CARE FOR DEPRESSION IN A CHANGING ENVIRONMENT by Kenneth B. Wells and Roland Sturm Prologue: Psychologist Martin Seligman has referred to depression as "the common cold of mental illness." The incidence of depression has continued to climb, ranking it among the leading causes of chronic illness among Americans. As such, depression was one of five "tracer conditions' that were part of the Medical Outcomes Study (MOS), conducted longitudinally over four years beginning in 1986. The authors of this paper were investigators in the MOS; here they use their findings as a test case to discuss the effects of various payment strategies and managed care on the treatment of mental health conditions. The paper places their clinical findings in a policy context. The authors found that the cost-effectiveness of care can be improved, although this does not necessarily mean that treatment costs are lowered. In fact, often the opposite is true. "Much discussion about [mental health care coverage] reflects an implicit hope that higher-quality care is the magic bullet that miraculously lowers health care costs," the authors write. "This wishful thinking appears to be so ingrained that our simulation of the effects of quality improvement is regularly misquoted as evidence for it, even though we explicitly say that quality improvement by itself raises treatment costs." Kenneth Wells, a psychiatrist, holds a medical degree from the University of California, San Francisco, and a master of public health degree from the University of California, Los Angeles (UCLA). Since 1980 he has been a professor in the Department of Psychiatry, Neuropsychiatric Institute, at UCLA; a senior research analyst in the Systems Science Department of RAND; and director of mental health research for the National Study of Medical Care Outcomes. Roland Sturm is an associate economist at RAND in Santa Monica, California, and is a visiting assistant professor in the UCLA Department of Economics. He holds a doctorate in economics from Stanford University.
CARE FOR DEPRESSION 79 Abstract: The U.S. health care system is quickly changing, but is it moving in the right direction? Focusing on care for clinical depression as a test case, this paper summarizes our previously published findings on the effects of various payment strategies, managed care, and primary care gatekeepers on the outcomes and costs for the treatment of mental health conditions. We then synthesize the policy implications of these findings for achieving value of care, lower costs, and good health outcomes. The U.S. health care system is changing rapidly. Understanding the consequences of these changes such as various payment strategies, managed care, and an increasing reliance on primary care gatekeepers is a difficult task. Health care delivery systems are complex, and it is easy to remain grounded in superficial statistical comparisons of mortality rates or costs. We believe that to provide valid information for policy purposes, one has to study clinical processes and outcomes. One research approach that can combine clinical details with an evaluation of the consequences of changes in the U.S. health care system is a tracer condition approach, which focuses on one specific clinical condition. Among mental health conditions, serious depression is the best tracer condition: It is common, well-defined, and clinically understood. Depression is important because of its prevalence and impact, which are comparable to or worse than those of arthritis, hypertension, or diabetes. Depression also results in higher annual social losses than those caused by coronary heart disease or arthritis. 1 Although depression can be treated successfully, and clinical practice guidelines are available, many depressed patients do not receive efficacious treatments. 2 The first large-scale tracer condition study to include depression or any mental health tracer on an equal footing with more commonly studied chronic medical conditions was the Medical Outcomes Study (MOS), a four-year longitudinal study that started in 1986 and that involved more than 20,000 patients in different practice settings and competing financing systems in three cities (Boston, Chicago, and Los Angeles). 3 The MOS compared the use of services, quality of care, and health outcomes of adult outpatients with diabetes, hypertension, congestive heart failure, recent myocardial infarction, or depression. The latter were identified by independent study screening, regardless of the treating clinician's diagnosis. Clinicians and patients provided data over the follow-up period. In this paper we summarize what we have learned from the MOS about different payment systems (prepaid versus fee-for-service) and provider specialties (psychiatry, psychology and other mental health specialty, and general medical clinicians) regarding treatment, health outcomes, and costs for depression. The depression component of the MOS and individual results are documented in more detail in the cited research papers and a forthcoming book, which also provides the necessary tools for other re- Health Affairs, Volume 14, Number 3 1995 The People-to-People Health Foundation, Inc.
