The impact of treatment-resistant depression
Among people with major depression, some of those most affected are those with treatment-resistant depression (TRD), which can be defined as people who have tried at least 2 antidepressants without adequate symptom relief.4 People with DRT experience longer depressive episodes with shorter periods of remission compared to depressive episodes without DRT.5 This means that in addition to the physical and mental toll of DRT, patients also have to deal with additional medical appointments, pharmacy bills, and in some cases hospitalizations, resulting in almost twice as much medical costs. higher than the others without treatment. -MDD resistant.6
Untreated or undertreated DRT also has a significant impact on quality of life, including challenges with daily functionality like social and family relationships and difficulty functioning at work and at home.7 In fact, all-cause loss of work for patients with TDR is twice as high as for those with untreatment-resistant MDD and three times as high as for those without MDD.8
The cost burden isn’t just on patients – the economic burden of MDD on society has recently been reported to be around $ 210.5 billion per year, a 21.5% increase in the United States from 2005 to 2010.9
The acute need to treat depression more effectively is clear, but accessing innovative treatments for those seeking treatment can often seem like an insurmountable burden. The most common barrier to receiving mental health services in patients with severe depression was the cost associated with these services.ten
Insurance policies are not designed for mental health care
More than ten years ago, Congress passed a law requiring insurance companies to cover mental health services at levels similar to physical health services.11 Yet today, mental health care providers are still reimbursed at lower rates.12 There are also strict insurance criteria requirements designed to benefit insurance companies, and binding pre-authorization processes still exist, delaying necessary processing.13
It was recently reported that patients were much more likely to seek out-of-network providers for mental health treatment than for other conditions.12 This is because behavioral health care providers are routinely reimbursed at lower rates by insurance companies, so that many choose not to participate in insurance plans,14 which makes it more difficult for patients to find the right mental health care provider within the network. If the provider is off-network, they may not be able to automatically access a patient’s medical records, adding additional steps for providers and patients to coordinate care.15
Strict provisions are often in place for mental health treatments that create barriers to access. These include rigid medical necessity criteria, a review of use, and pre-authorization standards for mental health treatments. This can create barriers to mental health services for patients in need.16.17 In most medical conditions, patients can expect insurance to cover their treatment in a timely manner, until significant recovery is achieved. But due to the high cost of mental health care, insurance companies often have inaccurate definitions of effective and necessary care, making it more difficult for patients to qualify for coverage. This reduces the costs of insurance companies in the short term,13 but the consequence is that patients have more difficulty accessing the mental health care they need.
The real value of mental health
For years, assessments of the value of drugs to mental health did not sufficiently take into account the value that drugs bring to the lives of individuals and the overall savings they provide to the health care system. Some of the commonly used assessments focus excessively on a person’s physical health and therefore are not always appropriate for measuring the quality of life of people with mental health problems.18 These types of assessments underestimate the true value of appropriate mental health care, which has a negative impact on how insurance companies reimburse for treatment. It is a disservice to the patients who are most in need of therapeutic innovations. For many, the effects of mental illness can be just as severe as the consequences of physical illnesses, but their ability to afford mental health treatment can often be much more difficult.
Our work at Janssen is focused on assessing the real impact of our medicines, both the impact on the people who use our medicines, as well as the value to the healthcare system. When insurers and payers make approval requirements patient-centered, holistic, and comprehensive, the results are good not only for the patient, but for society as a whole.
A study published in the Journal of Clinical Psychiatry found that the bulk of the economic toll of depression on society came from absenteeism (missed work days) and presenteeism (reduced productivity at work).9 By effectively treating depression, we see improvements in educational attainment and earning potential, as well as lower unemployment and reduced work incapacity.19
These are just a few examples that we think payers should consider when assessing drug value: It should be based on criteria that go beyond medical and drug cost offsets and take into account benefits for patients.
In a world where 1 in 5 Americans struggle with mental illness,20 we must facilitate access to drugs and care that provide value, both for the patient and for the health system. This will ease the burden of healthcare costs on our system in the long run and, most importantly, improve the lives of millions of people across the country.
