Depression: Cost of Health Services in HMO Patients 65 and Older

Most literature in reference to the cost and consequences of depression focus upon patients who fit the DSM criteria for major depressive disorder. On the other hand, many older adults are burdened with symptoms that are below the threshold to make a formal diagnosis of major depression. The purpose of this study was to examine 2558 older adults in an HMO in a four-year prospective trial to determine the cost of health care services in relation to depressive symptoms.

Subjects completed a mail survey and telephone interview at baseline, two years later, and four years later. Depressive symptoms were measured using the Center for Epidemiological Studies Depression scale (CES-D). At baseline, 14% of respondents had significant depressive symptom scores (> 16 on CES-D). This percentage increased to 16% at two years and 18% at four years.

Patients with significant depressive symptoms at baseline had substantially higher median health care costs than those without significant symptoms ($2147 vs $1461). Similarly, four-year expenditures were approximately 1.5 greater amongst individuals with significant depressive symptom scores.

Unutzer and colleagues note that individuals with symptoms that fall below the DSM threshold for diagnosis of major depressive disorder still have substantial limitations in function and unfavorable effects on quality of life. It is likely that improved recognition of the impact of depressive symptoms and appropriate treatment, will favorably affect the lives of these individuals and their family members. v Unutzer J. JAMA 1997;277: 1618-1623.

Clinical Scenario: Identify the irregular tachycardia in the Figure that begins with beat #4. How certain are you of your diagnosis?

Interpretation: Although there is baseline artifact—the first three beats in this tracing are sinus. Thereafter the rhythm changes, and an irregular, wide-complex tachycardia is seen. Despite the irregularity—this rhythm is ventricular tachycardia.

The most suggestive clue to the etiology of this rhythm is the presence of AV dissociation. As already noted—the first three beats in this tracing are sinus. The sinus rate is approximately 70 beats/minute. The key to interpreting the rhythm lies with recognizing that regular P waves continue throughout the tracing. Arrows in the figure mark the first four P waves in the rhythm strip. Setting your calipers to a P-P interval of just over four large boxes allows you to "walk out" a regular atrial rate throughout the entire tracing. Thus, the fifth P wave occurs right after beat #8. Ultimately, P waves conduct again at the end of the tracing. They do not conduct during the wide-complex tachycardia. This defines the presence of AV dissociation—a finding that is virtually diagnostic of ventricular tachycardia (VT). Also consistent with the diagnosis of VT is the relatively long post-ectopic pause that is seen after the last ventricular beat.

We are then left with explaining the irregularity of the ventricular response during the wide-complex tachycardia. Although ventricular tachycardia is usually regular (or at least fairly regular)—there will sometimes be more obvious variation in the ventricular response. One of the patterns that may occur is a "warm up" phenomenon, in which VT begins slow—and then speeds up to an almost regular more rapid rate. This is the pattern that is seen in the figure.