Major Depressive Disorder: An Underserved Community
Guidelines for the management of major depressive disorder (MDD) recommend pharmacotherapy, psychotherapy, their combination, and modalities such as electroconvulsive therapy, transcranial magnetic stimulation, and ketamine for treatment of refractory cases.1,2 These treatments can only be helpful if patients utilize them, but current evidence suggests that many individuals with MDD are undertreated. Barriers to the treatment of MDD include systemic (ie, socioeconomic and practical) factors but also several patient-specific factors.3
Systemic Barriers to Treatment
In a 2018 study3 of 20,785 US adults with depression, 30.2% reported needing treatment but not receiving it. Among the untreated, 47.7% reported being unable to afford it, 16.7% didn’t know where to go for service, and 11.7% lacked sufficient insurance coverage.3
These numbers seem optimistic. In a 2017 survey4 of 51,547 patients with MDD living in 21 countries, 56.7% recognized that they needed treatment, and of these, 71.1% visited a health care provider at least once for their emotional problems. However, only 41% of these patients met established criteria for minimally adequate treatment. The 44.2% treatment rate reported in high-income countries with well-developed health care systems and few economic barriers to treatment4 suggests that there are other practical barriers in place. For example, rural areas typically have a scarcity of mental health care professionals,5 and many individuals may be reluctant or unable to travel long distances to receive care.6
In a 2008 telephone survey7 of 1054 US adults, 43% of respondents reported facing at least 1 barrier to even discussing depression with a primary care physician. Fear of being prescribed an antidepressant was the most frequent reason given (42.7%), far more than the 24% who were averse to referral to a psychiatrist.7
In the 2018 study,3 22.2% of patients with MDD believed that they could handle their condition without treatment, 15.2% feared they might be committed or forced to take antidepressants, and 10.9% thought treatment wouldn’t help. Factors suggestive of stigma were also deterrents, including concern about neighbors’ opinions (11%), confidentiality (9.7%), effects on their jobs (8.1%), and people finding out about their condition (6.5%).3
Feelings of stigmatization – a sense of shame, disgrace, and others’ disapproval – may be more predictive than disease severity of whether patients seek treatment for MDD.8 Feelings of stigmatization strongly magnify the impact of other barriers to treatment, such as the structural barriers, negative attitudes about help-seeking, and negative treatment expectations.9 Moreover, structural barriers, particularly a lack of insurance coverage, can suggest to patients that MDD is not worth treating, thereby reinforcing the stigma attached to help-seeking.
Removing Barriers to MDD Care: The Changing Insurance Landscape
Efforts to reduce barriers to MDD care have focused largely on the structural barriers. The 2008 Mental Health Parity and Addiction Equity Act and 2010 Affordable Care Act (ACA) required insurance providers to offer the same coverage for mental health services as for other medical/surgical services.10 Although these acts have extended treatment access, challenges remain.
Researchers from the Congressional Budget office reported that insurers pay 13-14% less for mental health services provided in-network than for other medical services.11 Patients have to go out-of-network for mental healthcare more frequently than for other medical care, which also increases out-of-pocket costs.11 According to the National Alliance on Mental Illness, signs that insurers may be noncompliant with federal guidelines include higher costs for mental health services relative to other services and fewer in-network mental health care provider options.12
Patients report less satisfaction with their mental health care than with other types of health care. In a 2021 survey13 of 728 privately insured US adults, respondents rated their mental health network as inadequate significantly more frequently than their primary health network. However, among 193 individuals who also received mental health services through their primary care provider, satisfaction between mental health and primary care networks did not differ.13 Not surprisingly, successful integration of primary care into mental health care delivery to improve mental health care literacy and access has become a focus of ongoing research.14,15
The Impact of COVID: An Expansion of Telemedicine
The evolution of telemedicine in mental health, accelerated by the COVID-19 pandemic, may also help reduce structural barriers to MDD care16 as well as to the stigma associated with mental health care outside the privacy of the home.17 A telemedicine program conducted in Oakland, California accessed and treated 6,248 patients with depression and/or anxiety disorders between October 2018 and April 2021.16 During 12 weeks of treatment, all patients received at least 1 psychiatric medication, which was prescribed or adjusted using a precision medicine algorithm that considered patients’ genetic, biomarker, phenotypic, and psychosocial characteristics. Eighty-nine percent of participants paid $95 per month for program participation, compared with an average monthly cost of $600 for in-person psychiatric services, which suggests that costs were largely acceptable to patients.16
However, insurance status was not presented in the results, leaving it unclear how much of the program costs were out-of-pocket. Moreover, the very high response (90%) and remission (75%) rates16 reported in these patients suffering from depression and/or anxiety greatly exceeded those reported in clinical trials and actual practice. For example, in the STAR*D study,18 3,671 patients with MDD received 1 to 4 antidepressant trials, with remission rates of 36.8% after the first trial and progressively lower rates with the second (30.6%), third (13.7%), and fourth (13.0%) trials. In the Precision Medicine in Mental Health Care (PRIME) study,19 pharmacogenetic testing to guide antidepressant prescribing in veterans with MDD greatly reduced the risk of drug-gene interactions that might be expected to alter treatment response, but differences in remission rates between pharmacogenomic-guided treatment and usual care after 24 weeks were not improved.
