The push toward nontraditional care—and implications for health equity

While there is a lot of innovation happening in the behavioral health space, these innovations must still contend with legacy questions even as they raise new ones.

Behavioral health conditions are prevalent and have gotten increasingly more prevalent, even before Covid-19. The current state of affairs is not meeting patient needs for treatment and several systemic reasons, such as inconsistent reimbursement, staffing shortages, and fragmented care are exacerbating these issues.

We have seen a host of new products that serve to improve upon the status quo. Potential adoption of these therapies could disrupt various elements of health care and raise important questions for which we do not have definitive answers.

In this blog we look at three promising therapies and the questions they raise for health equity.

1. Psychedelic-assisted therapy

Psychedelic-assisted therapy entails using a high dose of a psychedelic substance to treat a variety of behavioral and mental health issues such as addiction, mental health conditions like depression and anxiety, and post-traumatic stress disorder (PTSD).

Currently, ketamine is the only psychedelic that is legalized for the treatment of mental health conditions, although many others like MDMA and psilocybin are in the pipeline for FDA approval.

Hispanic and African American  populations have higher rates of major depressive disorder and Native American and multiple-race populations are at higher risk of substance abuse. Historically, these communities battle stigma and persecution related to these drugs and face higher rates of addiction. However, access to psychedelic assisted therapy could serve as an alternate to traditional medication where patients may experience suboptimal treatment and adverse side effects.

Acknowledging the history and moving forward will require health care leaders to think intersectionally about how to address systemic issues and not perpetuate them in practice.

Some solutions will be to address and acknowledge stigma surrounding mental health conditions in marginalized groups and recruiting diverse and inclusive groups of researchers and participants. Additionally, clinical staff need adequate training for the administration of these therapeutics, including cultural sensitivity and education of communities about harm reduction and risk of abuse.

2. Deep brain stimulation

Deep brain stimulation (DBS) is the implantation of a device that modulates brain circuits to send signals to areas responsible for body movement, to treat neurodegenerative conditions such as Parkinson's, epilepsy, but these devices may also be medically indicated in other mental disorders, such as treatment for treatment resistant depression, bipolar disorder, schizophrenia and more.

Innovative treatments in this area are now less invasive and can also include medical devices such as helmets and electrode patches.

There are clear racial disparities in treatment for therapeutic areas that brain stimulation is used for. For example, Black patients are less likely to be diagnosed with Parkinson's Disease, are more likely to have delays in diagnoses, and once diagnosed, are undertreated when compared to White patients.

While deep brain stimulation has the potential to bridge health disparities, it could also frustrate equity efforts if marginalized groups receive the procedure less frequently than their White counterparts. It will also be vital to ensure adequate representation in clinical trial data and evidence across a broad spectrum.

Access also has a part to play for equitable outcomes across demographic groups. In a recent NeuroNews article, Myrdalis Diaz Ramiriz stated that these devices tend to be more accessible to White men, those who are privately insured, those with fewer comorbidities, those who are seen at higher volume hospitals, and those with higher socioeconomic status.

The cost alone of deep brain stimulation (including the implanted device, hospital fees, etc.) can hinder access to treatment for lower income individuals, or the uninsured, thus cost will need to be regulated to ensure equitable outcomes.

3. Digital therapeutics

Digital therapeutics (DTx) are scalable software solutions built on clinically-proven approaches to behavior change that can be used for long-term disease prevention and management. The current wave of investment in DTx stems from an uptake in remote patient monitoring devices, telemedicine, and digital apps.

Although the adoption of digital therapeutics is a strategy to combat high-cost drugs and improve access to quality healthcare, it has the potential to exacerbate health equity efforts. Recent research shows that lack of access to technology is a social determinant of health.

While digital inequities in health care are not new, the rapid scaling and use of technology for digitally-enabled care has increasingly excluded disconnected patients from accessing care. Uptake will also depend on digital literacy and how patient education is tailored from patient to patient, to ensure that patients are able to manage their care.

Because of the technology aspect of DTx, only patients who can operate and afford the technology may benefit from its utilization, which could lead to biases in health outcomes.

Disruptors present a unique opportunity to improve access and health disparities

Generally, these disruptive therapeutics may present an opportunity where therapies are difficult to access and may be ineffective for more severe or rare disease as a more accessible alternative for a larger segment of the population.

These therapies have a lot of promise, but there are serious risks that they might exacerbate the problem instead. They have the potential to alleviate health inequities if there is fair representation in clinical trial phases and evidence generation.

On the other hand, inadequacies in access and affordability may exacerbate health inequities by posing an even greater economic burden on underserved populations.