80 HEALTH AFFAIRS Fall 1995 searchers to perform their own health system evaluations using depression as a tracer condition. 4 What is depression? Clinical depression is a period of intense, often continuous feelings of sadness and hopelessness accompanied by cognitive and somatic symptoms that can require treatment. The prevailing diagnostic systems distinguish between two major categories of unipolar mood disorders: major depression, a severe episode of daily depressed mood accompanied by symptoms such as suicidal thoughts, weight loss, poor sleep, and poor concentration, lasting at least two weeks; and chronic depression, called dysthymia in the United States. 5 Many patients have subthreshold depressive symptoms that do not meet these formal disorder criteria. For major depression, antidepressant medication is efficacious in both the acute phase and a maintenance phase that focuses on reducing the probability of recurrence. Different types of psychotherapy have also been shown to be efficacious in the acute phase but not in the maintenance phase. There have been few efficacy studies on dysthymia, but it is widely believed that treatments for major depression are efficacious for dysthymia. There is much uncertainty about whether subthreshold depressive symptoms respond to these treatments. Studying Effectiveness Policymakers need to know if the care provided in actual practice improves health, that is, whether care is effective. This is a different concept than the information provided by clinical studies that establish the efficacy of different treatments. Typical patients in actual practice are not the "pure" case selected for clinical trials: They have multiple comorbidities, and they receive care mainly in the general medical sector, not in an academic or specialty setting. In addition, the incentives for providers and patients in clinical trials, in which treatment costs are part of the research budget, differ from those in actual practice. Thus, a specific medication may not lead to the same outcomes in usual care settings as it does in clinical trials. This complicates an evaluation of care because we cannot simply compare processes of care across systems of care; we also have to study outcomes directly. We consider outcomes data complementary because relying on health outcomes alone is not without problems. Health outcomes are difficult to measure and are not sensitive enough to detect substantial differences at standard significance levels with commonly available sample sizes. Comparisons with low statistical power could easily be abused to "prove" the absence of a significant difference and justify promotion of a less effective alternative. This health-oriented perspective still lacks one major social outcome:
CARE FOR DEPRESSION 81 health care costs. As long as one focuses on health outcomes in isolation, quality of care can never be high enough. But quality improvement generally means higher total costs, which makes quality improvement much less attractive in the current policy environment. Many strategies in today's health care market, such as shifting mental health care from specialty providers to generalists, largely reflect a focus on costs that ignores health outcomes (which is tempting because some cost data are usually available, while outcome data are not). An often overlooked criterion is value of care in terms of health improvement per dollar spent on care. For a health care plan or employer, value of care, or cost-effectiveness, should be as important as absolute costs: There is little point in spending money on something that provides no benefits just because it is cheap. Why Complete Evaluations Are Difficult Health care delivery can be inefficient because sick persons do not receive care that is appropriate for their health problem or because they receive unnecessary treatment. A tracer approach mainly limits one to analyzing the first type of error. Overuse, the second type of error, has cost implications but is often difficult to study: Screening patients for not benefiting from mental health care is much more difficult than screening patients for needing surgery. Most health services research is biased toward health care that reduces underuse. The MOS is no exception, although we studied use of minor tranquilizers that are not efficacious for depression. The only possibility to study "care as usual" requires an observational design, like the MOS, because experimental designs structure systems and processes of care or alter the selection of care by patients. However, an observational study poses design and analytic challenges because factors outside a statistical model can bias results. Selection bias is generally a consequence of missing data and incomplete statistical models. For example, sicker patients have a poorer prognosis, regardless of treatment effects. As a consequence, a simple direct outcome comparison of two different sectors that ignores sickness differences is biased against the one starting with initially sicker patients. On the other hand, more depressed patients generally improve more than less depressed patients do ("regression to the mean"), even if they remain sicker. A similarly misleading analysis of changes in health status therefore would be biased against the sector starting with initially less-sick patients. The MOS paid particular attention to health status and case-mix measurement and selection problems. While observational studies are necessary to address important policy issues, their inherent potential for selection effects also opens the opportunity to misleadingly promote certain types of treatments and medications.
