Why Certain Psychiatric Medications Aren't Always Covered

After decades of prescribing, it’s become second nature. My brain is now wired to make decisions based on my clinical experience, bolstered by my efforts to continually update my knowledge. 

Sometimes I forget that making these decisions is complicated, because while I’m helping my patient make the best choice, I must simultaneously consider whether it will be effective, tolerable, accessible and affordable, in the context of what treatments they’ve tried before, which can limit the options.

In this blog, I will share that journey, because most people aren’t aware of the complexities of medication access.

I will also share why psychiatric medications aren’t always available and why they don’t all work the same for everyone.

psychiatric medications not covered, dr. diane mcintosh
Sometimes it can take months, or even years, of trial and error to find a treatment that is both effective and tolerable. No drug will work if it’s not taken, and no one wants to take a treatment that makes them feel worse.

Consider antidepressants: There are more than twenty approved by Health Canada for the treatment of major depressive disorder (MDD). They’re also helpful for treating anxiety disorders, such as panic disorder or generalized anxiety disorder (GAD), as well as obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD). 

Some antidepressants have special attributes, such as helping to manage chronic or nerve pain or depression-related cognitive symptoms. 

Unfortunately, like any medication, antidepressants can have side effects. Most are transient, resolving in the first few weeks, such as nausea or headaches. Others, such as sexual side effects, emotional blunting or weight gain, can persist.

How Medications Get Approved

To be approved for use in Canada, a drug is evaluated in clinical trials for a specific disorder and age group. Health Canada (the FDA in the US) sets out the rules for the type of studies that are required: there are short term trials (in psychiatry, commonly 6-12 weeks) and longer-term trials (one year). 

If a drug is proven to be safe and effective, it is given an “indication”. For instance, an antidepressant might be indicated for the treatment of MDD in adults aged 18-65 because it was studied in that population. In psychiatry, we often prescribe medications “off label” because, through clinical experience and post-marketing research, it has demonstrated safety and efficacy for disorders outside its formal indication, such as GAD, OCD, or PTSD. It’s extremely expensive to seek an official Health Canada indication, so most companies don’t apply for more than one.


Not All Medications Work for Everyone; It Can Take Trial and Error

All antidepressants with a Health Canada indication have been shown to effectively treat MDD, but that doesn’t mean they will work for every person who has a MDD diagnosis. 

There’s a great deal of inter-individual variability when it comes to antidepressant response. That’s really frustrating for patients who just want to get better RIGHT NOW! 

Sometimes it can take months, or even years, of trial and error to find a treatment that is both effective and tolerable. No drug will work if it’s not taken, and no one wants to take a treatment that makes them feel worse or causes them to gain a great deal of weight or messes with their sexual functioning. Fortunately, there are some antidepressants that are better at preserving sexual functioning and less likely to cause weight gain.

Regional Disparity in Access to Mental Illness Medication in Canada

When I’ve diagnosed a patient with MDD that is severe enough for me to recommend an antidepressant, my job is to personalize each treatment plan, determining the best possible options that should manage symptoms quickly and fully with the least risk of burdensome side effects. Unfortunately, getting my patient access to the best possible medication is one of the greatest challenges I face as a clinician.

I can prescribe any drug approved by Health Canada, but unless a patient is willing and able to pay out of pocket, I’m limited by their insurance coverage or provincial formularies. Those with good health insurance have access to the most options, at little or no cost, but those who rely on their provincial formulary have limited options, especially in British Columbia. BC’s formulary is the most limited in Canada.

A recent report detailing that challenges with drug access in Canada found it takes far too long for provinces to list medications on their formularies and there are regional disparities leading to inequitable access.

The Canadian Drug Agency (CDA) is the federal program charged with advising provinces on whether to list a product on their formulary. CDA’s process takes nearly three years from Health Canada approval for a new medication to be added to a provincial formulary. Critically, formulary listing is not a given.

The MDSC report found that psychiatric medications receive a negative recommendation from CDA more than half the time (54%), compared to just 17% for non-psychiatric medications. As a result, most new psychiatric medications are not made available to citizens who rely on their provincial formulary for medication access.

Newer antidepressants aren’t necessarily more effective, but they’re often better tolerated when compared to most older options. Despite multiple trials, some patients remain symptomatic and require other options that might not be accessible. 

Even when drugs are covered on the provincial formulary, they can come with extra work for prescribers, who must undertake a cumbersome application process so their patient can receive that treatment. Denials are common and some prescribers are unwilling to take the time required to apply, re-apply when rejected, and, when accepted, renew the application every year.

The “doctor knows best” approach to medicine is changing, because we’ve learned that patients do much better when they have control over their treatment decisions. In the past, many physicians believed patients couldn’t “handle” having access to their own medical information, much less make their own healthcare decisions. 

Every doctor is, at some point, also a patient, and I know I don’t like that approach one bit, so why would I perpetuate that with my own patients? They are the captains of their healthcare journey. I am an educated navigator, but ultimately, it’s up to each individual I see whether they wish to take a treatment or not. 

I believe it’s my responsibility to offer my patients multiple top options and describe the pros and cons of each.

Dr. Diane McIntosh is a psychiatrist, innovator, educator, author and speaker. She is a passionate advocate for better mental health care, and a champion for all who suffer from mental health challenges. Read Diane’s 7 tips for finding your best antidepressant

This blog post is part of a series looking at the state of our mental healthcare system and ways we can create sustainable change to improve quality and outcomes for anyone impacted by mental illness. 


Dr. Diane McIntosh is a psychiatrist, innovator, educator, author, and speaker. She is passionate advocate for better mental health care, and a champion for all who suffer from mental health challenges.

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