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Jaime is a freelance writer for The American Journal of Managed Care® (AJMC®), where she previously worked as an assistant editor.

She has a BA in print journalism from Penn State University. You can connect with Jaime on 

Articles

With greater attention being paid to the heterogenous patient population, researchers questioned whether this has resulted in a more diverse group of patients included in Parkinson disease (PD) studies in the Netherlands.


Certain Patient Groups Continue to Be Underrepresented in PD Studies in the Netherlands

Matthew is an associate editor for The American Journal of Managed Care® (AJMC®). He joined AJMC® in 2019 and creates content for 

, a 24-hour online program developed MJH Life Sciences® focusing on pressing topics within managed care, as well as the nonwork-related activities of health care stakeholders.

He has a BA in journalism & media studies and economics from Rutgers University. You can connect with Matthew on 

Vaccination was shown to lower risk of developing severe COVID-19 in both variants, with the largest difference in risk observed in patients aged 40 to 59 years.

Lower Risk of Severe COVID-19 Associated With Omicron vs Delta Variant

Rose is a freelance writer for The American Journal of Managed Care® (AJMC®), where she previously worked as an editor.

She has a BA in journalism & media studies and Spanish from Rutgers University. You can connect with Rose on 

A novel test developed at Cedars-Sinai Medical Center was able to detect and characterize even microscopic amounts of prostate cancers and could potentially help individualize treatment in the clinical setting. 

Novel Assay Detects and Characterizes Even Microscopic Prostate Cancers

Jared is a freelance writer for The American Journal of Managed Care® (AJMC®), and previously worked as a senior editor for HCPLive® at MJH Life Sciences®.

He has an MA from University of Sioux Falls. You can connect with Jared on 

A study attempted to see how symptoms affect quality of life after adjusting for confounding factors.

Common PsA Symptoms Negatively Impact Quality of Life

The American Journal of Managed Care provides insights into the latest news and research in managed care across multimedia platforms.

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Compendium

The top 5 most-read articles on major depressive disorder (MDD) in 2022 discussed US treatment updates, drug assistance in talk therapy, further exploration of transcranial magnetic stimulation’s capabilities, and screening improvements and outcomes.

Having Lower Personal Reserve Predicts Sustained Remission of Major Depression

While the combination improved multiple depression scores, patients receiving both therapies did have more adverse events than those in control groups, the meta-analysis found.


Analysis Finds Efficacy in Combining Esketamine With Antidepressants

Data from the study lend support for the need for improved global health policies related to adolescent mental health, a new study finds. 

Mental Health Hospitalizations Among Adolescents in the US, France Rose During the Pandemic 

The changing landscape of health care during COVID-19 placed focus on increasing accessibility to mental health resources other than the emergency department (ED), with potential savings of over $4 billion in annual costs and improvements in patient outcomes. 

Reducing “Avoidable” ED Visits for Mental Health Could Cut Billions in Costs, Improve Patient Outcomes

 There are many contributors to long-term outcomes in members with MDD [major depressive disorder], and it spans social determinants of health. It spans access to high-quality care. [One contributor is] finding the right provider or therapist that works for them. Often, this is very individualized. Ensuring they have access to medications that they can afford and that they can be adherent on [is also important]. This often is a tricky balance of adverse effect vs effect. Finding the right medication can take time. That’s a key component to long-term adherence. [Another contributor is] that peer support group, which decreases the stigma of any mental health disorder, MDD specifically. The long-term outcomes encompass the entire ecosystem that a patient is in, whether it’s socially, at home, in their work environment, with their providers, or with the access to medication and treatments that they have.

 The background efficacy rates of the therapies are key to that long-term outcome improvement. There’s a gap. Some of these therapies still don’t work for a number of folks, despite being very helpful for the people they do help. That’s a key driver, along with all the comments made around access to the right providers and the right care are additional contributors to long-term outcomes. [It’s important to have] continuity of care between all those and the ability to connect the different pieces to the provider at the right time—data, information about the patient’s status, the plan, and the plan’s ability to follow up with the person and make sure they’re going to continue to seek care as they’re doing poorly and need advanced care, or doing better and need follow-up care. There’s a lot of opportunity in this space.

