Considering the personal, societal, and economic toll of treatment-resistant depression, we must make it easier to access medicines and care that provide value, both for the patient and for the health care system.
Depression is the leading cause of disability in the world, with an estimated 17.3 million adults in the United States reporting at least 1 major depressive episode in the past year.1,2 These rates are expected to continue to rise, particularly in light of the extended COVID-19 pandemic and its associated isolation, the stress associated with the fight for social justice, and other political and societal issues plaguing the country.
Major depression can be a debilitating condition with negative consequences across many areas of life. A recent study found that adults with major depressive disorder (MDD) reported lower full-time employment, lower income, lower rates of completing a university education, and higher rates of smoking and alcohol use compared with the general public.3
The Impact of Treatment-Resistant Depression
Among those with major depression, some of the people most negatively affected are those with treatment-resistant depression (TRD), who may be defined as people who have tried at least 2 antidepressants without adequate symptom relief.4 People with TRD experience longer depressive episodes with shorter remission periods compared with non-TRD depressive episodes.5 This means that in addition to the physical and mental toll of TRD, patients must also deal with additional doctor appointments, pharmacy bills, and, in some cases, hospitalizations, leading to nearly twice as much in medical costs compared with others with non–treatment-resistant MDD.6
Untreated or inadequately treated TRD 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 home.7 In fact, all-cause work loss for patients with TRD is twice as high as for those with non–treatment-resistant MDD and three times higher than those without MDD.8
The cost burden isn’t just for patients—the economic burden of MDD on society was most recently reported at an estimated $210.5 billion per year, a 21.5% increase in the United States from 2005 to 2010.9
The acute need to more effectively treat depression is clear, yet access to innovative treatments for people seeking treatment can often feel like an insurmountable burden. The most prevalent barrier to receiving mental health services among patients with severe depression was cost associated with those services.10
Insurance Policies Are Not Designed for Mental Health Care
More than a decade ago, Congress passed a law that required insurance companies to cover mental health services at levels similar to physical health services.11 Yet, today, mental health providers are still reimbursed at lower rates.12 There are also still strict insurance criteria requirements designed to benefit insurance companies, and burdensome prior authorization processes still exist, which delay needed treatment.13
It was recently reported that patients were much more likely to resort to out-of-network providers for mental health treatment than for other conditions.12 This is due to the fact that behavioral health providers are consistently reimbursed at lower rates by insurance companies, so many opt not to participate in insurance plans,14 which makes it more challenging for patients to find the right mental health provider within network. If the provider is out of network, they may not be able to automatically access a patient’s medical records, which adds additional steps for providers and patients to coordinate care.15
Strict stipulations are often in effect for mental health treatments that create barriers to access. These include rigid medical necessity criteria, utilization review, and prior authorization standards for mental health treatments. This can create barriers to mental health services for patients in need.16,17 Across most medical conditions, patients can expect insurance to cover their treatment in a timely fashion, until meaningful recovery is achieved. But because of the high cost of mental health care treatment, insurance companies often have inaccurate definitions of effective and necessary care, making it harder for patients to qualify for coverage. This lowers insurance company costs in the short term,13 but the consequence is that patients have a more difficult time accessing the mental health care they need.
The Real Value of Mental Health
For years, mental health medication value assessments have not adequately accounted for the value that medications bring to individual lives and the overall savings they offer the health care system. Some of the assessments in common use focus overly on the physical health of an individual and therefore are not always appropriate for measuring the quality of life for individuals with mental health problems.18 These kinds of assessments underestimate the true value of proper mental health care, negatively impacting the way insurance companies reimburse treatment. This is a disservice to patients most in need of treatment innovations. For many, the effects of mental illness can be just as serious as the consequences of physical illnesses, yet their ability to afford mental health treatment can often be much more difficult.
Our work at Janssen is focused on assessing the real-world impact of our medicines—both the impact on the individual people who use our medicines, as well as the value to the health care system. When insurers and payers make approval requirements patient centric, holistic, and comprehensive, the results are beneficial 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 on society from depression came from absenteeism (missed days from work) and presenteeism (reduced productivity while at work).9 By treating depression effectively, we see improvements in the level of educational attainment and earning potential, as well as lower unemployment and decreased work disability.19
These are just a few of the examples we believe payers should consider when assessing the value of medications: It should be based on criteria that go beyond medical and pharmacy cost offsets and consider the benefit to patients.
In a world where 1 in 5 Americans struggle with a mental illness,20 we must make it easier to access medicines and care that provide value, both for the patient and for the health care system. This will alleviate health care cost burdens on our system in the long term and, most importantly, will improve the lives of millions around 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 among patients with major depressive disorder: an analysis of healthcare resource use, work 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 evaluation of the treatment journey of patients with major depressive disorder and treatment-resistant depression. PLoS One. 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 treatment-resistant and non-treatment-resistant major depressive disorder. Curr Med Res Opin. 2010;26(10):2475-2484. doi:10.1185/03007995.2010.517716
7. Hofmann SG, Curtiss J, Carpenter JK, Kind S. Effect of treatments for depression on quality of life: a meta-analysis. Cogn Behav Ther. 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 U.S. patients with physical conditions. 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. Access and cost barriers to 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. Addiction and mental health vs. physical health disparities in network use and provider reimbursement. Milliman. 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 you’re denied care by your insurance. 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-Denied-Care-By-Your-Insurance
15. What’s 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. Clinical necessity guidelines for psychotherapy, insurance medical necessity and utilization review protocols, and mental health parity. J Psychiatr Pract. 2018;24(3):179-193. doi:10.1097/PRA.0000000000000309
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. Psychiatr 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