Economic burden of major depressive disorder: a case study in Southern Iran

The rising costs of health systems around the world, especially in low- and middle-income countries such as Iran, have become a major concern for health managers and policymakers, the main reason for which is the increasing number of non-communicable and chronic diseases such as major depressive disorder. The medical costs of the MDD patients have increased rapidly in recent years [28]. The present study aimed to calculate the costs of MDD for the patients referred to the reference medical centers in southern Iran and determine the economic burden of the disease in the country in 2020.

As to demographic characteristics, the results of this study showed that most of the patients were male, were of 25–44 years of age, were married, had under-diploma education levels, were unemployed, had a health insurance, were not covered by supplemental insurance, were residents of the cities in Fars province, and had no income. The results of the study by Pourahmadi et al. (2019) on the patients with depression in Iran showed that most of them were male, were averagely aged 41 years, and were covered by a health insurance [29].

In terms of the costs, the results of the present study indicated that the economic burden of MDD was $ 7,120,456,596 PPP. Cheng et al. (2012) in South Korea estimated the economic burden of depression at $ 4049 million, with the IC, DMC, and DNMC accounting for the highest shares, respectively ($ 3880 million, $152.6 million, and $15.9 million, respectively) [30]. This is consistent with the results of the present study in terms of the total economic burden of the disease in the study year, but is not consistent in terms of indirect costs. One of the reasons for such a discrepancy could be the calculation of intangible costs.

The economic burden of medical direct cost of MDD was approximately 7% of the total healthcare costs in 2020. The total cost of the health system in Iran was $512 billion PPP in 2020, accounting for 7% according to the gross domestic product (GDP) that was $1.69 trillion PPP in that year as reported by the International Monetary Fund [31, 32].

As stated in this study, the mean cost of MDD was $ 2717.41 PPP per patient, which is in line with the results of the studies by Zhdanava et al. (2021) in the United States [33], Tanner et al. (2020) in Canada [34], and Zaprutko et al. (2019) in Poland [35] in terms of the mean cost of the disease.

The results also showed that DMC accounted for the largest share of the total cost of MDD treatment (73.67% of the total cost of the disease), implying that DMC was the most important cost component for the patients with major depressive disorder. Furthermore, the largest share of DMC was related to hoteling and regular beds of these patients (57.70%), which could be due to the high average length of stay (number of hospitalization days), and the cost of service provision per hospital bed in Iran. Pourahmadi et al. (2019) in Iran calculated the economic burden of depression and suggested that hoteling services accounted for the highest cost of the patients (62%) [29], which is consistent with the results of the present study.

Olchanski et al. (2013) examined the economic burden of refractory depression and showed that the disease was associated with significant medical costs per patient due to greater use of care and treatment, and the costs increased significantly with increasing disability. Moreover, DMC was one of the most important cost components for the patients suffering from depression [36]. In Poland, Zaprutko et al. (2019) conducted a study on 548 patients with depression and showed that direct costs accounted for the largest percentage of the costs [35]. In addition, Ruggeri et al. (2022) in Italy studied the patients with depression and stated that direct costs accounted for a high percentage of the total costs [37].

However, Cheng et al. (2012) carried out a study on economic burden of depression in South Korea and found that DMC accounted for the lowest percentage of the total costs. They estimated the total cost of depression at $ 4049 million, of which $ 152.6 million belonged to DMC. On the other hand, the IC was estimated at $ 3880.5 million. They concluded that, especially in terms of disability, depression imposed a significant burden on the society and patients, and societies should strive to increase public health in order to prevent and diagnose depression to ensure that appropriate treatment would be provided. Such measures might lead to a significant reduction in the overall burden of depression [30].

In their study aiming at examining the economic burden of MDD on the adults in the United States from 2005 to 2010, Greenbergh et al. (2015) found that DMC accounted for the lowest percentage of the total economic burden on the adults with major depression, which is not consistent with the results of the present study [38]. This can be due to the provision of more services in outpatient care centers and lower costs of hoteling and hospitalization of the patients in these countries.

The present study also showed that DNMC had the lowest share of the total treatment costs, accounting for 7.53% of the total costs. The results of this study are not consistent with those of Cheng et al. (2012) in South Korea and Tanner et al. (2020) in Canada who concluded that DNMC accounted for the highest percentage of the total costs, and travel expenses accounted for a small share [30, 34]. The reasons for this discrepancy could be the extent to which aids were available to adapt to the environmental conditions at home and work, and the cost of purchasing them varied in the countries under study.

Greenberg et al. (2021) in the United States also found that DNMC accounted for less than 4% of the total costs and therefore, had the lowest share of the costs for MDD patients [39]. The reason for this discrepancy could be the difference in the number of non-native patients in these studies as well as the difference in travel and accommodation costs in the countries studied.

In this study, IC accounted for 18.8% of the total cost of patient treatment, which is in line with the results of the study by Pour Ahmadi et al. (2019) [29].

However, the results of a study by Sobocki et al. (2007) on the economic burden of depression in Sweden from 1997 to 2005 showed that the total cost of depression increased from € 1.7 billion in 1997 to €3.5 billion in 2005. In other words, the economic burden of depression was doubled in the society, while direct costs were relatively stable over time. In 2005, indirect costs accounted for € 3 billion (86% of the total costs), which is inconsistent with the results of the present study, perhaps due to the high daily wages of the patients in these countries [40].

The results of the studies by Cheng et al. (2012) in South Korea [30], Greenberg et al. (2015) in the United States [38], Sobocki et al. (2007) in Sweden [40], and Tanner et al. (2020) in Canada [34] showed that IC accounted for a relatively high percentage of the total costs.

Regarding to increase the prevalence rate in psychiatry disorders and the high cost for their treatment during the last decade, the government should focus on prevention this type of diseases. These diseases have several causes, one of the most important causes is socio-economics problem that need to governments’ effort through programming and problem solving. Also, the ministry of health should foresight the hospital beds and in order to financial protection, health insurance organizations must participate in share of costs greatly.

One limitation of the present study was the self-declaration of the patients or their companions about DNMC and IC, as they were likely to forget or approximate recall some of the costs (recall bias). Another research limitation, defect information in some patients’ medical records including prescribed medicines Furthermore, intangible costs were not calculated in this study due to the impossibility of measuring them accurately.

Moreover, Due to lack of some patients’ income information, we used minimum wages of labor department and for improving the process of cost estimation, the sensitivity analysis was done.

The number of patients was another limitation in finding generalizability. Although, we include almost all patients with major depressive disorder.

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