection period ( 35 data points for each respondent ) . RESULTS Seven conditions ( allergies , arthritis , back pain , headaches , high blood pressure , asthma , and major depression ) occurred often enough in this group of respondents to be studied . Major depression was the only condition significantly related to decrements in both of the dimensions of work performance assessed in the diaries : task focus and productivity . These effects were equivalent to approximately 2.3 days absent because of sickness per depressed worker per month of being depressed . CONCLUSIONS Previous studies based on days missed from work significantly underestimate the adverse economic effects associated with depression . Productivity losses related to depression appear to exceed the costs of effective treatment OBJECTIVE The authors evaluated the incremental cost-effectiveness of stepped collaborative care for patients with persistent depressive symptoms after usual primary care management .  METHOD Primary care patients initiating antidepressant treatment completed a st and ardized telephone assessment 6 - 8 weeks after the initial prescription . Those with persistent major depression or significant subthreshold depressive symptoms were r and omly assigned to continued usual care or collaborative care . The collaborative care included systematic patient education , an initial visit with a consulting psychiatrist , 2 - 4 months of shared care by the psychiatrist and primary care physician , and monitoring of follow-up visits and adherence to medication regimen . Clinical outcomes were assessed through blinded telephone assessment s at 1 , 3 , and 6 months . Health services utilization and costs were assessed through health plan cl aims and accounting data . RESULTS Patients receiving collaborative care experienced a mean of 16.7 additional depression-free days over 6 months . The mean incremental cost of depression treatment in this program was $ 357 . The additional cost was attributable to greater expenditures for antidepressant prescriptions and outpatient visits . No off setting decrease in use of other health services was observed . The incremental cost-effectiveness was $ 21.44 per depression-free day . CONCLUSIONS A stepped collaborative care program for depressed primary care patients led to substantial increases in treatment effectiveness and moderate increases in costs . These findings are consistent with those of other r and omized trials . Improving outcomes of depression treatment in primary care requires investment of additional re sources , but the return on this investment is comparable to that of many other widely accepted medical interventions
target: Depression frequently causes unemployment , absenteeism , and presenteeism , which results in significantly reduced productivity .
  Improving patients ' compliance with their antidepressant medication results in improved outcomes and prolongs remission from depression , increasing work productivity , and thus reducing overall costs .
  The implementation of remote enhanced-care programs may improve compliance and reduce overall costs .
  In conclusion , depression is a common disorder with a high economic impact .
  Enhanced-care programs may lower costs associated with depression and improve patients ' lives
background: This systematic review examines the economic and human costs of depression and the potential savings associated with improvement in patient adherence to treatment with antidepressants through the use of enhanced-care programs .