Risk Factors for TRD and Payer Considerations

Steve Levine, MD: Dr Ares-Romero, within your practice, how common do you see TRD [treatment-resistant depression]?

Patricia Ares-Romero, MD, FASAM: Thank you for having me. Nice to see you again, Steve. Unfortunately, it’s quite common in my practice. When patients come to see me, that journey that Sam was talking about has already happened. They come to me because they’ve been on the 2 traditional antidepressants, some maybe on a third, or maybe some augmentation therapy. They’ve been to the therapist, they’ve had CBT [cognitive behavioral therapy]. They’ve had all these other options, and they come to me and they’re at their wit’s ends. They’ve been through all these and they still haven’t had any resolution of their symptoms. It’s heartbreaking for our patients. When they come to me, it’s very common that I see patients with TRD where we have to start looking into other treatment options for them so we don’t continue in the same paradigm of just throwing more medicine at them.

Steve Levine, MD: As you try to identify them, are there certain risk factors in terms of either demographics or comorbidities?

Patricia Ares-Romero, MD, FASAM: Yes. We’re looking at the research. In my patient population, we’re seeing a co-occurrence with substance use, so we always have to look at that. Personality disorders and chronic medical illnesses have also been noted. When patients are also struggling with other medical problems, it’s hard for the depression to be resolved. Trauma is another factor. Those are the things that we’re seeing in our patient population.

Steve Levine, MD: Dr Rosenzweig, as a payer, can you talk about what your priorities are among patients with TRD and what some of the key drivers of cost may be?

Martin Rosenzweig, MD: Sure. Thank you for including me in this. There are a couple of things from a payer perspective. What drives our clinical initiatives are alignment with the quadruple aim. How do we make sure that the members we cover are getting the right care, right time, right place, and the right cost? This population presents a lot of challenges. One is around identification. One of the things we struggle with is that 70% of the antidepressants prescribed aren’t prescribed by psychiatrists. They’re done by non-behavioral specialists. Primary care physicians are probably the biggest group. Part of it is, how do we know within that population of millions of people exactly what we’re looking at? How do we identify them from our data sources? How do we set up a system that can shepherd the patients to a place where they’re going to get the care that’s going to make a difference?

One of the problems with misidentification from a population health point of view is that we waste a lot of resources. As Dr Ares-Romero mentioned, the problem with these patients is if we don’t treat them or we don’t recognize the comorbidities, they end up in very high-cost settings, either medical or behavioral or inpatient. It often doesn’t solve the problem. There’s a lot of importance in trying to figure out what the rules are and what can we do to identify and support the patient in terms of getting them to the right treatment setting where the response rates for treatment-resistant depression are pretty good with the right approach. Our task as a national carrier is finding the role we can play in that shepherding or funneling of the patient.

Steve Levine, MD: Thank you. If I can play that back to you a little and see if I’m understanding correctly, some of those key drivers of cost are the higher acuity services, some of the medical comorbidities, and to some extent, the misidentification or lack of identification or delay to effective treatment. Those ultimately are part of that pathway to the endpoint of those higher-cost services.

Martin Rosenzweig, MD: That’s correct. The other piece, particularly in a postpandemic environment, is we’re looking at resource constraints. It’s estimated that we only have about 70% of the number of psychiatrists we need. The more time that you have a patient like this using up psychiatric time, the more it bogs down the system. If we treat them and get them to a point of stability, it frees up the resources to take care of newer patients.

Transcript Edited for Clarity