Improving Access to Alternative Therapies for Treatment Resistant Depression - Episode 4
Dr Samuel Nordberg and Carrie Jardine discuss barriers to accessing care for patients with TRD and provide insight on addressing these concerns to achieve optimal care.
Steve Levine, MD: When you talk about the third, fourth, or fifth attempted treatment—you also mentioned the use of algorithms—it makes me think about the STAR*D study. Dr Ares-Romero, can you talk a little about that study and the implications, what we learned from that?
Patricia Ares-Romero, MD, FASAM: Sure. It was an attempt by the NIMH [National Institute of Mental Health] to find out how many treatments patients need in order to get better. What are the outcomes? That’s what the STAR*D study was. It took over 4000 patients in an outpatient setting with depression and they wanted to see what the alternatives were. They found that the more chronic the patient was or the longer the illness was, the longer and poorer the outcome was. The cumulative remission rate after 2 treatments was only 50%, or 1 out of every 2 patients. If you did 4 different treatments, the remission rate was 67%, which isn’t much more improvement. We have patients who have gone through these 4 treatments and still haven’t had full remission of their symptoms. That’s where other alternatives come into play. What else can we do for our patients who shouldn’t have to live with depression day in and day out?
Steve Levine, MD: And we’d all agree that those are the outcomes under a best-case scenario. This is within a research study. This is optimal care, and those are still the outcomes we see, clearly underscoring a big unmet need.
Patricia Ares-Romero, MD, FASAM: The other thing that we also need to consider is that if you look at studies and try to do a meta-analysis of the studies, what is TRD [treatment-resistant depression]? I don’t think we’re capturing that. We need a true definition. Yes, more than 2 trials, but some people might consider 3 or 4 trials. We’re not capturing that. It’s the same as in the claims data that Dr Nordberg spoke about. We’re not coding for TRD. We’re coding for depression. There are a lot of gaps that we don’t know about. I’d venture to say that we have a lot more untreated depression and treatment-resistant depression than we think.
Steve Levine, MD: That touches upon what Dr Nordberg said earlier about identifying TRD within claims. One of the difficulties there is that we don’t code for it. Dr Nordberg, you also talked about if patients can get the care, an allusion to access. Can you talk about some of the barriers to access you see, whether it’s things like prior authorizations or step edits or whatever comes to mind?
Samuel Nordberg, PhD: We’re in Massachusetts, which has the best ratio of licensed mental health providers to the population of any state in the country. Broadly, we have a very good lens on the total scope of behavioral health challenge within Reliant patients because we triage and assess so many of our primary care patients. Our greatest challenge is that at any given time, we’ve got 3000 patients on a waitlist for care in the community. One of the principal challenges is that there’s a resource constraint that generally cuts across all aspects of treatment. That resource constraint exists for other treatments, like ECT [electroconvulsive therapy] and things that we might want to channel patients directly into.
That’s 1 real challenge that exists. Even if we’re able to navigate all of the authorization barriers and things like that, there just aren’t enough resources out there. At Reliant, we have 6 full-time referral managers. All they do is try to connect patients with care. If you’re more poorly resourced than that, your job is even harder.
The other thing is that there is a continuum of the level of depression and the amount of responsibility that somebody can take for their own care versus the amount of responsibility that an organization needs to shoulder. One barrier that we don’t talk about very often is that we often might tell a patient, “Here’s a phone number, Give them a call,” when the likelihood that that’s going to happen is extremely low. Another barrier is looking at when the organization needs to own responsibility for connecting that patient with care and shepherding them to care. Even when we make appointments, we see a lot of patients who fail to show up for those appointments, which is a huge problem, especially when those appointments are in very rare supply.
Another barrier that we see is transportation. Transportation is a challenge, particularly for some of our patients who have other challenges related to social determinants, which we’ll get to later. Transportation is often one of those things where even when you make the appointment, a patient fails to get there. I’m going to let Carrie speak with a bit more authority to some of the authorization and bureaucratic-related things, but these are some of the principal barriers that prevent our patients from getting connected with care. It’s either that there isn’t enough of it out there or that patients don’t have the wherewithal to actually connect with care in the way that it’s being offered.
Steven Levine, MD: Those are important points. Over to you, Ms Jardine.
Carrie Jardine: Thank you very much. Thank you for having me. Dr Nordberg, you are so correct. There are a lot of things that we can do to help the patient through the process in regard to education and knowing the policies of the different payers for the patients so that we can help them navigate what the step therapy requirements may be. If they qualify or don’t qualify, we can help get them over that hurdle. It’s important to be the advocate for the patient in regard to the prior authorization process, which can be lengthy and a bit difficult if we haven’t been treating the patient in the past.
With the area that we’re treating in Austin, Texas, we’re seeing a lot of patients who are new transplants to the area. It’s growing, so we’re seeing a lot of patients who are coming from out of state. Getting medical records from previous doctors can be difficult. We don’t necessarily have all of the information at hand that carriers need in order to necessitate and show that this is a medically necessary treatment for the patient. Unfortunately, by the time the patients get to us, they’re desperate. They needed this treatment yesterday. We need to keep them in the loop. We have to play that middleman and that patient advocate to let them know what’s going on. Every step of the way, we have to let them know what’s going on so that we can get them the treatment that they need.
Transcript Edited for Clarity