82 HEALTH AFFAIRS Fall 1995 For example, a simple comparison of health care use among depressed patients by type of psychotropic medication (effective antidepressant medication versus minor tranquilizers) shows fewer visits by depressed patients using minor tranquilizers. Of course, this finding does not prove that minor tranquilizers save money; it is only a consequence of the fact that antidepressant medication is given to sicker patients. To compare payment systems, the MOS first studied whether fee-forservice or prepaid patients differ, but we found little evidence that depressed patients in different payment systems vary in any aspect of depression severity, health status, or functioning. The absence of health-related biased selection does not mean that patients are identical, of course. Patients who prefer intensive care, regardless of their clinical status, are likely to choose plans that permit easy access to specialty care (typically fee-forservice plans), and patients who prefer more limited care and lower costs are likely to choose prepaid managed care. Such selections should have no quality-of-care implications per se because the clinical characteristics of patients are similar, but they affect our interpretation of the extent to which patient preferences versus system characteristics shape utilization. Financing systems also could differ in their enrollee pool the MOS did not study nonusers which could give a plan with healthier enrollees an advantage because costs per enrollee would be lower. Provider specialty (psychiatry, other mental health specialty, and general medicine) is a different dimension of policy interest. Here we paid special attention to health-related selection effects because probability and type of treatment depend on sickness and because psychiatrists treat the sickest patients in terms of psychological health. Obviously, we cannot just compare the average patient across sectors but instead need to select comparable groups or achieve comparability through statistical controls. Patients are likely to select themselves into specialty sectors that emphasize treatments they prefer, and we cannot determine to what extent providers, rather than patients, shape differences in treatment style, after adjusting for health differences across specialty sectors. How Does Treatment Differ By Payment System And Specialty? To compare quality of care, we contrasted payment and specialty groups in three clinical processes (detection, psychotropic medication, and counseling), utilization (the main determinant of costs), and continuity of care. Detection. The widespread concern about underrecognition of mental health conditions in the general medical sector requires some qualifications. First, it is effective treatment, not detection per se, that improves depression. Detection does not guarantee that a patient will receive appro-
CARE FOR DEPRESSION 83 priate treatment: Many detected depressed patients in the MOS received medications that were at best of questionable value for their depression. It is possible to have both high detection rates and poor quality of care if organizational and financial incentives reduce the use of appropriate clinical treatments. In such cases, increased detection rates channel more patients into ineffective treatment and may be one reason for the disappointing health outcome results of interventions focusing solely on detection. Second, high detection rates are not unambiguously preferable if emphasizing one particular condition comes at the expense of poorer quality of care for other conditions. That being said, studying detection of a specific condition provides a "first cut" at understanding quality of care. We found a major difference between mental health specialists, who detect most depressed patients, and general medical providers, who detect only about half of their depressed patients. 6 Detection rates were slightly lower under prepaid care, but the main difference was between general medical and specialty providers. Psychotropic medication. Two different types of medications are commonly used by depressed patients: antidepressants and minor tranquilizers. Although antidepressants are efficacious for treating depression, there is little evidence that minor tranquilizers by themselves are useful, and they could be cited as an example of overuse because they are costly and have negative side effects, 7 The low rates of detection of depression in general medical practices also are reflected in low rates of antidepressant medication use, which are similarly low among patients of nonphysician mental health specialists. But patients in nonphysician mental health practices encounter an additional problem: These practices do not appear to be able to target antidepressant medication to psychologically sicker patients, which suggests a lack of coordination between the nonphysician therapist and the prescribing physician. In contrast, the MOS found that psychiatrists were more likely both to prescribe antidepressant medications and to respond to patients' illness: About half of their patients with high-severity depression and just under a third of those with low-severity depression used an antidepressant. 8 Nevertheless, subtherapeutic dosages of antidepressant medications were common in all mental health practices, and more patients received minor tranquilizers than received antidepressant medications. Prepaid practices had an even higher rate of use of minor tranquilizers for depression than did fee-for-service practices, which directly contradicts the often-heard claim that prepaid care is more efficient because it reduces unnecessary care. Some managed care clinicians (not participants in the MOS) have suggested to us that pressures to reduce costs and increase caseloads lead to using minor tranquilizers as a substitute for visits. Maybe clinicians who are
