Funding options for the management of major depressive disorder in Canada

Major depressive disorder (MDD) is highly prevalent in Canada, and the care and support of individuals affected by this illness is associated with high societal costs. In this article, we provide a sample case of a patient diagnosed with MDD, and present different management and funding options that would be available to her in the current health care system. We demonstrate that there exists a large degree of variability in services that can be accessed based on type of insurance coverage. As a result of the high cost of care for MDD, many patients have immense difficulty funding a prescription for antidepressants or a course of psychological therapy. Yet leaving mental illness untreated is associated with greater costs due to worse patient outcomes. Increased investment in effective prevention and early intervention efforts may be one way to bring about long-term cost savings.


INTRODUCTION
One in five Canadians are affected by a mental illness. Of these individuals, approximately 8% develop major depressive disorder (MDD). Furthermore, the prevalence of mental illness is expected to rise as the population grows and ages. Depending on the type and severity of mental illness, the resulting disability and use of health care services can be quite substantial. While mental illnesses account for only one-third of disability claims, they are associated with longer disability episodes and approximately 70% of total disability claim costs. 1 In 2011, the estimated direct annual cost of mental illness in Canada was Can$42.3 billion (including hospitalizations, physician visits, medication, community and social services, and income support) and an additional Can$6.3 billion in indirect costs (including total and partial disability days). In fact, societal costs associated with mental illness have been projected to exceed Can$2.3 trillion by 2041, emphasizing the necessity to optimize access to appropriate treatment and prevention services. 2 Mood and anxiety disorders are the most commonly diagnosed mental illnesses in Canada, consequently accounting for the majority of service costs related to mental illness. 2 Of the mood and anxiety disorders, the World Health Organization ranks MDD as the leading cause of disability worldwide and a major contributor to the global burden of disease. 3 The high costs of MDD in particular are attributed to its high prevalence, early age of onset, and often chronic-recurrent clinical course. 4 The consequences of untreated MDD include but are not limited to worse physical health outcomes and poor function at work, at school, and in the family. High-quality treatment for MDD can mitigate or even reverse many of its adverse effects and thus its long-term societal costs, yet large numbers of individuals diagnosed with MDD do not receive appropriate nor adequate services. 4 The reasons for this are multifactorial. A major contributor to inappropriate and inadequate services includes differential access based on the patient's socioeconomic status and level of insurance coverage. This will be highlighted in the case presentation and discussion below.

PATIENT CASE PRESENTATION
The following is a fictional case presentation delineating a patient's experience accessing mental health services: Jane is a 20-year-old student at Western University who grew up in Peterborough. She is actively involved in campus life, playing defense on the soccer team and volunteering with the Heart and Stroke Club. In the last month, Jane has been experiencing a loss of appetite, sleep, and energy coupled with persistently low moods. She has lost interest in school and her extracurricular activities. When she tries to catch up on missed schoolwork, she finds it difficult to concentrate. She declines invitations to social events, preferring to be alone in her apartment. One of her teammates has expressed their concern, encouraging Jane to book an appointment at Student Health Services. Upon taking her teammates advice, Jane is referred to a psychiatrist who diagnoses her with MDD. Her psychiatrist prescribes an antidepressant and recommends that she participate in cognitive behavioural therapy.

COSTS OF PHARMACOLOGICAL TREATMENTS IN MDD
The cost of antidepressants ranges from Can$30 to Can$200 per month. 5 Since Jane is a Western University student, her antidepressant medication is covered by the school's University Students' Council Benefit Plan. For people without such a private plan who are under the age of 25, medications are covered by Ontario Heath Insurance Plan Plus (OHIP+). 6 However, individuals over the age of 25 are not eligible for medication coverage under OHIP+. Thus, they must rely on either private health insurance or special assistance programs for coverage. These plans most often require individuals to pay either a set deductible amount or a portion of the total prescription cost. 5 Undoubtedly, this can be difficult for people who do not have disposable income. Additionally, some antidepressants may not be covered, and some plans may only cover generic forms of antidepressants. 5 Furthermore, plans differ in their coverage of medication dispensing fees, which can result in an additional cost incurred by the patient. 5 Unemployed individuals between the ages of 25 and 65 do not have access to any form of private or employer coverage. Thus, these health economics

