When it comes to treating depression, ‘step therapy’ is a costly misstep

Imagine a young college student struggling to keep up in class while battling symptoms of depression, or a mother debilitated with severe depression for months trying to juggle work and family, or a father whose head is stuck in a fog living in fear of losing his job due to persistent depression. These are the daily struggles of our friends, loved ones and neighbors. One in five Americans wrestle with major depressive disorder (MDD), the second leading cause of disability among working adults in this country.

As a practicing psychiatrist for the past 25 years, I have treated several thousand patients experiencing MDD and other mental illnesses. And while MDD is a complex disease, getting my patients access to the right medicines shouldn’t be. But a health insurance restriction known as “step therapy” stands in the way between my patients and the treatments they need.

{mosads}Insurance companies typically require patients to try and “fail” one, two or even three drugs within the same class before they will consider allowing them to “step up” to a more clinically appropriate therapy. And by “practicing medicine” without thorough knowledge of a patient’s other health conditions, current symptoms, or functional impairments, insurance companies will make patients retry these failed steps or “missteps” annually or when their insurance shifts to a new plan. So it’s not surprising that step therapy protocols that are put in place to cut costs quite often have the opposite effect that proves costly in the life of a patient. 

While cost savings are desirable, forcing patients onto treatments solely for financial reasons is never good medicine – and it’s often more expensive. Delayed wellness means ongoing and costly disability, inability to return to normal function and productivity, and more medical visits – including hospitalization. Perhaps most concerning, the longer a person suffers with depression, the harder it is for their brain pathways to heal and return to normal function.

Step therapy is one of many roadblocks to care confronting patients today that compound their – and my – frustration with our health care system. For example, a large, national insurer has recently decided to make one antidepressant an “excluded benefit” regardless of a patient’s history of previously failed drugs or intolerable side effects from the “covered” treatment options – without a defensible explanation or medical rationale. Patients with MDD can vary widely in their responses to antidepressant medications, and often require access to multiple therapies to achieve full recovery and return to normal function; excluding any Food and Drug Administration (FDA) approved MDD treatment for one of the most vulnerable populations solely on the basis of cost is both unethical and medically negligent.

So, what can be done to fix this broken system? While bipartisanship seems rare these days, when it comes to reforming step therapy policies and putting patients first, some lawmakers have found common ground. Reps. Brad Wenstrup (R-Ohio) and Raul Ruiz (D-Calif.) – both of whom are physicians – recently introduced H.R. 2077, Restoring the Patient’s Voice Act, to change step therapy policies by giving doctors and patients increased autonomy in determining their care by defining clear and transparent processes for requesting an exception for patients requiring access to needed therapies sooner rather than later. With 32 co-sponsors and counting, the progress is encouraging, but we must keep the momentum going.

I bear expert witness that changes made on Capitol Hill can forever change the lives of my patients. I strongly urge every member of Congress to join the bipartisan effort to reform step therapy policies. Patients, providers and families in your districts are counting on your help.

Dr. Gregory Mattingly is an associate clinical professor in the department of psychiatry at the Washington University School of Medicine in St. Louis, and is president of the Midwest Research Group in St. Charles, Missouri. Dr. Mattingly is a principal investigator in key clinical trials, as well as a presenter at numerous medical conferences, both nationally and internationally.