Category Archives: Economy

India named world’s most depressed nation

A WHO research has revealed that people living in wealthier nations are more depressed than those in relatively poorer ones.

According to research, India was recorded to be the nation with the highest rate of depression in the world at 36%, making it an exception to the rule. The booming democracy is going through an unprecedented socio-economic change, which often becomes the reason for depression.

In France, the Netherlands, and America, more than 30% of people suffered from a “major depressive mode” which was far higher than China’s figure of 12%. People in wealthier countries were also more likely to be disabled by depression.

The WHO found that  one in seven people in rich countries are likely to get depression over their lifetime, which is equivalent to 15%. One in nine people  (11%) in middle and low income countries are likely to experience depression within their lifetime.

France is more depressed than Mexico

 Following India, France and the United States had the highest rates of reported depression. 21% of people in France and 19.2% of people in the U.S. reported having an extended period of depression within their lifetime. The lowest rates of depression included China (6.5%) and Mexico (8%).

An average of 15% of people in wealthy countries reported having an episode, compared to 11% of people in low income countries.

The higher percentage of depression reported by people in wealthier countries may reflect differences in societal expectations for a good life.

“There are a lot of people in the U.S. who say they aren’t satisfied with their lives. U.S. expectations know no bounds and people in other countries are just happy to have a meal on the table,” said study co-author Ronald Kessler, a professor of health care policy at Harvard.

Depression is the third largest contributor to lowered productivity in the workplace, according to Kessler.

Researchers took into account both clinical depression and types of mild depression. Clinical depression is  a biological condition which leads to low self-esteem and loss of interest in otherwise enjoyable activities. Types of mild depression can be situational or caused by environmental influences. The latter was likely the cause of higher rates in the U.S. and France, Kessler said.

“There’s no change in biological depression, but what’s going up is the more mild depression,” Kessler said. “Objective things haven’t changed. We have an expectation that everything’s going to turn out perfect but it doesn’t.”

Scientists from twenty different institutions worldwide worked with the WHO’s World Mental Health Survey Initiative, obtaining data by interviewing 89,037 people in 18 different countries from 2000 to 2005. Trained interviewers spoke with respondents in person or over the phone about traumatic events in that person’s life, substance abuse, relationships, happiness, and other factors that could influence mental health.

The report also found that women were twice as likely to experience depression, and the strongest link to depression was separation or divorce from a partner.

It is unclear what exactly accounts for the pattern but the richest countries in the world tend to have the highest levels of income inequality, which has been linked to higher rates of depression.

The authors also explained that poorer people may be less likely to recall or relate episodes of depression from their past. Comparing depression rates among different countries is challenging because survey particpants may be influenced by cultural norms (never speaking about depression) or their interactions with the interviewer.

“There are significant disparities across countries in terms of the availability and social acceptance of mental health care for depression,” says Timothy Classen, economic professor at Loyola University.  He noted that there tends to be more stigma surrounding depression in a country like Japan than in the U.S. Classen says this may explain why Japan has a higher suicide rate, even though its depression rates in the study were three to four times lower than those in the U.S.

Different age groups appeared to fare better than others depending on a country’s level of affluence. For instance, older adults in high-income countries generally had lower rates of depression than their younger counterparts, while the trend was reversed in several poorer countries.

In a country like the Ukraine, “older people have enormous pressure on them and they don’t have enough money to live and take care of grandchildren and health problems. Their lives are extremely difficult relative to older people in this country,” explained Evelyn Bromet, lead author of the study.

Hopefully the study findings will help countries identify their own high-risk populations, whether it’s older adults in Ukraine or young divorced women in Japan.

“I hope people in these countries will start thinking about social and medical support for these groups in particular, and what they can do to prevent depression in the future,” Bromet said.

Talk doesn’t pay, so psychiatry turns to drug therapy

Via the New York Times

Doylestown, PA – Alone with his psychiatrist, the patient confided that his newborn had serious health problems, his distraught wife was screaming at him and he had started drinking again. With his life and second marriage falling apart, the man said he needed help.

But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”

Like many of the nation’s 48,000 psychiatrists,  Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy. Instead, he prescribes medication after a brief consultation with each patient. So Dr. Levin sent the man away with a referral to a less costly therapist.

Dr. Levin, 68, first established a private practice in 1972, when talk therapy was in its heyday. Like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart.

Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.

Dr. Levin has found the transition difficult. He now resists helping patients to manage their lives better. “I had to train myself not to get too interested in their problems,” he said, “and not to get sidetracked trying to be a semi-therapist.”

A 2005 government survey found that just 11 percent of psychiatrists provided talk therapy to all patients. Apex Behavioral Health provides both psychiatry (medication management) and psychologists (counseling) to our clients. Clients are able to see both the psychiatrist and therapist in the same building; often, our psychiatrists will refer their patient to a therapist and vice versa.

Recent studies suggest that talk therapy may be as good as or better than drugs in the treatment of depression, which is why it is really beneficial to see a therapist. Insurance company reimbursement rates and policies that discourage talk therapy are part of the reason. A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.

Competition from psychologists and social workers — who unlike psychiatrists do not attend medical school, so they can often afford to charge less — is the reason that talk therapy is priced at a lower rate.

Of course, there are thousands of psychiatrists who still offer talk therapy to all their patients, but they care mostly for the worried wealthy who pay in cash. In New York City, for instance, a select group of psychiatrists charge $600 or more per hour to treat investment bankers, and top child psychiatrists charge $2,000 and more for initial evaluations.

