Childhood ADHD and Medicaid

December 31, 2010

A study out of UCLA shows that there is a need for significant improvement in the delivery of ADHD care to children on Medicaid.  The study was published in the Journal of the American Academy of Child and Adolescent Psychiatry and a summary can be found at Medscape.

The study followed over 500 children with ADHD.  All were on Medi-Cal (California’s Medicaid program) and were observed over a one-year period.  Some participated solely in primary care treatment, while others received “specialty care” in mental health clinics.  (Because this was an observational study, children were not randomized or assigned to each group, but were simply followed over their course of treatment.)  The study found that at the end of the year, both groups of children fared the same on measures of ADHD symptoms, functioning, academic achievement, family function, and other parameters.

How did primary care differ from “specialty” care?  For one thing, children in the primary care group received stimulant medication 85% of the time (nearly all of these children received a prescription for some medication) but that was about it:  They only followed up with their providers an average of 1 or 2 times in the entire
one-year followup period, and their prescription refill rate was less than 40%.  (50% dropped out of care.)

On the other hand, over 90% of the children in the specialty care group received some sort of psychosocial treatment, and only 40% of these children received medication (30% received stimulants).  Office visits were far more frequent in this population, too, averaging over 5 per month for the duration of the one-year study.

So on the face of it, one might predict that specialty treatment would provide much better care; children had far more frequent contact with their providers, medications were used judiciously (one would assume), and psychosocial interventions were included.  However, the end result was that children did not fare differently in each group.  Academic scores and measures of clinical impairment and “parent distress” were similar in both groups.  Dropout rates and medication discontinuation rates were also similar in each group.

One obvious limitation of this study, which the authors emphasize, is that this is not a randomized trial, but rather an observational study of “real world” patients.  But then again, that’s what they wanted to do:  to observe whether mental health clinics provided better ADHD care.   Two unfortunate conclusions can be drawn.  First, primary care mental health clinics do very little to treat childhood ADHD (cynically, one might look at the data and conclude that they simply “throw meds at the problem” with little to no follow-up).  Secondly, even when these clinics do refer children to a higher level of care, the outcomes aren’t that much better (and the resource costs are undoubtedly much higher).

With the promised expansion of the Medicaid program under PPACA, more children will be receiving care, with mental health as a priority area.  Hopefully, studies like this one will prompt us not simply to provide more care to the increased number of children that will undoubtedly seek it, but to provide better care along the way.

Allen Frances and the DSM-5

December 30, 2010

There’s a great (and long) article in the January 2011 Wired magazine profiling Allen Frances, lead editor of the DSM-IV and an outspoken critic of the process by which the American Psychiatric Association (APA) is developing the next version, the DSM-5.  It’s worth a read and can be found here, as it provides a revealing look at a process that, according to the author (somewhat melodramatically, I might add) could make or break modern psychiatry.

I have many feelings about what’s written in the article, but one passage in particular caught my attention.  The author, Gary Greenberg, writes that he asked a psychiatrist (in fact, a “former president of the APA”) how he uses the DSM in his daily work.

He told me his secretary had just asked him for a diagnosis on a patient he’d been seeing for a couple of months so that she could bill the insurance company. “I hadn’t really formulated it,” he told me.  He consulted the DSM-IV and concluded that the patient had obsessive-compulsive disorder (OCD). 

“Did it change the way you treated her?” I asked, noting that he’d worked with her for quite a while without naming what she had.


“So what would you say was the value of the diagnosis?”

“I got paid.”

I include this excerpt because the “hook” here—and the part that will most likely attract the most fervent anti-psychiatry folk—is the line about “getting paid.”  But this entirely misses the point.

See, the DSM-5 is easy to criticize because it seems like a catalogue of invented “syndromes”, from which any psychiatrist can pick out a few symptoms (some of which, I would venture to say, both you and I are experiencing right now), name a diagnosis, and prescribe a medication—and get paid by the insurance company because he believes he is confidently treating a “disease.”  But the truth of the matter, if you talk to any thoughtful psychiatrist, is that, more often than not, the book gets in the way.

