Advances in Treatments for Depressive Disorder Yield Faster and Better Results
by Micah Hoffman, MD, DABPN, FAPA
AllMed Behavioral Health Medical Director
Did you know that depression is one of the top three causes of years lived with disability in the United States?1 This is, in part, because standard antidepressant medications don’t work for everyone. In fact, 5.5 million adults in the U.S. who are treated for depression don’t get better with first-line psychiatric medications.2
The good news is that the number of alternate treatment options is expanding. These options include recent advances in psychopharmacology such as mood-stabilizing medications, more targeted antidepressants, and ketamine along with non-medication treatments such as transcranial magnetic stimulation (TMS). The challenge for health plans is that it’s not always clear when it’s time to augment or replace first-line therapies—or how best to go about it. As in any specialized area of medicine, developing an appropriate psychiatric treatment plan depends on fully understanding the options and the member’s individual circumstances.
This is where AllMed can help. Our board-certified psychiatrists bring up-to-date, comprehensive knowledge of current treatment options to the review process, ensuring that your team is equipped to support members with optimal, plan-aligned care.
When Standard Antidepressants Aren’t Enough
The point at which it seems clear that first-line antidepressants are not meeting a member’s needs can be a pivotal one—a chance to reassess the direction of care and thoughtfully consider next steps. It’s at this juncture, especially, that collaborating with a board-certified psychiatrist can make a critical difference.
It’s understandable that there might be some uncertainty because, in fact, there is no universally accepted definition of treatment-resistant depression (TRD). A patient is typically considered to have it when treatment with at least two products of different pharmacological classes, at proper dosages and for a sufficient length of time, fails to bring clinically meaningful relief.3 But what length of time is sufficient? And what should come next? These are questions we at AllMed hear often from our practitioner colleagues and health plan partners.
Our board-certified psychiatrists take a methodical and multifactorial approach to answering, starting with considering the original diagnosis and developing a detailed understanding of the patient’s history. At times, the information we learn in this phase leads us to conclude that the patient may have been misdiagnosed at the outset.
Once we confirm the diagnosis, then we drill down further into the details, evaluating whether the medications tried previously were appropriate and were taken faithfully for an adequate length of time. While patients, understandably, become frustrated if they feel no improvement after two to three weeks, strict research protocol stipulates that five-to-six weeks is the minimum length of time required for trials to be considered adequate. We balance the knowledge we gain in this phase with the urgency of knowing from experience that the longer someone is depressed, the harder it is to treat that depression, and the longer it takes to get them better. Our focus is on finding a way to get the member better, faster.
Evidence-based Treatment Alternatives
When we have confirmed that first-line antidepressants have been given a reasonable chance and that, even with psychotherapy, they are not effective enough, then we begin to consider other options, keeping in mind what is available both geographically and within the parameters of the member’s health plan. Newer psychopharmacological advancements that may help include targeted antidepressants that have been developed to treat specific types of depression, for example post-partum depression. Other possibilities include mood-stabilizing antipsychotic agents that have been specifically formulated to augment standard antidepressants. These mood stabilizers are designed to augment the effects of antidepressants.
In specific circumstances, intranasal ketamine, which is FDA-approved and can be highly effective for treatment-resistant depression, may be appropriate. Intranasal ketamine can be prescribed through outpatient clinics, which gives it the advantage of being accessible as well as effective. Whether this treatment is right for a specific member depends on the member’s individual history and prior experience. It’s important to distinguish between intranasal ketamine, which is an FDA-approved, valuable tool, and intravenous ketamine, which is not FDA approved. While intravenous ketamine is being marketed widely and actively researched, currently there is not sufficient evidence of clinical benefit to support its use.
Beyond medication, several neurostimulation treatment options exist for members with severe treatment-resistant depression. Electroconvulsive therapy (ECT), long considered the gold standard for TRD, continues to be widely used across the U.S.4 For those who find ECT’s side effects on memory and cognition difficult to tolerate, the newer transcranial magnetic stimulation (TMS) may be appropriate.
TMS is a noninvasive form of brain stimulation that uses devices operating outside the body to apply powerful magnetic fields to specific areas of the brain known to be involved in depression. TMS does not require anesthesia and has relatively few side effects, though, as with any medical treatment, it is vital to understand the member’s history and circumstances to determine whether TMS might be an approach worth trying. Seizures are a rare but serious side effect, so TMS may not be appropriate for people with epilepsy, a history of head injury, or other serious neurologic issues.5
TMS is becoming more widely available, and more health plan policies are covering it for TRD. At AllMed, we see TMS as one of several proven modalities that can be beneficial when used under appropriate diagnosis following a lack of response to standard antidepressants.
The Potential of Pharmacogenetic Testing in Psychiatry
A topic that comes up frequently in reviews that we receive is psychiatric pharmacogenetic testing. Over the past 10 years, a significant amount of research has been done on the use of pharmacogenetic testing to identify which medication(s) a member will respond to best and which they should avoid. While this testing shows great promise, as of right now there is not robust enough evidence to suggest that it should be widely used. Given the high cost, the fact that it is not covered by Medicaid, and the lack of longitudinal studies, we believe that this testing technology should be viewed as experimental and investigational—for now. As the technology evolves and begins demonstrating long-term clinical benefits, we anticipate that psychiatric pharmacogenetic testing will become a cost-effective tool that’s appropriate for use in everyday practice.
Charting a Course for Improved Outcomes
Identifying an appropriate treatment plan for TRD requires familiarity with recent research, clinical experience, and a thorough understanding of a member’s specific circumstances. At AllMed, our board-certified psychiatrists bring expertise and current experience to the review process. We consider the referring practitioner’s suggestions and research that’s been done to substantiate the proposed plan as well as the member’s prior medication history, plan policies, and relevant guidelines, assimilating this information to inform a solution that meets a variety of needs. Collaborating with AllMed helps your team support members effectively with the most appropriate, evidence-based treatment available within the parameters of their plan.