84 HEALTH AFFAIRS Fall 1995 unfamiliar with appropriate care for depression are also more susceptible to advertising or patients' requests for a specific medication, or are confused by conflicting statements in the clinical literature. The extensive marketing and publicity surrounding newer antidepressant medications such as fluoxetine (Prozac), which were used only in the MOS's follow-up years, may have tilted the balance toward antidepressants in recent years. Nevertheless, the underlying causes of poor quality of care are unlikely to have disappeared, making medication management probably one of the most promising areas for quality improvement interventions in terms of health benefits and avoiding wasteful treatment, especially in psychiatry. Counseling. Psychotherapy is the second most commonly used treatment for depression, but it is difficult to measure in actual care settings. We had to rely on providers' self-reports on whether or not at least very brief counseling occurred. Not surprisingly, almost all (80 percent) depressed patients of mental health specialists received counseling, primarily individual psychotherapy. In contrast, only a third of the patients in general medical practices received even three minutes of counseling for depression, and rates of counseling were significantly lower under prepaid care than under fee-for-service care in this sector. 9 Training and practice constraints are undoubtedly central reasons for the lower rates of counseling in general medical practices, but patients' preferences also are important, as patients who want psychotherapy choose specialty care. Usual counseling style differed primarily by specialty, but not by payment mode. It was more intensive and psychodynamically oriented in the mental health specialty sector, and briefer and more advice oriented in the general medical sector. Specialists provide what is typically called psychotherapy, while medical providers deliver a more general form of medical counseling. 10 Most mental health specialists would claim that medical counseling is less effective than psychotherapy, although there are virtually no comparative data. We found that counseling had a significant beneficial effect on patient functioning, and this effect was similar across specialty sectors, suggesting that some form of counseling for depression is a priority but that provider type and form of counseling may be of secondary importance. Payment systems and health outcomes. Because depressed patients can improve without care, low rates of appropriate treatment might not be a serious problem. So we asked, Are patients treated well enough, given the natural course of the illness? The answer is no: Because partial recovery is the rule, new episodes of depression are common even among the initially less sick, and substantial functioning limitations persist. 11 So, do treatment differences by payment system matter? Although the intensity of mental health care visits was lower in prepaid than in fee-for-service plans, there were no major differences in health
CARE FOR DEPRESSION 85 outcomes on average, despite somewhat lower detection and counseling rates under prepaid general medical care. 12 However, the largest reductions in utilization under prepaid care were among patients of psychiatrists, who were also the sickest patients in both payment systems, whereas there was little difference by payment system in utilization among patients in the general medical sector. Prepaid psychiatry patients also had significantly worse functioning outcomes than patients receiving fee-for-service psychiatry care had, which is consistent with other quality-of-care measures: a more rapid decline in antidepressant medication use over time, shorter patient/provider relationships, and greater use of minor tranquilizers. The quality-of-care results for psychiatry suggest problems with maintenance care (for example, stopping use of antidepressant medication or changing providers) as one explanation for the outcome difference by payment system. Unfortunately, the MOS measures were not as strong for the maintenance phase as for the acute care phase. For example, discontinuities in patients' provider relationships could either cause or result from a quality problem, although a descriptive comparison indicated that patient/ provider relationships were more likely to end in prepaid care for "involuntary" reasons (the provider was no longer available, the patient was referred elsewhere, or the plan changed), whereas fee-for-service patients were more likely to report that they no longer needed care. 13 Future longitudinal studies therefore should closely examine the maintenance phase. Prepaid psychiatry and general medical practices showed some evidence of poorer quality of care for depressed patients than for their fee-for-service counterparts in a variety of process and health impact measures (detection, counseling, use of minor tranquilizers, continuation of antidepressant medication, provider continuity, and functioning outcomes). The finding of no significant differences in functioning outcomes by payment system is therefore not as reassuring as it otherwise might be. Moreover, fee-for-service care did not distinguish itself in terms of quality, despite much higher costs. Thus, the main policy question for depression treatment is not whether we should promote one type of payment or managed care system, but how to achieve more cost-effective care for depression overall. What Makes Care For Depression More Cost-Effective? If we want to spend our depression-care dollars efficiently, an important criterion should be the health improvement realized for each additional dollar spent. Cost-effective does not necessarily mean cheap but instead means high value; quality improvement may be cost-effective even if it increases direct treatment costs. We have integrated the data collected in the MOS regarding processes of