1. Major depression. National Institute of Mental Health. Accessed September 16, 2021. https://www.nimh.nih.gov/health/statistics/major-depression
2. Depression. World Health Organization. September 13, 2021. Accessed September 16, 2021. https://www.who.int/news-room/fact-sheets/detail/depression
3. Chow W, Doane MJ, Sheehan J, et al. Economic Burden in Patients with Major Depressive Disorder: An Analysis of Health Resource Use, Labor Productivity, and Direct and Indirect Costs by Depression Severity. The American Journal of Managed Care®. February 14, 2019. Accessed September 16, 2021. https://www.ajmc.com/view/economic-burden-mdd
4. Gaynes BN, Asher G, Gartlehner G, et al. Definition of Treatment-Resistant Depression in the Medicare Population. CMS. February 9, 2018. Accessed June 7, 2021. https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id105TA.pdf
5. Wu B, Cai Q, Sheehan JJ, Benson C, Connolly N, Alphs L. An episode-level assessment of the treatment course of patients with major depressive disorder and treatment-resistant depression. PLoS A. 2019; 14 (8): e0220763. doi: 10.1371 / journal.pone.0220763
6. Ivanova JI, Birnbaum HG, Kidolezi Y, et al. Direct and indirect costs of employees with a major depressive disorder resistant or not to treatment. Curr Med Res Opin. 2010; 26 (10): 2475-2484. doi: 10.1185 / 03007995.200.517716
7. Hofmann SG, Curtiss J, Carpenter JK, Kind S. Effect of treatments for depression on quality of life: a meta-analysis. Cogn behaves. 2017; 46 (4): 265-286. doi: 10.1080 / 16506073.2017.1304445
8. Zhdanava M, Kuvadia H, Joshi K, et al. Economic burden of treatment-resistant depression in privately insured US patients with physical problems. J Manag Care Spec Pharm. 2020; 26 (8): 996-1007. doi: 10.18553 / jmcp.2020.20017
9. Greenberg PE, Fournier AA, Sisitsky T, Pike CT, Kessler RC. The economic burden of adults with major depressive disorder in the United States (2005 and 2010). J Clin Psychiatry. 2015; 76 (2): 155-162. doi: 10.4088 / JCP.14m09298
10. Rowan K, McAlpine DD, Blewett LA. Barriers to Access and Cost of Mental Health Care, by Insurance Status, 1999-2010. Health Aff (Millwood). 2013; 32 (10): 1723-1730. doi: 10.1377 / hlthaff.2013.0133
11. The Mental Health Parity and Addiction Equity Act (MHPAEA). CMS. Accessed September 16, 2021. https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet
12. Melek S, Davenport S, Gray TJ. The disparities between drug addiction and mental health compared to physical health in the use of the network and the reimbursement of providers. Milleman. https://www.milliman.com/-/media/milliman/importedfiles/ektron/addictionandmentalhealthvsphysicalhealthwideningdisparitiesinnetworkuseandproviderreimbursement.ashx
13. Pelech D, Hayford T. Medicare Advantage and Commercial Prices for Mental Health Services. Health Aff (Millwood). 2019: 38 (2): 262-267. doi: 10.1377 / hlthaff.2018.05226
14. What to do if your insurance denies you treatment. National Alliance on Mental Illness. Accessed May 12, 2021. https://www.nami.org/Your-Journey/Living-with-a-Mental-Health-Condition/Understanding-Health-Insurance/What-to-Do-If-You-re- Refused-of-care-by-your-insurance
15. What is in my electronic health record (EHR) and who can access it? Health champion. June 18, 2019. Accessed June 17, 2021. https://myhealthchampion.com/whats-in-my-electronic-health-record-ehr-and-who-can-access-it/
16. Becker J, Accordino R, Hazen E. Prioritizing the elimination of prior authorizations for inpatient psychiatric care. Health affairs. October 23, 2020. Accessed May 12, 2021. https://www.healthaffairs.org/do/10.1377/hblog20201020.957372/full/
17. Lazar SG, Bendat M, Gabbard G, et al. Guidelines on clinical necessity for psychotherapy, protocols for examining medical necessity and insurance use, and mental health parity. J Psychiatrist Pract. 2018; 24 (3): 179-193. doi: 10.1097 / PRA.00000000000000309
18. Connell J, O’Cathain A, Brazier J. Measuring quality of life in mental health: Are we asking the right questions? Soc Sci Med. 2014; 120: 12-20. doi: 10.1016 / j.socscimed.2014.08.026
19. Kessler RC. The costs of depression. Psychiatrist Clin North Am. 2012; 35 (1): 1-14. doi: 10.1016 / j.psc.2011.11.005
20. Mental illness. National Institute of Mental Health. Accessed May 17, 2021. https://www.nimh.nih.gov/health/statistics/mental-illness