"Interventional Psychiatric Care" Needs To Include A Feeling of "Being Cared For"
A Meditation on business models that work
We've seen a real series of disasters when it comes to behavioral health businesses. I had the pleasure of speaking with my friend Chris at Behavioral Health Business about the unfortunate state of affairs for Greenbrook TMS. Getting delisted from a stock exchange is a bad day for a company. It is a worse day for the field of interventional psychiatry. Welcome to The Frontier Psychiatrists, a newsletter.
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Since the company only provides psychiatric interventions, it’s subject to several powerful market forces with nothing else to stabilize it. It also forces this business model to grapple with potentially unsustainable unit economics. Dr. Owen Muir, founder of the New York-based interventional psychiatry firm Fermata and an expert in TMS, told BHB that this constrains the profitability of clinics.
Greenbrook TMS relies heavily on referring clinicians, as it says in its documents. So, it doesn’t have a consistent tether to its patients or another service line with recurring revenue. Further, TMS is widely seen as effective, but payers have been hesitant to make it easily accessible through health benefits without difficult prior authorizations and utilization management.
“Widely seen as effective” is a gracious way to put that sentiment. I would argue that TMS is not widely seen as anything. Nobody knows what it is. I didn't think it was real before I was treated with it either. Three confusing letters, that become three even more confusing words? Not good branding!
People know what doctors are. They know what depression is, or at least they think they do. They know they're suffering. They know they don't want to suffer. I think that's about as far as anybody has gotten with Branding for any “mental health product.” They know they have a problem, they know it might be depression or something, and they really would rather not suffer.
One of the difficulties with traditional TMS treatment is that it takes 36 days. Insurance decided to pay once a day, and as I've endlessly written, this is a problem. Finally, even authors like Tim Ferris have gotten on board!
A Crucial Issue? People who are depressed have pathological indecision. They can't make up their mind. This problem even has a dedicated word— Aboulomania. The ability to make a decision definitively is one of the things that's impaired by depression1. It's also impaired by obsessive-compulsive disorder, which people don't talk about much, but co-occurs with depression frequently2. It occurs with anxiety. Anxious people who can't make up their minds have a really hard time deciding that they're going to take 36 days and go from their home or to another office for 30-minute treatment, and then go back to whatever else they were doing. This is not a particularly practical way to get treatment. Business models built on this impracticality won’t work either. Then again, investors may have a case of Aboulomania also?
Less impaired people have work to go to, and more impaired people often can't get out of the house.3 It takes too long to deploy that treatment in a hospital setting, where the length of the state is all of a day, and there's no way to pay for it anyway.
People who are trying to sell TMS as a treatment for depression forget that depression is a huge pain in the ass. It makes it hard to make any decision. It makes it even harder to make 36 decisions in a row. It makes it even harder to decide whether you're going to find yet another doctor, on top of the doctor you already have, to add another treatment. Maybe the treatment is more of a hassle than a pill, and that's more of a hassle than therapy, and both pills and therapy you would at least heard of before!
The failure of Greenbrook? It is a failure of imagination when it comes to how to make a plan to get anybody with depression to get any treatment whatsoever. That's what depression does. We have got to make it easy. You make it easier by building trust, reducing friction, providing hope, perhaps education, and ensuring the treatment you're offering is wildly effective. Anything we do to get in the way of somebody getting depression treatment makes it less likely that a person with depression will get that treatment!
It can be as simple as a prior authorization, an extra step, or an additional co-pay. Even one more visit can be too much for someone with depression. Someone with anxiety can worry that it might not work, or what if it does, or if it doesn't, or what if it does, or what if it doesn't!
TMS and depression don't get along if it's only ever offered in a way that is not depression-friendly. People with depression need to make fewer decisions, not more. They can walk into a treatment for a day, or they can walk into a pharmacy for a refill, but the more days they have to do a thing, the less likely is to happen. It's not because they don't want to get better. It's because depression creates impairments in the variability to do things that seem completely reasonable to people who are not depressed.
Greenbrook TMS didn't fail just because the market forces pushed it in the wrong direction, which is of course, also true. Payers did not want to pay for a thing that wasn't a drug they got to kick back on. Payers didn't want to pay for a thing that reduced the spending on drugs they did get kickbacks on. Payers probably didn't even think about it. They are too busy counting billions of dollars.
The real failure is a failure to understand that depression is hard. Getting out of bed is a major decision when you have depression. Getting out of your house is sometimes an overwhelming difficulty. Deciding to go to another appointment, after so many things have failed, can seem insurmountable. There could be $1 billion at the end of 36 treatments. It wouldn't matter to many people with depression.
We need to re-understand depression: every impediment to getting treatment? Obstacles make it less likely that patients will receive treatment. Depression has hopelessness as a symptom. You might not be able to imagine how much better you could feel. It doesn't matter how good 36 once-a-day treatments are, it's less likely that someone with depression is going to make that choice.
Accelerated TMS. Now. Not Later. Paid for, by health plans, for everyone.
Thanks for reading. And good luck to my colleagues at Greenbrook TMS, and every physician working to help their patients get better with treatments that are proven, effective, and safe—thank you.
Bistas K, Tabet JP. Aboulomania, a Mental Disorder Characterized by Pathological Indecisiveness. Cureus. 2023 Jul 9;15(7):e41592. doi: 10.7759/cureus.41592. PMID: 37559848; PMCID: PMC10407977.
Hellberg, S. N., Abramowitz, J. S., Ojalehto, H. J., Butcher, M. W., Buchholz, J. L., & Riemann, B. C. (2022). Co-occurring depression and obsessive-compulsive disorder: A dimensional network approach. Journal of Affective Disorders, 317, 417-426.
Choi, N. G., & McDougall, G. J. (2007). Comparison of depressive symptoms between homebound older adults and ambulatory older adults. Aging & mental health, 11(3), 310-322.