86 HEALTH AFFAIRS Fall 1995 care, health outcomes, and costs for acute care in prepaid plans to simulate the consequences of different treatment patterns for depression on three policy outcomes: total costs, health outcomes, and value of care (health improvements per dollar spent on care). 14 Our two main questions were, What can quality improvement achieve, and what are the consequences of the current practice of shifting patients toward the general medical sector? Focusing on quality improvement, we found that the marginal cost of removing one additional serious functional limitation through more appropriate treatment the cost-effectiveness ratio is in the $l,000-$2,000 range. It is well known that efficiency requires that cost-effectiveness ratios be equalized at the margin; that is, interventions are worthwhile until their cost-effectiveness ratio exceeds a cutoff point. While this point is generally unknown and depends on resources, we can estimate what prepaid health plans are now spending on average to remove one serious functional limitation based on their current practice patterns: $5,000 (we cannot estimate the more appropriate concept of the incremental cost for an additional depressed patient). This suggests a high cutoff point: All of the levels of quality improvement we studied within and across specialty sectors had lower ratios. After considering quality improvement that reduces costly but ineffective care (regular use of minor tranquilizers), we found that the most cost-effective quality improvements (increased use of counseling and antidepressant medication) are in the general medical sector, which is also the sector that provides the lowest quality of care for depression. However, the most apparent trend in mental health care is not quality improvement, but a shift from mental health specialists to general medical providers. This shift can reduce treatment costs, but it also produces poorer functional outcomes and does little to improve the value of care. Care for depression is much cheaper in general medical practice than in psychiatry, but health outcomes are worse in general practice because general medical patients are less likely to receive appropriate care during their visits. Yet psychiatric care is not more efficient, because the higher rates of appropriate care are accompanied by greater use of ineffective minor tranquilizers and high visit costs. However, combining the strategies of quality improvement and shifting specialty mix could contain costs and improve outcomes or even reduce costs and improve outcomes simultaneously: Specialty shifting reduces total costs, whereas quality improvement raises costs, but to a lesser degree than it improves outcomes. Improving cost-effectiveness does not mean lowering treatment costs, and we have little doubt that quality improvement within each specialty sector increases absolute health care costs for depression in that sector. In contrast, much discussion about coverage for mental health care reflects an
CARE FOR DEPRESSION 87 implicit hope that higher-quality care is the magic bullet that miraculously lowers overall health care costs, the so-called cost offset effect. This wishful thinking appears to be so ingrained that our simulation of the effects of quality improvement is regularly misquoted as evidence for it, even though we explicitly say that quality improvement by itself raises treatment costs. 15 One of the reasons for this belief may be that many studies other than the MOS can neither distinguish between mental and physical health reasons for a visit nor classify visits according to provider type. This can easily generate spurious "cost offsets" because patients of mental health specialists have fewer visits to general medical providers than patients who receive their mental health care in the general medical sector and whose visits are misclassified as medical visits. Another reason is that many studies sample already detected or treated patients and thus miss the effect that quality improvement would have on previously undetected and untreated cases. However, even if the idea that health care plans can save money through better care is too simpleminded, and that the correct answer is that plans can reduce wasteful spending, we would agree that cost offsets can exist from a larger societal perspective because the main element of the social costs of depression is indirect losses through illness, not direct treatment costs. Low treatment rates leading to prolonged illness may therefore be socially inefficient, and resources could be redistributed to make everybody better off. This is a weak social efficiency criterion because it requires only that we do not waste resources. This broad perspective, however, is not the one considered in the usual cost-offset discussion, although it is more meaningful to evaluate whether the incremental health gains of quality improvements are worth the incremental increases in costs than to hope that quality improvement could lower costs and improve outcomes simultaneously. Policy Implications Our research suggests that quality improvement for the care of depression is necessary to raise the value of care and that it can be raised. In a textbook economy, low-value products and services are not viable in the long run, regardless of their price, because competitors would offer higher quality at the same price or the same quality at lower prices, but current trends do not seem to raise the low value of care for clinical depression. There are two reasons why markets may fail to make care for depression socially efficient: externalities and information problems. High-quality care leading to better health outcomes creates benefits for many parties that are not involved in health care. For example, such positive externalities accrue to the employers of better-treated patients
