Depression a costly burden for older adults with chronic diseases in Singapore

In Singapore, depression pushes up healthcare spending by twofold among older adults already struggling with chronic illnesses, according to a study.

Survey data from the Well-being of the Singapore Elderly (WiSE) study showed that for annual total healthcare expenditure, the average incremental cost of chronic diseases alone was SGD 3,780 (p<0.001), while that of depression alone was SGD 1,480 (p=0.214). When chronic diseases were coupled with depression, the average incremental cost was doubled at SGD 7,940 (p=0.016), exceeding the sum of the costs associated with each condition individually (SGD 5,260). [BMC Public Health 2024;24:3119]

Depression and chronic diseases combined were also associated with significant incremental costs for primary care (SGD 257, p=0.021) and for specialist outpatient clinics (SGD 970, p=0.018). Meanwhile, the average incremental cost for inpatient care was not significant (SGD 6,180; p=0.066).

Older adults with depression and chronic diseases incurred an annual productivity loss of SGD 676 (p<0.001).

Depression underdiagnosed

“Excess cost with depression and chronic diseases in the inpatient setting was not statistically significant, which was consistent with previous studies in the US, where depression had no significant effect on the frequency of hospital admission or length of stay,” the investigators noted. [Am J Geriatric Psychiatry 2001;9:169-176; Int J Psychiatry Med 2000;30:1-13]

In primary care settings, on the other hand, a key factor contributing to the elevated healthcare costs associated with comorbidity between chronic diseases and depression among older adults is underdiagnosis of depression, they said.

Studies consistently demonstrate that older patients with depression present with a significantly higher frequency of nonspecific somatic complaints, such as fatigue, dizziness, headache, and pain, compared with their nondepressed counterparts. Unfortunately, depression frequently goes undetected in primary care settings, with studies indicating that as many as half of all depressed patients remain undiagnosed. [Am J Geriatric Psychiatry 2001;9:169-176; Arch Gen Psychiatry 1992;49:91-100; Am J Psychiatry 1995;152:352-357; Psychiatr Serv 1997;48:59-64]

The investigators pointed out that the underdiagnosis of depression, along with the associated somatic symptom burden, can lead to increased healthcare use and, in turn, higher expenditure.

“As the first point of contact in our healthcare system, it is recommended that physicians actively look out for nonspecific complaints associated with depression, especially among older adults with multiple comorbidities so appropriate treatment can be introduced promptly, abating the rising costs,” they said.

Study details

A total of 2,510 survey respondents (56 percent female) at least 60 years of age were included in the study. Of the respondents, 35.5 percent had chronic diseases and 3.7 percent had depression. The respondents were grouped into four: no depression and no chronic diseases (reference group); no depression and had chronic diseases; had depression and no chronic diseases; had both depression and chronic diseases.

“As Singapore’s population ages, the incremental cost associated with depression among the older adults with chronic diseases will begin to impose increasing pressure on the healthcare system, thereby inflating healthcare costs,” the investigators said. “Thus, there is a pressing need to prioritize the capabilities of the healthcare system to manage depression among older adults in Singapore.”