In closing, despite being a plan administrator, I’m first and foremost a health care provider and a human. Providing hope for people often isn’t seen as [important] as it is in this disease. Many people with this disorder sometimes consider ending their life because of the symptoms of the disease. Providing people with some type of hope to continue moving forward and working through their illness is pretty fundamental to us and to our existence.

Videos

Drs Chitre and Weaver share their finals thoughts, highlighting key contributors to long-term outcomes for patients with major depressive disorder.

Video Series

Key Contributors to Long-term Outcomes for Patients With MDD

 Because MDD [major depressive disorder] is a symptomatic disease with such an impact on quality of life, the goal is to have early, effective treatment as quickly as possible. That enables the patient to feel improvement from the condition and supports treatment adherence. Treatment is often customized and specific for the patient, but if we can have early, effective treatment, there’s a whole host of downstream improvements around overall improvement of health that our members will benefit from. That’s always a goal in treating this condition.

 One of the main contributors to outcomes is how quickly we begin to see a response in someone. As we talked about before, these medications have a downstream effect on neurotransmitters both up- and downregulating different parts of that process. It can take time to achieve. During that time, as the time wears on and people aren’t getting relief, they begin to withdraw more. They’re less committed to care. We lose them to follow-up. There are all sorts of things that happen over that time, so a key contributor is finding the effective therapy fast or, if it’s not going to work, moving them quickly onto another therapy that could work for them. For a multitude of reasons, that’s the key driver to be able to move forward with these therapies.

Early effective treatment strategies can have a significant impact on long-term effects for patients with MDD.

The Impact of Early Effective Treatment in MDD

 I think about our goals of therapy in several domains. First is the clinical domain. Our goal is to reach the most rapid remission and potentially cure the condition. Some people receiving medications that are effective quickly and behavioral cognitive services can find themselves without symptoms, and they eventually may be able to discontinue therapy. There’s a set of clinical goals.

We also know that with depression and other chronic disease, management—such as diabetes management—often goes hand in hand. As people do more poorly with their diabetes, their depression gets worse. Or when they’re depressed and have trouble committing to and engaging in therapy, they do more poorly with their diabetes. That’s our clinical sphere of things. Second is some financially oriented goals around reducing cost of care. We think of ourselves as a fiduciary working on behalf of employer groups, hopefully reducing the number of admissions for major depressive disorder [MDD] in patient stays and reducing the number of other services needed because of poor outcomes. Those are goals.

The third set of goals are employer focused. Many people are buying group benefits on behalf of their employees. Think about the workforce shortage we have at the moment coming out of COVID-19 and the great resignation. Many of my employers say, “We don’t have enough staff to do all the work. We have disability. We have people missing work or at work but not working very well because they’re ill.” They call that presenteeism. Absenteeism and presenteeism have a real impact, especially today. For many years in benefits, we’ve talked about this as a consideration. It has only recently become super important because this is having a financial impact on the businesses buying these benefits.

Lastly, I think about the patient-oriented goals, which could be their quality of life, as Dr Chitre pointed out. It could be the ability to engage in family activities or other things that they want to do. Their depression has kept them withdrawn from things that they love. We’re bringing that holistic set of goals together—many times those things are aligned—and hopefully align the plan, the member, and the provider to achieve good things.

 Our goals with MDD therapy are similar to the goals I previously commented on: to provide access to high-quality, affordable care. This includes working through the care continuum and ensuring patients find the right provider, have access to the therapies that are right for them, and have the tools they need to be adherent. One other thing we focus on is the stigma, ensuring that mental health is as focused on physical health, and that our members have tools and are having these conversations with their peers, their support group, and their family members.

Whether it’s MDD or a different disease state, we want to encompass a member from the global population perspective all the way to what their questions may be to support them through their care journey of access to affordable, high-quality care so they can stay on therapy, follow up with their physician, get their questions answered, and have a good quality of life.

Drs Weaver and Chitre discuss aligning key considerations for payers and goals of therapy for patients in the treatment of MDD.