Funding options for the management of major depressive disorder in Canada
Caroline R. Piccininni, Justine Fletcher health economics individuals often have no choice but to rely on special assistance programs in order to afford medications for their mental illness. In Ontario, examples of such programs include the Trillium Drug Program, Ontario Disability Support Program, and Ontario Works. People over the age of 65 can receive medication coverage through the Ontario Drug Benefit Program. 7 However, these provincial programs tend to offer only partial medication coverage and the patient is responsible for paying a set deductible amount. 7 Given the unaffordability of these expenses, at least 10% of Canadian adults are unable to access prescription medication. 8 In addition, these programs can be difficult to access due to strict eligibility criteria and lengthy applications with considerable documentation requirements. 7 Overall, the costs associated with pharmacological therapy in MDD can render this treatment modality inaccessible for many patients.

COSTS OF PSYCHOLOGICAL TREATMENTS IN MDD
Upon reviewing the costs of non-pharmacologic treatment modalities for MDD, an even greater financial barrier to care surfaces. The cost for private counselling or therapy ranges from Can$50 to Can$220 per hour long sessions. 5 For MDD, it is generally recommended that the patient attends between six and eight sessions. Having five or fewer sessions has been shown to be less effective and having more than eight sessions does not confer any additional benefit. 9 Thus, the average cost of counselling can range from Can$300 to Can$1760 per patient. 5 Group therapy tends to be a cheaper option than individual therapy; however, this may not be appropriate for all patients. 5 In reference to the fictional case presentation, because Jane is a student, she has additional health coverage through her university health plan. A 2013 analysis showed that 68% of universities and 41% of colleges offer a similar private health plan to students enrolled at the institution. 10 These plans typically cover a percentage (usually 80 to 100%) of counselling or therapy sessions, up to an annual maximum of Can$300 to Can$1000, so long as the sessions are provided by a registered social worker or psychologist. 10 Thus, it is rare for these plans to provide sufficient coverage for the psychological treatment of MDD.
Similar to the health plans at universities and colleges, employer health insurance covers a set percentage of the costs of counselling and therapy for employees and their family members. However, costs are covered up to an annual total or for a limited number of sessions. 5 Unemployed individuals can be provided with counselling and therapy at no cost through hospitals or medical clinics funded by the government. 5 For example, psychological treatments provided by family doctors and psychiatrists are covered by OHIP. 11 However, it is important to note that these publicly funded services tend to be associated with longer wait times than the private options. 5 There are also some community agencies that provide services at little to no cost, and others that determine the cost of services relative to an individual's income. 5 Although several lower cost options exist, the often limited coverage for psychological treatments makes them financially inaccessible for a substantial number of patients with MDD.

ANALYSIS AND FUTURE DIRECTIONS
It has been shown that 60 to 80% of individuals diagnosed with MDD effectively manage it via antidepressants and psychotherapy. 3 However, many patients, such as those who are unemployed, encounter financial barriers when attempting to access the right combination of services, treatments, and supports. As such, there is great pressure on the publicly funded system to increase investment in mental health services. This makes potential cost-saving strategies of utmost importance. To decrease costs, therapies can be further integrated into primary care practice or offered through innovative models of service delivery, such as telecounselling and mobile mental health applications. 12 Another potentially costsaving strategy is investing in preventative care. 13 School programs to enhance positive thinking in children and adolescents, as well as exercise programs to boost mood and energy levels in older adults, have been shown to be effective and cost-saving prevention approaches. 3 In fact, the Mental Health Commission of Canada has pushed for an increase in the number of initiatives and targeted prevention efforts at all levels of education in order to promote mental health among children and adolescents. 12 A case has also been made for the implementation of screening programs, with the goal of early identification of mental illnesses and those who are at high risk for their development. 14 As such, while there is a dire need for increased mental health funding, there are strategies that can be adopted and implemented to offset some of these costs.

CONCLUSION
Based on the data presented in this article, the average cost for the pharmacological and psychological management of MDD is at least several hundred dollars per case per year. Taking into account the high proportion of Canadians affected by MDD in their lifetimes, the societal cost attributable to MDD is alarmingly high. For Jane, she may have received a combination of antidepressant medications and cognitive behavioural therapy, with funding support through OHIP+ and her university health plan, respectively. With this being said, it is evident that someone in a different age group or life situation may face greater difficulty with financial access to the same services. Leaving MDD untreated is associated with even higher direct and indirect costs, and as such, increased investment in both mental health care and prevention approaches is justified.