In the example above, the doctor had seen his patient for several sessions but hadn’t yet come up with a firm diagnosis.  He settled upon OCD because he was required to write a diagnosis on some form or another.  Yes, ultimately to get paid, but I think we’d all agree that professionals deserve to be reimbursed for their time.  (And if he’s actually listening to his patient instead of comparing her symptoms to a list in a book, his patient would probably agree as well.)

Did this woman have OCD?  Judging by his hesitancy, it’s arguable that perhaps she didn’t have all of the symptoms of OCD.  But she was probably suffering nonetheless, and such presentations are typical of most psychiatric patients.  Nobody fits the DSM mold, we all have quirks and characteristics that present a very complicated picture.  I would argue that this psychiatrist was probably doing well by not rushing to a diagnosis, but instead getting to learn about this woman and develop a treatment plan that was most appropriate for her.

The article’s author writes that if the DSM-5 is a “disaster,” as some observers predict it will be, the APA will “lose its franchise on our psychic suffering, the naming rights to our pain.”  Quite frankly, this could turn out to be the best possible outcome for patients.  If we as a profession ditch the DSM, and stop looking at patients through the lens of ill-defined lists of symptoms, but instead see them as actual individuals, we can better alleviate their suffering.  Yes, a new system will need to be devised to ensure that we can prescribe the interventions that we believe are most appropriate (and yes, to get paid for them), but a patient-centered approach is preferable to a formula-based approach anytime.

A new take on placebos

December 29, 2010

It has long been known in medicine that placebos can be surprisingly
effective, for the treatment of a wide range of disorders.  A placebo, whose name is taken from
the Latin for “I please,” is an inert substance, a sugar pill, that
should have little to no effect on any physiological process.

A “placebo-controlled study” is considered the gold standard in medication
trials; in such a study, half of the patients with a given condition
are prescribed an active medication, while the other half are
prescribed a placebo.  In virtually all studies, there is some
improvement in the placebo group, and this improvement can, at times,
be significant.  In trials of antidepressants, for example, it has
been estimated that up to 75% of the antidepressant response may be due
to a placebo effect, an observation that has received much
popular press
of late.

A research group at Harvard Medical School has taken this one step
further.  They took a group of patients with irritable bowel
syndrome (IBS), gave half of them a placebo, and the other half nothing.  (This would be, I
guess, “placebo-placebo controlled study”!)  More importantly,
however, they even told the
placebo group that they were getting a placebo!  Specifically,
they told patients that they would get “placebo pills made of an inert
substance, like sugar pills, that have been shown … to produce
significant improvement in IBS-symptoms.”

In their report (available freely here), they
showed that the placebo was more effective at treating IBS symptoms
than nothing at all, and– even though they did not directly compare
placebo to any active medication– they found that the rate of
improvement was twice the success rate of the most powerful IBS

While this raises several important questions about the utility of
placebos in medicine, it also hits at the heart of a lot of what we do
in psychiatry.  Most psychiatrists have the experience of seeing a
patient fail multiple medications but exhibit a positive response to
yet another medication from the same class, for no obvious
reason.  Or giving two similar patients the same medication and
finding that one responds while the other does not.

Modern biological psychiatry looks at situations like these and asks,
what are the interindividual biochemical or physiological differences
that predict response to one agent over another?  Are there
genetic or other biological markers that make one person a better
candidate for medication X than for medication Y?

This study, however, raises new questions in situations such as
these.  If patients’ symptoms can improve after taking an inert
substance (and I’d be interested to see a repeat study on patients with
a mental illness– although IBS itself is a “psychosomatic” illness
with strong psychological features), this result cannot be ignored and
ascribed to chance.  Something is
working in this treament, but exactly what?  Is it the way we talk to patients about
treatment?  Something about patients’ expectations of treatment?  If
patients don’t believe that their meds will work, does this prompt them
to enact more effective behavioral changes in their lives?  It
appears that patients have more of an ability to solve their problems
than we often give them credit for, and this study should prompt us to
look for those strengths, not serve as ammunition to attack the
weaknesses of psychiatric medicine.

Are we more depressed?