Aligning MDD Treatment Goals for Payers and Patients

 Our plan has taken efforts to implement pharmaceutical care programs that seek to identify members with poor adherence through calculations, such as their MPRs [medication possession ratio] or PDCs [proportion of days covered], to say, “These look like folks who are at risk of not taking a medication enough to get efficacy.” We’ve created a set of cognitive services provided by nurses and pharmacists to do outreach to members who seem to be at risk. Or when a member is calling us around a particular concern that they have, such as about their medical benefits, we can flag that person. That way, when they call us, we can say, “We also have something to address about your medication. Can you speak to one of our nurses or pharmacists?” depending on the level of medication complexity we’re dealing with.

As you can imagine, nurses are very qualified to speak to people about their motivations of taking medication to clarify information about medications and all that. Those are great resources. They’re used to engaging members very often around these things. For very complex pharmaceutical issues—maybe the person has 5, 7, or 10 medications, and they aren’t sure which medications are causing a certain adverse effect, or they’re concerned about the cost—we have pharmacists available to help sort through drug regimen reviews and help solve those problems for them.

 We take a number of strategies to improve adherence. Our philosophy is to ensure we provide access to high-quality, affordable care for our communities. Specifically in the MDD [major depressive disorder] population, we work across the continuum across every stakeholder in health care to ensure adherence. We start with the members. We provide them support services and ensure they know what to expect from their health care system. They know the questions to ask and the outcomes they should expect.

We work with clinicians and provide data and information related to treatment options. We also work with them around specific data points that might be helpful. We work with our employers, ensuring that they provide access to critical components around the mental health spectrum and care delivery. Across our communities, we work to ensure there’s visibility to the services and programs we offer that can deliver on our goal: providing access to high-quality health care. We do this at the macro level from a data and population health perspective and then at the member level through care management outreach, pharmacy outreach, and awareness, where our providers and members know they can call us directly.

Drs Weaver and Chitre share strategies to support MDD treatment adherence across their patient populations.

Supporting Adherence for Patients with MDD

 One of the especially troublesome adverse effects from our core therapy for MDD [major depressive disorder], SSRIs [selective serotonin reuptake inhibitors], and SNRIs [serotonin-norepinephrine reuptake inhibitors], are sexual adverse effects. These affect joy in their life or a connection point with a partner. We’re giving them therapy that in many cases may impede that. That’s a challenge. That’s 1 piece.

Another finer point is that even as people begin to understand that these treatments take a long time to work, we find that there’s a background rate of inefficacy among many therapies, such that by waiting 8 or 12 weeks or beyond, the therapy isn’t doing much good. People tend to abandon a therapy that isn’t working for them, especially in the face of those adverse effects we spoke of. There are a number of challenges in this space. Fortunately, some of the therapies are affordable. They’re inexpensive. As we move to newer generations, some of the older therapies are much more costly, but there are affordable therapies. But oftentimes, people need to go through several therapies to find one that works for them and that they can tolerate. It isn’t an easy disease to treat and to titrate for.

 Treatment adherence is basically taking a medication as prescribed by your health care provider for the duration of time. In the mental health space, specifically in MDD, treatment adherence is so important because it takes 6 to 8 weeks for a medication to work. In that time, before the medication works, often patients experience adverse effects. They can include weight gain, weight loss, and fatigue. It can feel like worsening of your MDD symptoms.

It’s important to talk with your provider and pharmacist about what you’re experiencing. Will the adverse effects go away with time? Many will. Will adverse effects require a change in medication or a change in dose? Adherence in MDD is critically important. Some of the challenges of adherence are balancing safety and effectiveness. The nice thing is there are many treatment options available. We can take the time to tailor the right medication to the right patient. Then there are other barriers that we see commonly: the price of medications, remembering to take the medication, access to medications, and access to follow-up. Adherence is critically important to MDD because this is a symptomatic condition, and with adherence, we can help the health and well-being of our patients and members.

Expert panelists consider factors affecting treatment adherence for patients with MDD.

Factors Affecting MDD Treatment Adherence

 In our population of health space, we have some specialized mental health services. We have counselors, case and care managers, within our suite. Those folks can engage members and help them navigate care. They aren’t there to deliver counseling as much as they are to help facilitate care, get people to the right type of provider, and work through the challenges they may have with their mental health disease.

