Insurance is often an invisible third party in psychiatric care. Justin Ray, MSN, PMHNP-BC of South Chesapeake Psychiatry examines how neuroscience, clinical judgment, and coverage intersect, and what it means for patients seeking psychiatric care and medication management in Chesapeake, VA.
Modern psychiatry is advancing rapidly, from neurotransmitters to neural circuits and plasticity. Yet in everyday clinical practice there is often an unspoken participant shaping treatment decisions — the insurance company sitting quietly in the room.
As a psychiatric nurse practitioner, part of my job is staying on top of where the science is going. That means understanding the latest research, the newest mechanisms, the evolving treatment models, and the deeper biology that is increasingly reshaping psychiatry. Over the last several editions of this brief, I have written about the shift away from thinking about depression and other psychiatric illness as simple neurotransmitter deficiencies and toward a more layered understanding rooted in neural circuits, plasticity, and the architecture of recovery.
It is an exciting time in psychiatry. We are no longer confined to a conversation that begins and ends with serotonin, norepinephrine, and dopamine. The field is moving toward something deeper. We are talking more seriously about synaptic remodeling, network function, excitation and inhibition, and the ways chronic illness may alter the brain over time. We are asking better questions now. What if depression is not merely a disorder of mood, but a disorder of impaired adaptability? What if treatment is not simply about changing chemicals, but about helping injured systems reorganize themselves in ways that restore stability, function, and resilience?
That is the science side of the story.
But being a good clinician requires more than understanding mechanism. It also means understanding the system you work inside of, because no matter how compelling the science may be, treatment only matters if your client can actually receive it.
That is where psychiatry becomes both intellectually interesting and deeply frustrating.
The STAR*D trials made something painfully clear years ago. A large number of people simply do not respond adequately to traditional antidepressants. Even when they do respond, response is not the same thing as remission, and remission is not the same thing as recovery. A scale can improve while a life remains functionally narrowed. Symptoms can soften while motivation, initiative, cognition, and real-world engagement remain far behind. That distinction matters. It matters in research, and it matters even more in clinic. We should never confuse movement on a rating scale with restoration of a person’s life.
At the same time, we practice within a world of labels, indications, formularies, prior authorizations, and diagnostic architectures that do not always map neatly onto the biology or the lived clinical reality in front of us. Anyone who has practiced long enough understands this. We do not simply diagnose and treat in a vacuum. We diagnose and treat inside a reimbursement system, inside an approval system, and inside a regulatory system. That reality influences care whether we like it or not.
This is part of why clients with bipolar disorder so often also carry a diagnosis of major depressive disorder. On paper, that may strike some people as contradictory or inelegant. In practice, it reflects something far more pragmatic. I do not know what that client may need in a year, in two years, or in five. If someone with bipolar disorder becomes depressed while stable on a mood stabilizer or neuroleptic, the next treatment step may be limited not by the biology of the depression, but by the language of the indication. A medication like Trintellix is not indicated for bipolar depression. That may become highly relevant later, and clinicians who think longitudinally understand that these coding realities are not theoretical. They shape access.
That brings me to the case that pushed me to write this special edition.
I took over a client’s Spravato treatment while a friend and colleague was away on vacation. She had already been in treatment for roughly a year. She was on once-weekly maintenance dosing. From the outside, it would have been easy to assume the plan was settled. She was still in treatment, still coming, still receiving care. But when I looked more closely, the picture did not feel stable. Her PHQ-9 made it clear that she was not doing well. Not catastrophically, not in a way that would necessarily trigger alarm for someone glancing quickly, but clearly not where she needed to be.
So I did what good clinicians are supposed to do. I reassessed. I looked at the symptoms, the trajectory, and the response pattern, and I discussed with her the possibility of returning to twice-weekly treatment. She was receptive to it. Clinically, it made sense. The problem was that there is always another participant in American psychiatry: the insurance company.
At that point I went looking for literature, case support, anything I could find that would help justify the return to twice-weekly dosing in a maintenance-phase client who had not truly held her gains. I was surprised by how little I could find that directly matched the question I was trying to answer. There was enough around esketamine to support its role in treatment-resistant depression generally. There was enough to support individualized care conceptually. But there was far less than I expected when it came to the specific real-world problem of needing to intensify treatment again after inadequate maintenance response.
And yet the client in front of me did not need a conceptual paper. She needed approval.
So I fought it.
Ultimately, I was successful in getting the twice-weekly treatment approved, and the outcome reinforced exactly why this matters. In the case materials, the client began with severe depressive symptoms, showed only modest improvement during the initial phase, resurfaced symptomatically during weekly maintenance, then improved significantly after transition to twice-weekly dosing. When treatment frequency was reduced again due to insurance barriers, symptoms worsened, and when twice-weekly dosing was reinstated, she moved into remission.
That sequence matters. It matters because it is not just a story about a medication working. It is a story about dose intensity, durability, and clinical listening. It is a story about not mistaking partial stabilization for adequate treatment. And it is a story about the uncomfortable truth that sometimes the biggest barrier between a client and improvement is not the illness itself, but the system standing between the clinician’s judgment and the treatment plan.
That was what made this worth writing up.
I believed then, and I still believe now, that this sort of case has value beyond a single clinic. I tried to get it out through traditional channels. It was turned down for an APNA poster board and by a couple of journals. That happens. Not every clinically meaningful observation fits neatly into the formal structures that decide what gets elevated and what does not. But rejection by a conference or a journal does not make an idea clinically useless. Sometimes it just means the conversation has to happen somewhere else.
So I am bringing it here.
I am bringing it to colleagues, clinicians, prescribers, and anyone else working in the messy middle where biology, suffering, access, and real-world treatment collide. Because this is what actual psychiatric practice looks like. It is not just understanding glutamate, plasticity, mTOR, or circuit dysfunction, though those things matter. It is also recognizing when a client is not truly maintaining gains, understanding when a treatment needs to be intensified, and being willing to navigate the approval machinery required to make that happen.
The future of psychiatry will absolutely involve better science. It will involve more precise mechanisms, better circuit models, better biomarkers, and hopefully more flexible treatments designed around how people actually recover rather than how formularies prefer to categorize them. But until then, good psychiatry still requires something less glamorous and just as important.
It requires advocacy.
It requires knowing the evidence, understanding the system, documenting the case, and fighting when necessary. Because sometimes the difference between a client staying stuck and a client getting better is not whether we have a promising treatment.
It is whether someone is willing to push hard enough to get that treatment through the gate.
South Chesapeake Psychiatry offers psychiatric evaluation and medication management in Chesapeake, VA, with in-person and telepsychiatry options across Hampton Roads.
Coverage decisions can influence which medications and treatments are accessible. A knowledgeable prescriber can help navigate options within your plan.
Yes. South Chesapeake Psychiatry provides virtual psychiatric care in VA and telehealth medication management for patients across Hampton Roads.
South Chesapeake Psychiatry provides expert psychiatric care and medication management in Chesapeake, VA, with in-person visits and secure telepsychiatry for patients across Hampton Roads and throughout Virginia. To request an appointment for psychiatric care and medication management, contact South Chesapeake Psychiatry today.
To schedule an appointment with South Chesapeake Psychiatry, call 757-908-2124.
This article is for educational purposes only and is not medical advice. Always consult a qualified clinician about your individual care.
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