Optimizing the Management of TRD

EP: 1.Defining and Recognizing Treatment-Resistant Depression (TRD)

EP: 2.Risk Factors for TRD and Payer Considerations

EP: 3.Approaching Patient Identification for Alternative Therapies for TRD

EP: 4.Patient Barriers to Access Treatment for TRD

EP: 5.Defining Value for TRD Treatment Options

EP: 6.Effective Care Delivery for TRD

EP: 7.Alternative Treatment Options for TRD

EP: 8.Risk Evaluation and Mitigation Strategies for Intranasal Esketamine in TRD

EP: 9.Benefit Design and Overcoming Barriers to Access for Alternative Therapies in TRD

EP: 10.Understanding Billing and Coding for Alternative Therapies in TRD

EP: 11.Navigating Payer Policies for Alternative Therapies in TRD

EP: 12.Integrated Policymaking and Measuring Patient Outcomes in TRD

EP: 13.Payer Strategies to Reduce Delay to TRD Therapy

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EP: 14.Optimizing the Management of TRD

Steven Levine, MD: Before we conclude, I’d like to get some final thoughts from each of you, if you have any. Let’s start with you, Dr Nordberg.

Samuel Nordberg, PhD: From my perspective, treatment-resistant depression and other complex mental health challenges are systems challenges as much as they are clinical challenges. We haven’t moved the needle in treatment effectiveness in about 50 years, and in no small respect that may be because we haven’t changed our systems that provide care. I’m a big fan of looking at developing systems where we’re doing a lot more precision referral work, and to Martin’s earlier point, identifying different providers, clinics, and centers of strength, and referring to strengths. The only way to do that is to collect the data.

There are challenges around collecting the data. It creates vulnerability and a lot of visibility where there hasn’t been historically. One of the things that we’re working on at Reliant Medical Group is trying to be more precise about how and who we refer. A lot of that involves understanding the patient that we’re being presented with, and also understanding how that person matches up with what we believe is the most likely treatment to be effective for them based on data.

I’m pretty confident that if we can do that work in naturalistic settings, we’ll get past the archaic requirement of failing 2 bonafide medication interventions and get more rapidly to something that’s going to allow a care delivery organization to say, “This is a patient with treatment-resistant depression,” and a payer to say “No problem,” and then allows that care delivery organization to connect that patient with a reimbursed intervention that has a likely shot of helping them. That’s a lot of work to be done, but it starts with measurement and having the confidence to integrate that measurement into your clinical routine.

Steven Levine, MD: Well said. To your original point, we haven’t moved the needle much in these past 50 years. You’re calling for improved systems, better measurement, and moving toward precision care. Hopefully that will be supported by the validation of some biomarkers that can lead to more precise and predictive treatments. Would you also agree that part of this as well is that we haven’t had very many new tools in the past 50 years, and potentially having some effective new tools in the toolbox may also help move that needle?

Samuel Nordberg, PhD: It may. We also know that there’s a lot of variability between different providers and that there are different kinds of treatments that appeal more to different kinds of patients. The biomarker research is sexy and exciting because of that possibility of carving nature at its joints and being precise. It’s also a long way off. RDoC [Research Domain Criteria] didn’t deliver the promise of precision opportunities for understanding and deep learning about what drives mental health on a physiological level.

We still have a lot of opportunities with the systems and treatments that are already out there. This system still has a lot of room for optimization. It starts with having the courage to collect more data and letting those data start to tell us what kind of a patient this is and the best place for the patient to go based on what we’ve already learned about similar patients. That’s where my focus is, less so on developing novel interventions. It’s important to figure out where the patients that we’ve been discussing fit in that overall model, but we’re not going to be able to figure that out if we’re not collecting the right data.

Steven Levine, MD: Ms Jardine, final thoughts from you.

Carrie Jardine: For those of us who deal with the fun stuff, the insurance and billing portion of things, like I’ve been saying this whole time, it’s important to make sure that you understand your payers and their guidelines and policies. You have to play that middleman role between the insurance carriers, providers, and patients. We need to make sure that we’re educating our providers so that they know if there are any changes to these policies so that they can find the right fit for patients.

It’s also important to educate the patients in regard to what qualifies them as having treatment-resistant depression and what’s available out there. Be an advocate for the patient with the payer and keep them involved in the process so that they’re not at home wondering, “What’s going on with my prior authorization? When is my treatment going to start?” Let them know everything along the way and be there for them.

Steven Levine, MD: Thank you, Carrie. Dr Rosenzweig?

Martin Rosenzweig, MD: The theme that I’d leave with is the idea of “better together.” If you think about it, there are 3 participants in the goal here. Front and foremost is the patient because they want to get better. They’re suffering. There’s the provider who’s trying their best to figure out the appropriate care. There’s also the payer who wants to make sure that the patient gets access to the benefit that they deserve and that they’re able to go on and live a healthier and happier life. You have to see that triad.

There’s a likelihood that you can blame the insurer or blame [someone else], but at the end of the day, it’s about figuring out how to work better together, that triad, because we have a common interest in improving the life of that patient. That’s the part that I like to focus on. What are we doing this for? Who matters the most? The other stuff can be worked out.

Steven Levine, MD: Thank you. Last but not least, Dr Ares-Romero.

Patricia Ares-Romero, MD, FASAM: I love that. I love how you ended with that. Because as somebody who treats treatment-resistant depression regularly, I’m very passionate about having my patients improve their lives. Their quality of life is what’s important, and that they get passion and fulfillment from their lives. It’s beautiful to hear that, that we can work together. That’s key, getting the payer together with a provider. It’s not about you or me. It’s about the patient and how can we come together to work together. I love that.

Despite the hurdles and challenges and everything we’ve talked about, it’s an exciting time in psychiatry. This is a time when we have new modalities, new things, all the data collection, all the systems, and the artificial intelligence that we have now that we haven’t explored. There are so many wonderful things coming that I’m excited. I’m excited for our patients. I’m excited for everything that we’re doing.

Steven Levine, MD: I join you in your hope and optimism.

Patricia Ares-Romero, MD, FASAM: That’s me.

Steven Levine, MD: Thank you all again. To our viewing audience, we hope you found this AJMC® panel discussion to be useful and informative.

Transcripts edited for clarity.