We also provide specialized services around pharmacy-based population health. When folks have a diagnosis, such as MDD [major depressive disorder], and the lack of a treatment, it might help us to understand their barriers to taking their medication. Do they just discontinue the therapy? Are they getting it through a different channel? Do they have a misunderstanding about the treatment? We have specialized pharmaceutical-based population health services to align with this disorder.

 Some of our population health approaches are from the macro level to the micro level. From the broadest level, we want to decrease the stigma around mental health. Mental health care is as important as physical health care. We’re disseminating this message to our members, providers, and employer groups. We’re starting at the very top of what mental health is and how important it is to be treated.

Second, as Dr Weaver indicated, we’re expanding our clinician base, including telehealth specialists, to enable our members to access care in a space where they feel comfortable and that’s convenient for them. Third, we’re using our data to identify gaps in care, noncompliance, and support our providers in ways that they perhaps weren’t supported before. We’re also starting to look at racial and ethnic data to understand what disparities may exist so that we can close gaps and reduce barriers.

From a member perspective, we’re looking to empower, inform, and educate our members. An educated and empowered member knows what to expect from the health care system and ensures that they get the care they need. Finally, with our case managers team along with our pharmacists, we’re starting to work with community-based organizations. [We have our] feet on the street at the ground level to address any barriers or gaps that may exist across all our populations.

Drs Weaver and Chitre illustrate a population health approach strategy for MDD.

Population Health Approach in MDD

 Every social determinant of health has the impact and the potential to exacerbate MDD [major depressive disorder]. MDD and social determinants of health have a unique relationship. Social determinants of health can trigger mental health disorders, and mental health disorders can cause someone to make poor life decisions that trigger social determinants of health.

Let’s talk about social determinants of health. I often say it’s anything in your environment that can enable you to thrive, be well, or see a positive future. In the mental health arena, some pop up frequently. In no particular order, one is safe housing. Is there a safe housing option for our members? Are they in a safe community? Are they free of trauma and stress? Food and transportation are some basics. Do they know where their next meal is going to come from? Do they have access to a physician’s office or a pharmacy? Income level is another. Income level has many triggers toward health care disparities in general. It affects health care literacy, access to care, and access to treatment. Is their job secure? Is it a toxic environment? Is it safe? Family relationships [are another factor]. That’s just to name a few. Is there a family support group? Any social determinant of health can trigger a mental health challenge, a mental health crisis, or a mental health disorder.

 I have to agree with Dr Chitre. Most of the things she outlined were spot on. The only thing I’d add would be some of the nutritional challenges. We’re coming to understand that there’s a link between the foods that we eat and have access to and our sense of well-being. Things like high-calorie foods and high-carbohydrate foods are typically less expensive than higher-quality foods. We also know that the amounts of sugar and other things in those foods can affect our mental well-being. Sometimes food insecurity plays into major depressive disorder in ways that we don’t fully understand.

Key social determinants of health impacting MDD are discussed by expert payer panelists.

Social Determinants of Health in MDD: Part 2

 As we looked across our populations most affected by disparities of care in major depressive disorder, we noticed that 1 population had more isolation and maybe more limited access to care: persons of Medicare age. Some of our older populations have fewer people in their home or fewer people to care for them. That was 1 group that we noticed had some challenges. As we spoke about before, people of color also presented with especially big challenges in getting access to care and seeking care. The third population that we noticed had fewer specialized services available to them were some of our LGBTQ [lesbian, gay, bisexual, transgender, questioning] populations. They had a lack of specialized services for some of the things that they’re dealing with as they’re seeking health care services and finding people who can relate to their needs.

 I agree with Dr Weaver. There are a number of populations that have different and pronounced effects because they have different types of diagnosis, lack of access, and no clear treatment plan. There are differences in how they may be treated. I agree with Dr Weaver’s comments. The Black and brown populations, our pediatric patients, and sometimes our female patients all have disparities. We’re always looking at that from both a population perspective and a health plan perspective, ensuring equal treatment and trying to close some of those disparities.

Drs Chitre and Weaver explore social and health care disparities more prominently affecting various MDD patient populations.