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.