I often think about what the future of psychiatry looks like. Not in a super-futuristic “The Jetsons” type of way, but: “What would it look like for psychiatrists to make a bigger impact on our patients’ mental health?”
Today, the retail sector can access all kinds of information about their customers’ shopping habits over the years. However, as a psychiatrist, if I want to know what medication a patient was on 2 years ago when they lived in another state, it becomes a game of telephone.
I look forward to a future in which mental health care has all the advantages of technological progress that have benefited other industries. We would have access to not only the most recent research related to novel mental health treatments, but also the ability to offer them to all patients because the capture of more clinical data will drive evidence-based insurance coverage. We will be able to measure and understand our patients’ progress and include them in their journeys as collaborative partners. A patient’s entire psychiatric and medical history (medications, therapist history, and significant medical milestones) would exist in a living document.
We’ve made a lot of progress in mental health. Where do we go from here to make this vision closer to a reality? To me, there are three areas of innovation — in all of which, thankfully, progress is being made — that lead to this brighter future:
Continuing clinical innovation
Psychiatry already looks vastly different than it did even a few years ago. A comfy couch has been supplemented with a tidal wave of telehealth virtual care and the emergence of promising new treatments.
Psychedelics — which are far from new but were not a part of mainstream medicine — are having a renaissance and being actively explored as clinically relevant novel treatments for the first time in over 50 years. There are a number of innovative mental healthcare treatments currently undergoing FDA clinical trials including MDMA-assisted therapy, which is showing promise to treat PTSD. There has also been massive innovation with transcranial magnetic stimulation (TMS); the FDA recently cleared the SNT Neuromodulation System for use in people with treatment-resistant depression, which can be life threatening. Essentially, SNT expands the way we can use traditional TMS to treat depression and results are seen in much less time. Broader TMS approaches can take up to six weeks to ease depression symptoms, whereas with the SNT technology patients can go into remission after only five days.
Psilocybin, psilocybin-derived compounds, and psilocybin-assisted therapy are also in various stages of development and clinical evaluation in partnership with the FDA for the treatment of depression. It’s exciting to see these treatments re-emerge thanks to organizations that have been advocating and pushing through research for several decades to bring them into the mainstream in a very valid medical way.
This forward movement in psychiatry is extraordinarily important, especially for the 20%–60% of patients with psychiatric disorders who are not helped by standard medications and treatments.
A more collaborative care model
More collaborative care models within healthcare are also critical to advancing psychiatry. Primary care plays an increasingly big role addressing mental health access shortages. Primary care doctors and pediatricians have been flooded by people coming in with mental health care needs. PCPs are seeing patients with complex mental health care issues or in crisis who aren’t able to get in to see a psychiatrist for months. This is not necessarily where a primary care physician’s expertise stands, which is why a collaborative care model is becoming increasingly important. Ideally, a PCP has relationships with psychiatrists that can be utilized to get the patient in a calmer space, and then referred to a specialist if necessary, and psychiatrists can similarly refer patients to PCPs as needed.
When we talk about the “future” of psychiatry or the “future” path of medicine in general, it’s hard not to go to the concept of telehealth, that healthcare can in fact exist and succeed outside of the four clinic walls. However, while the idea of care on-demand is compelling and can be beneficial, we’re finding that this model does not necessarily serve more severe mental illness. Across medicine, the idea of hybrid care, where people can do telehealth when it would make sense and have in-person when necessary, is ideal.
Payers as partners, not barriers, to care
The future of psychiatry is bright, but there are significant hurdles preventing clinical progress from becoming a widespread option for the masses. Without a sufficient payment structure in place to support these more innovative treatments, our hands are tied. Better support from payers is essential.
It’s no secret that payers have a history of not providing adequate coverage for mental health care. Insurance systems in the U.S. are set up to value procedures in medicine. The metrics so integral in mental health care — Is this treatment keeping people in the workplace? Is this treatment keeping people out of the ER? Is this treatment keeping people alive? — are being missed by payers’ antiquated measures of success. When you have a patient with diabetes, you can measure a hemoglobin A1C and see how a patient is doing. With depression, it can be more complex.
It’s important that psychiatry build pathways to universally quantify progress so that it’s something an insurance company will readily reimburse. This data is also essential to validate clinical effectiveness of the novel treatments that are perhaps the only option for the nearly three million Americans who have treatment-resistant depression. Integration of digital biomarkers of mental health using data from everyday technologies such as smartphones and wearable devices will also help, as can companies that are creating tools such as behavioral electronic health records (EHRs) specifically designed to foster and leverage digital and patient-reported measures to improve clinical decision-making and treatment outcomes.
Prior authorization processes can also be major barriers to care and have been widely criticized for being time consuming and mentally draining for clinicians, as well as negatively impacting patients’ clinical outcomes. 89% of 1,001 practicing physicians surveyed by the American Medical Association said they believed that the prior authorization process has a “somewhat or significant negative impact” on patient clinical outcomes.
Psychiatrists and their patients are especially affected by these authorizations posed by insurance companies. “Basic medical services in other specialties don’t require prior authorization, but in psychiatry, they do,” said Jacques Ambrose, M.D., chair of the APA/APAF Leadership Fellowship and a clinical fellow in child psychiatry at Harvard Medical School and Massachusetts General Hospital. “For example, if a patient with chronic heart disease needs to be hospitalized for monitoring, it’s no problem. In psychiatry, if a patient with suicidal ideation needs to be admitted for monitoring, suddenly prior authorizations are needed.”
A report from PharmaExec found that when prior authorization requirements are imposed, 4 out of 10 patients abandon therapy altogether. Additionally, despite federal and state parity laws, denial of health insurance coverage for mental health treatment continues to be extremely common, as compared to coverage for general medical or surgical procedures. There have been pushes at the state and federal level increasingly requiring health plans to eliminate prior authorizations for specific behavioral health treatments because of parity violations.
It takes a village
There are many ways we as psychiatrists can move the needle toward better mental health care. A broad clinician network across the sector is key for psychiatrists and their patents. Psychiatrists can build their clinical network beyond just other local therapists. Consider a neurologist who understands the psychiatric components of a migraine while also treating a migraine or clinicians who can affirm and support non–gender conforming patients. The idea of connecting with therapists comes naturally for psychiatrists, but including specialists who can meet the unique needs of patients will be invaluable.
Mental health is as important as physical health, and psychiatrists have a unique opportunity to lead the charge in defining a world that embraces, and supports, medical treatments for the whole person. We are on the edge of rapid innovation in psychiatry. Now is the time to break out of our silos and take advantage of the promise the future holds.
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