88 HEALTH AFFAIRS Fall 1995 through reduced absenteeism and higher productivity, family members and friends through lower burdens of care for sick persons, and government agencies through fewer transfer payments (welfare, unemployment, and disability). However, a health care plan has no obvious way to capture all of these indirect benefits and only shoulders the increased direct treatment costs of higher-quality care, which diminishes its financial incentives to improve quality of care. This implies that even with perfect information about health care benefits and treatment costs, a purely market-based insurance system will not equate the social costs and social benefits that are central to an efficient system. Externalities are not the worst problem under the current employmentbased system, since most of the indirect economic benefits are likely to be obtained by patients and their employers, who are paying for health care and insurance. An even bigger problem may be imperfect information: Employers cannot determine if a health care plan that claims to provide higher-quality care is worth the additional expenditures. This is partly a problem of quality-of-care measurement and accountability for care and partly a problem of our ignorance about the indirect benefits of health care. The policy implications are twofold: First, from a regulatory perspective, it is necessary to establish standard quality-of-care measurements that would allow higher-quality providers to convincingly identify themselves as such. The measurements developed in the MOS can provide some guidance on how to do this for depression. Health care plans and employers need more feedback on outcomes, costs, and value of care. We emphasize this broader outcomes framework, even though many plans are still struggling with implementing basic outcome measures. Second, there must be incentives for higher-quality care ideally, reimbursement that permits plans to capture their social contribution. Excluding or markedly limiting mental health care coverage seems inconsistent with that task, and purely employment-based insurance may be insufficient. But good policy decisions in this area require more information on the potential for improving value of care, health outcomes, and cost implications across conditions that compete for resources. Maybe one criterion when considering generosity of coverage or other allocation decisions at a state or national level should be the potential for reducing social costs. Clearly, we have a long way to go before research can provide reliable data for these larger policy issues. The MOS was a first step. It identified cases in which quality problems are common and highlighted the importance of considering health and cost issues simultaneously. Future studies need an even stronger integration of economic and clinical health services research to separate out the various effects of clinical processes on direct treatment and indirect social costs that are affected through depression and
CARE FOR DEPRESSION 89 its treatment, as well as to identify the factors that maintain low-value care. Depression is only one of many illnesses that need to be studied from such a broad perspective. NOTES 1. K.B. Wells et al., "The Functioning and Well-Being of Depressed Patients: Results from the Medical Outcomes Study," Journal of the American Medical Association 262, no. 7 (1989): 914-919; and P.E. Greenberg et al., "The Economic Burden of Depression in 1990," Journal of Clinical Psychiatry 54 (1993): 405-418. 2. Depression Guideline Panel, Depression in Primary Care: Volume II. Treatment of Major Depression, Clinical Practice Guideline no. 5, AHCPR Pub. no. 93-0551 (Rockville, Md.: Agency for Health Care Policy and Research, April 1993). 3. The MOS was conducted by RAND in collaboration with other universities and practices. Its design is described in A. Tarlov et al., "Medical Outcomes Study: An Application of Methods for Monitoring the Results of Medical Care," Journal of the American Medical Association 262, no. 7 (1989): 925-930; and A.L. Stewart and J.E. Ware, eds., Measuring Functioning and Well-Being: The Medical Outcomes Study Approach (Durham, N.C.: Duke University Press, 1992). 4. K.B. Wells et al., Caring for Depression (Cambridge: Harvard University Press, forthcoming). 5. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (Washington: APA, 1994). 6. K.B. Wells et al., "Detection of Depressive Disorder for Patients Receiving Prepaid and Fee-for-Service Care: Results from the Medical Outcomes Study," Journal of the American Medical Association 262, no. 23 (1989): 3298-3302. 7. Depression Guideline Panel, Depression in Primary Care: Volume II. 8. K.B. Wells et al., "Use of Minor Tranquilizers and Antidepressant Medications by Depressed Outpatients: Results from the Medical Outcomes Study," American Journal of Psychiatry 151 (1994): 694-700. 9. Wells et al., "Detection of Depressive Disorder for Patients Receiving Prepaid and Fee-for-Service Care." 10. L. Meredith, K.B. Wells, and P. Camp, "Clinician Specialty and Treatment Style for Depressed Outpatients in Primary Care with and without Comorbidities," Archives of FamÜy Medicine 3 (1994): 1065-1072. 11. K.B. Wells et al., "The Course of Depression in Adult Outpatients," Archives of General Psychiatry 49 (1992): 788-794; and R.D. Hays et al., "Functioning and Well-Being Outcomes of Patients with Depression Compared with Chronic General Medical Illnesses," Archives of General Psychiatry 52 (1995): 11-19. 12. R. Sturm et al., "Utilization of Outpatient Mental Health Care among Depressed Patients under Prepaid or Fee-for-Service Financing," Health Services Research 30 ( 1995): 319-340; and W.H. Rogers et al., "Course of Depression for Adult Outpatients under Prepaid or Fee-for-Service Financing," Archives of General Psychiatry 50 (1993): 517-526. 13. R. Sturm, L.S. Meredith, and K.B. Wells, "Provider Choice and Continuity of Treatment for Depression," Medical Care (forthcoming). 14. R. Sturm and K.B. Wells, "How Can Care for Depression Become More Cost- Effective?" Journal of the American Medical Association 273, no. 1 (1995): 51-58. 15. A typical example is the opener on page 16 of the EAP Digest (March/April 1995): "Better treatment for depression leads to lower costs. That's the finding of a study appearing in the recent issue of the Journal of the American Medical Association."