When he started in psychiatry, Dr. Levin kept his own schedule in a spiral notebook and paid college students to spend four hours a month sending out bills. But in 1985, he started a series of jobs in hospitals and did not return to full-time private practice until 2000, when he and more than a dozen other psychiatrists were shocked to learn that insurers would no longer pay what they had planned to charge for talk therapy.

“At first, all of us held steadfast, saying we spent years learning the craft of psychotherapy and weren’t relinquishing it because of parsimonious policies by managed care,” Dr. Levin said. “But one by one, we accepted that that craft was no longer economically viable. Most of us had kids in college. And to have your income reduced that dramatically was a shock to all of us. It took me at least five years to emotionally accept that I was never going back to doing what I did before and what I loved.”

He could have accepted less money and could have provided time to patients even when insurers did not pay, but, he said, “I want to retire with the lifestyle that my wife and I have been living for the last 40 years.”

“Nobody wants to go backwards, moneywise, in their career,” he said. “Would you?”

Dr. Levin would not reveal his income. In 2009, the median annual compensation for psychiatrists was about $191,000, according to surveys by a medical trade group.

Dr. Louisa Lance, a former colleague of Dr. Levin’s, practices the old style of psychiatry from an office next to her house. She sees new patients for 90 minutes and schedules follow-up appointments for 45 minutes. Therapists at Apex Behavioral Health see clients for 45 minutes to an hour. Everyone gets talk therapy. Cutting ties with insurers was frightening since it meant relying solely on word-of-mouth, rather than referrals within insurers’ networks, Dr. Lance said, but she cannot imagine seeing patients for just 15 minutes. She charges $200 for most appointments and treats fewer patients in a week than Dr. Levin treats in a day.

“Medication is important,” she said, “but it’s the relationship that gets people better.”

Dr. Levin’s initial efforts to get insurers to reimburse him and persuade his clients to make their co-payments were less than successful. His office assistants were so sympathetic to his tearful patients that they often failed to collect. So in 2004, he begged his wife, Laura Levin — a licensed talk therapist herself, as a social worker — to take over the business end of the practice.

Ms. Levin created accounting systems, bought two powerful computers, licensed a computer scheduling program from a nearby hospital and hired independent contractors to haggle with insurers and call patients to remind them of appointments. She imposed a variety of fees on patients: $50 for a missed appointment, $25 for a faxed prescription refill and $10 extra for a missed co-payment.

As soon as a patient arrives, Ms. Levin asks firmly for a co-payment, which can be as much as $50. She schedules follow-up appointments without asking for preferred times or dates because she does not want to spend precious minutes as patients search their calendars. If patients say they cannot make the appointments she scheduled, Ms. Levin changes them.

“This is about volume,” she said, “and if we spend two minutes extra or five minutes extra with every one of 40 patients a day, that means we’re here two hours longer every day. And we just can’t do it.”

She said that she would like to be more giving of herself, particularly to patients who are clearly troubled. But she has disciplined herself to confine her interactions to the business at hand. “The reality is that I’m not the therapist anymore,” she said.

Ms. Levin, 63, maintains a lengthy waiting list, and many of the requests are heartbreaking. On a January day, a pregnant mother of a 3-year-old called to say that her husband was so depressed he could not rouse himself from bed. Could he have an immediate appointment? Dr. Levin’s first opening was a month away.

“I get a call like that every day, and I find it really distressing,” Ms. Levin said. “But do we work 12 hours every day instead of 11? At some point, you have to make a choice.”

Initial consultations are 45 minutes, while second and later visits are 15. At Apex, initial consultations are 30 minutes, while the second visits are also 15 minutes. In those first 45 minutes, Dr. Levin takes extensive medical, psychiatric and family histories. He was trained to allow patients to tell their stories in their own unhurried way with few interruptions, but now he asks a rapid-fire series of questions in something akin to a directed interview.

In 15-minute consultations, Dr. Levin asks for quick updates on sleep, mood, energy, concentration, appetite, irritability and problems like sexual dysfunction that can result from psychotropic medications.

“And people want to tell me about what’s going on in their lives as far as stress,” Dr. Levin said, “and I’m forced to keep saying: ‘I’m not your therapist. I’m not here to help you figure out how to get along with your boss, what you do that’s self-defeating, and what alternative choices you have.’ ”

Dr. Levin said that the quality of treatment he offers was poorer than when he was younger. For instance, he was trained to adopt an unhurried analytic calm during treatment sessions. “But my office is like a bus station now,” he said. “How can I have an analytic calm?”

And years ago, he often saw patients 10 or more times before arriving at a diagnosis. Now, he makes that decision in the first 45-minute visit. “You have to have a diagnosis to get paid,” he said with a shrug. “I play the game.”

In interviews, six of Dr. Levin’s patients — their identities, like those of the other patients, are being withheld to protect their privacy — said they liked him despite the brief visits. “I don’t need a half-hour or an hour to talk,” said a stone mason who has panic attacks and depression and is prescribed an antidepressant. “Just give me some medication, and that’s it. I’m O.K.”

Dr. Levin expressed some astonishment that his patients admire him as much as they do.

“The sad thing is that I’m very important to them, but I barely know them,” he said. “I feel shame about that, but that’s probably because I was trained in a different era.”