Future studies will be needed to determine the actual value of different configurations of precision prescribing methodology16 and whether remission rates, nonadherence, and attrition rates will resemble those with traditional care. If this turns out to be the case, clinicians and their patients with MDD may face fewer barriers to treatment but will likely still need to navigate the challenges posed by limitations of currently available treatments.
- Work Group on Major Depressive Disorder. Practice Guideline For the Treatment of Patients With Major Depressive Disorder. 3rd ed. American Psychiatric Association; 2010. Psychiatry Online website. Accessed August 14, 2022. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf
- Guideline Development Panel for the Treatment of Depressive Disorders. APA Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts. American Psychological Association; 2019. Accessed August 29, 2022. https://www.apa.org/depression-guideline/guideline.pdf.
- Chekroud AM, Foster D, Zheutlin AB, et al. Predicting barriers to treatment for depression in a U.S. national sample: a cross-sectional, proof-of-concept study. Psychiatr Serv. 2018;69(8):927-934. doi:10.1176/appi.ps.201800094.
- Thornicroft G, Chatterji S, Evans-Lacko S, et al. Undertreatment of people with major depressive disorder in 21 countries. Br J Psychiatry. 2017;210(2):119-124. doi:10.1192/bjp.bp.116.188078
- Bolin JN, Bellamy GR, Ferdinand AO, et al. Rural healthy people 2020: new decade, same challenges. J Rural Health. 2015;31(3):326-333. doi:10.1111/jrh.12116
- Pass LE, Kennelty K, Carter BL. Self-identified barriers to rural mental health services in Iowa by older adults with multiple comorbidities: qualitative interview study. BMJ Open. 2019;9(11):e029976. doi:10.1136/bmjopen-2019-029976
- Bell RA, Franks P, Duberstein PR, et al. Suffering in silence: reasons for not disclosing depression in primary care. Ann Fam Med. 2011;9(5):439-446. doi:10.1370/afm.1277
- Boerema AM, Kleiboer A, Beekman ATF, van Zoonen K, Dijkshoorn H, Cuijpers P. Determinants of help-seeking behavior in depression: a cross-sectional study. BMC Psychiatry. 2016;16:78. doi:10.1186/s12888-016-0790-0
- Arnaez JM, Krendl AC, McCormick BP, Chen Z, Chomistek AK. The association of depression stigma with barriers to seeking mental health care: a cross-sectional analysis. J Ment Health. 2020;29(2):182-190. doi:10.1080/09638237.2019.1644494
- Barry CL, Huskamp HA, Goldman HH. A political history of federal mental health and addiction insurance parity. Milbank Q. 2010;88(3):404-433. doi:10.1111/j.1468-0009.2010.00605.x
- 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
- National Alliance on Mental Illness. What is mental health parity? National Alliance on Mental Illness website. Accessed August 26, 2022. https://www.nami.org/Your-Journey/Individuals-with-Mental-Illness/Understanding-Health-Insurance/What-is-Mental-Health-Parity
- Busch SH, Kyanko K. Assessment of perceptions of mental health vs medical health plan networks among US adults with private insurance. JAMA Netw Open. 2021;4(10):e2130770. doi:10.1001/jamanetworkopen.2021.30770
- Jones AL, Mor MK, Haas GL, et al. The role of primary care experiences in obtaining treatment for depression. J Gen Intern Med. 2018;33(8):1366-1373. doi:10.1007/s11606-018-4522-7
- Lopez V, Sanchez K, Killian MO, Eghaneyan BH. Depression screening and education: an examination of mental health literacy and stigma in a sample of Hispanic women. BMC Public Health. 2018;18(1):646. doi:10.1186/s12889-018-5516-4
- O’Callaghan EO, Sullivan S, Gupta C, Belanger HG, Winsberg M. Feasibility and acceptability of a novel telepsychiatry-delivered precision prescribing intervention for anxiety and depression. BMC Psychiatry. 2022;22(1):483. doi:10.1186/s12888-022-04113-9
- Kim HM, Xu Y, Wang Y. Overcoming the mental health stigma through m-health apps: results from the healthy minds study. Telemed J E Health. 2022. doi:10.1089/tmj.2021.0418
- Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry. 2006;163(11):1905-1917. doi:10.1176/ajp.2006.163.11.1905
- Oslin DW, Lynch KG, Shih MC, et al. Effect of pharmacogenomic testing for drug-gene interactions on medication selection and remission of symptoms in major depressive disorder: the PRIME Care Randomized Clinical Trial. JAMA. 2022;328(2):151-161. doi:10.1001/jama.2022.9805