Clinicians face key barriers in treatment of major depressive disorder

The number of Americans living with a mental illness is at an all-time high, exacerbated in 2020 by a global pandemic, political tensions across the country and economic uncertainty.

Abigail Nash

Yet despite the pressing need, there remain serious obstacles to accessing and receiving optimal care. For generations, stigma has been one of the major barriers keeping people with mental illness from getting the treatment they need. Research shows that even when access to mental health care and funds are available, stigma continues to be a leading cause of not getting treatment.

While stigma persists, there has been some progress in normalizing the conversation around mental health and depression in recent years. A recent poll shows that nearly 9 in 10 people believe there is at least some stigma and discrimination associated with mental illness in society today, but more than one-third said there is less stigma compared to 10 years ago. According to the American Psychological Association, 87% of American adults in 2019 agreed that having a mental illness is nothing to be ashamed of and 60% of adults said they view seeing a mental health professional as a sign of strength. These statistics are encouraging, and we must continue to be vigilant in our efforts to fight stigma as it remains one of the major barriers to optimizing patient care from a clinical perspective.

It is not just stigma that is a barrier to access. There is a lack of parity when it comes to treating mental health care conditions compared to other medical conditions because of the way health care resources and funding are allocated. Patients often find it more financially burdensome to follow prescribed treatment regimens and recommended care schedules for mental health conditions than for other medical conditions. Clinicians also face other key challenges, particularly in patients with challenging-to-treat major depressive disorder.

There tends to be little communication between the myriad treatment providers involved in patient care when it comes to mental health. This siloed approach is a well-known issue and continues to be, as clinicians become more and more specialized. For example, the rise of “interventional psychiatry” has led to increased collaborative care between psychiatrists and other clinicians. This often makes it difficult to ensure the clinician is aware of important information about patients to best address their needs.

Collaborative care

An increase in collaborative care of patients with mental illness could help identify illness earlier, could implement more effective interventions and would allow the coordination of treatment plans that maximize positive outcomes, especially as new medication options come to market. Given the prevalence of comorbid psychiatric and medical disorders in this patient population, a collaborative holistic approach also would be expected to improve overall health outcomes. This could be made possible by increasing the amount of communication between health care providers and making relevant clinical data and notes accessible for providers taking care of the same patient.

The move toward a collaborative approach can take stress off the patient or caretaker to recall and provide details to their various health care providers, ultimately elevating their experience and bypassing opportunities for miscommunication or errors.

Access to new guidelines, treatments

Another challenge for clinicians is the reality that treatment guidelines in psychiatry typically take many years to be updated and often are not easy to access, making it difficult to stay up to date with the fast-changing pace of best treatment practices. For example, the gold-standard manual defining different mental illnesses was published in 2013. However, the treatment guidelines that define how to treat patients was published years earlier.

While evidenced-based best practices and consistent guidelines are important, clinicians also need easy access to the latest information and treatment updates in a timely way. This will help them determine where in the treatment paradigm various interventions should be deployed and for whom newer treatments may be appropriate. This lag in disseminating information poses a unique challenge for clinicians as they seek to provide the best care for their patients, while potentially being unaware of breakthrough advancements.

Another roadblock can be a lack of access to new treatments since newer treatments are often not reimbursed by insurance. This isn’t a new problem, but it is becoming an increasingly frustrating barrier to patients as more novel treatments enter the market. Current payer plans often require patients with mental illness to have tried and failed numerous, older and/or generic medications before they are eligible for newer treatment options. This prevents patients from accessing treatment options that may be effective for them and can leave patients and clinicians feeling both frustrated and hopeless after cycling through multiple medicines.

Telehealth

In the wake of the COVID-19 pandemic, there has been a marked migration from in-person consultation to telehealth, giving clinicians the opportunity to provide care and connect with patients that previously were out of reach due to location, illness, transportation or financial obligations. In this new environment where the use of telehealth has rapidly increased and become commonplace across comprehensive care plans, there need to be better guidelines and training for clinicians on how to effectively and safely use these technologies to bring care to those in need.

Telehealth training needs range from a need for knowledge and proficiency in cybersecurity to guidance on the establishment of a good doctor-patient relationship via virtual connection. Clinicians must be skilled in keeping patient information and medical records secure online. Additionally, much of a positive patient experience stems from the rapport one builds with their health care professional, so finding ways to remain both professional and empathic across a computer screen or telephone is vital to ensure patient care is delivered in a safe and responsible way that meets the needs of the patient.

Improving guidelines and training for clinicians will be incredibly important as telehealth continues to be an effective way to give patients access to health care in a timely manner.

Quality of care

While these are serious challenges that can make new treatment options difficult to access for people with challenging-to-treat depression, there are tangible ways the health care system can improve the quality of care for those living with depression. Advocate for parity in health care resources and funding for patients with mental health disorders. Increase collaborative care of patients across the health care continuum. Develop and refresh clinician treatment guidelines regularly so clinicians are aware of the latest psychiatric treatment options. Update payer plan requirements so patients can access new treatment options more easily. Provide guidelines and training to help clinicians best utilize telehealth.

Now, more than ever, there must be a comprehensive approach to improving the quality of psychiatric care. We have to keep pace with the influx of patients who will continue to need it, both as a result of a willingness to seek help due to slowly eroding stigma and the growing mental health needs we continue to see in the era and aftermath of the events of 2020.

References:

American Psychological Association (2019). Survey: Americans becoming more open about mental health. Accessed Jan. 20, 2021. Available at: https://www.apa.org/news/press/releases/2019/05/mental-health-survey.

Anxiety and Depression Association of America. College-aged adults face less mental health stigma. Accessed January 20, 2021. Available at: https://adaa.org/college-aged-adults-face-less-mental-health-stigma.

De Pinto J, et al. (2019). CBS News. Accessed Jan. 20, 2021. Available at:

https://www.cbsnews.com/news/most-americans-think-there-is-stigma-associated-with-mental-illness-cbs-news-poll/.

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National Alliance of Mental Illness. Out–of–network, out–of–pocket, out–of–options. Accessed Jan. 20, 2021. Available at: https://www.nami.org/Support-Education/Publications-Reports/Public-Policy-Reports/Out-of-Network-Out-of-Pocket-Out-of-Options-The/Mental_Health_Parity2016.pdf.

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