Your employee has tried to treat her depression with at least two different medications but nothing seems to be working. She’s not alone: research suggests at least half of adults with major depressive disorder will fail to respond to multiple attempts with antidepressants.
Treatment-resistant depression, also known as treatment-refractory depression, is commonly defined as an MDD that hasn’t responded adequately to two or more courses of therapy with different antidepressants (usually from different medication classes).
If a patient doesn’t respond to two different antidepressants, he or she can try a third course of treatment with a different antidepressant to see if there’s an adequate response. In some cases, it may simply be a matter of finding the right drug for that specific individual. The prescribing physician can also add a second antidepressant therapy to the existing treatment plan, or augment the antidepressant therapy with lithium, thyroid hormone or antipsychotic medication. Complements to drugs such as counselling, psychotherapy or lifestyle changes — are also expected to be part of the treatment considerations for all MDDs, including TRD, and should be discussed with the physician.
Read: Video: How depression impacts the workplace
The prevalence of TRD opens up a much-needed dialogue in the benefits industry. How should employers support members with a more severe form of depression or another serious condition? Can we develop plan designs to make appropriate resources easily available to members with unique needs? Can third-party providers play a more active, targeted role in supporting these members?
For plan sponsors, transactional-level claims data is key because it can be used to measure and determine severity within a given condition, such as TRD within depression, allowing them to look at plan design in different ways. For example, does it make sense to put a hard cap on the sum available to a member for services such as psychotherapy or counselling in a given benefits year if a TRD claimant’s needs are different from those of a member who can control his or her depression with less intervention? Would a plan sponsor’s perspective on benefits plan design change if it understood the relative cost implications of TRD? Can providers play a more active role in using claims data to prioritize resources toward members most in need while also respecting their privacy and confidentiality?
While it’s encouraging to see the conversation around mental health in the workplace get more attention, there’s an absence of updated financial and health metrics to help guide decision-making. To that end, Janssen, Great-West Life and Cubic Health collaborated on research into TRD in 2014 — focusing on prescription drug, short-term disability and long-term disability claims — on a population of roughly 58,000 employees over a two-year period.
Research results
In Year 1 of the study, 13.1% of all employees treated for depression were treated for TRD, and that figure grew to 13.4% in Year 2. The research shows TRD is more common in female employees, particularly those age 45 to 64. Across all claimants with TRD, the median age was 46.3, compared with 42.8 for those with non-TRD.
Looking at drug claims data alone, the research suggests employees who are being treated for TRD are, in general, treating multiple or more severe health conditions along with depression. Those with TRD spent an average of $2,168 in Year 2 on medications, compared with $1,039 for non-TRD employees and $567 for employees not being treated for any form of depression.
Read: Treat depression to boost productivity
Looking solely at drug costs for treating depression, the cost to treat TRD was substantially higher, averaging $794 per employee per year compared with $293 per non-TRD employee per year. Employees with TRD spent $1,374 on drug therapies for other conditions, compared with $746 for non-TRD employees and $567 for employees without depression. Interestingly, 2.9% of employees with TRD made one or more claims for a specialty medication (i.e., an expensive biologic or non-biologic medication for treating conditions such as rheumatoid arthritis, Crohn’s disease, multiple sclerosis and cancer), compared with 1.9% for non-TRD employees.
There was also a significant difference in STD and LTD rates. In Year 2, 5% of employees with TRD made an STD claim related to depression, compared with only 1% for non-TRD employees. And 4.1% of employees with TRD made an LTD claim related to depression compared with only 0.3% for non-TRD employees.
The population of employees with TRD also had significant STD and LTD claims growth for depression from Year 1 to Year 2. While the prevalence of STD claims for non-TRD employees decreased from 1.3% to 1% by Year 2, there was a material increase in the prevalence of STD within the TRD population—from 3.2% to 5%. And while the prevalence of LTD claims for non-TRD employees stayed flat at 0.3% in each year, within the TRD population, there was an increase from 3.5% to 4.1%.
Read: Return-to-work strategies needed for employees with depression
Interestingly, almost half of all STD claims submitted by employees with TRD are related to depression, versus just 19.5% of the claims for non-TRD employees. Similarly, while 40% of all LTD claims for TRD employees are related to depression, that figure was only 14% for non-TRD employees.
When considering the direct drug, STD and LTD costs to a plan sponsor for depression in Year 2, TRD employees had a per capita total burden of illness cost of $1,762—almost five times greater than non-TRD employees ($375). And direct plan spending on all disability benefits represented only 22% of the overall burden of illness for non-TRD employees, compared with 55% for TRD employees.
Taking action
The depth of data available at a transactional level and the level of insight buried within that information indicate TRD is a serious consideration for plan sponsors. It makes up a material number of employees treated for depression, and those plan members are much greater consumers of both drug and disability benefits than those with a more easily managed form.
Most depressed country: Afghanistan – more than 20% diagnosed
Least depressed: Japan – less than 2.5%
Source: 2013 University of Queensland study
Clearly, employers have a business case to implement policies on TRD. They can focus on identifying and supporting those with TRD as a meaningful and manageable high-risk group. They can provide flexible mental health benefits for this group, allowing for a needed array of services without imposing a substantial financial burden. They can focus on earlier intervention by third-party experts who can help ensure better health outcomes and support. And they can revise their disability management procedures or approaches to influence the number of STD claims related to depression that become LTD claims, as well as facilitating appropriate return-to-work strategies.
Read: What’s depression costing you?
Without meaningful business cases to support early intervention, expanded design and more proactive plan member engagement, it will be challenging to maintain the level of support needed to support those with TRD at work.
Mike Sullivan is president and co-founder, and Chris von Heymann is vice-president and co-founder, of Cubic Health.
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