December 21, 2010

A new study in the Archives of General Psychiatry examines trends in the treatment of depression between 1998 and 2007, and finds that—surprise, surprise!—we’re treating more depression.

The study finds that the rate of outpatient treatment for depression increased from 2.37 per 100 persons in 1998 to 2.88 per 100 persons in 2007.  That is, almost three of every 100 persons reported that they sought some sort of treatment for depression.

Some other findings from the study:

1998 2007
Percentage of depressed patients on antidepressants 73.8% 75.3%
Percentage of depressed patients who received psychotherapy 54% 43%
National expenditures for outpatient treatment of depression $10.05 B $12.45 B
Cost attributed to medications $4.59 B $6.60 B

(1998 numbers adjusted for inflation)

So what does this all mean?  Well, for starters, here’s how the study was done:  about 23,000 individuals were interviewed about their treatment over the past year.  If patients reported seeking help for “depression,” they were included, even though they may have been suffering from dysthymia, a depressed phase of bipolar disorder, an adjustment disorder, or an underlying anxiety or substance use problem.  Regarding the expenditures, these numbers were gathered from large databases of office visits and hospitalizations, and data were included only if the providers gave a diagnosis of major depression, dysthymia, or “depression not otherwise specified.”

Note the rise in medication costs, up to $6.6 billion in 2007.  (Of this, the proportion borne by Medicare rose from $0.5 to $2.25 billion, most likely due to the implementation of Medicare Part D in 2006.)  These numbers reflect a substantial increase in how much money we’re paying for antidepressants and other medications to treat depresssion.  (In case you were wondering, the total outlay for the entire Medicare program in 2007 was $375 billion.)

So we’re spending more money on depression treatment, and more than half of that money is on medications for depression.  (Incidentally, the same researchers also reported that the percentage of all Americans taking antidepressants in any given year rose from 5% to 10% over the same time period.)  Does that mean we’re winning the war on depression?  Doesn’t look like it.  Does it mean people are more depressed now than they were in the past?  Possibly.  Is there some other reason why patients are seeking help, and providers just find it more palatable to give a diagnosis of depression?  That’s a possibility, too.

All I can say is, when I see numbers rising like this—whether we’re talking about disease rates, costs, or numbers of prescriptions—it means we’re not handling this epidemic very well.  The question is, epidemic of what, exactly?

The future of psychiatric diagnosis?

December 20, 2010

What is a mental illness?  To most psychiatrists, the answer lies in the DSM-IV, essentially a catalog of diagnoses and diagnostic features of each disorder.  It has been derided as presenting a “cookbook” (or, perhaps less PC, a “Chinese menu”) approach to psychiatry, in which a diagnosis is made on the basis of the presence of a number of symptoms drawn from a list.

While this approach has proven helpful for research and clinical purposes, it unfortunately oversimplifies what is undoubtedly an extraordinarily rich spectrum of mental disorders.  (It also, of course, calls into question where is the demarcation between “normal” and “disorder” on that spectrum, but more about that some other time.)  As any clinician will tell you, no two depressed patients are alike, just as no two schizophrenics are alike, no two bipolar patients are alike, and so forth.

In reality, there may be dozens of diseases that we now call “scihzophrenia” (or “depression” or “panic disorder,” etc).  Some may stem from a clear genetic mutation in some as-yet unidentified gene, while others may be a consequence of endocrine dysregulation or disturbances in brain development.  Others may be defined by their propensity to respond (or not) to various pharmaceutical agents, or the patient’s biological tendency to endure side effects of such agents such as weight gain or movement disorders.

The National Institute of Mental health (NIMH) is trying to expand our nosologic system by incorporating neurobiolgoical and physiological measures as well as observable behavior in our classification of psychiatric disorders.  The Research Domain Criteria aims to

… define basic dimensions of functioning (such as fear circuitry or working memory) … across multiple levels of analysis, from genes to neural circuits to behaviors, cutting across disorders as traditionally defined.

What might this mean for the future of psychiatry?  For starters, instead of a checklist to generate a diagnosis, a clinician might order a brain scan, a blood test, a measure of some genetic marker, or a more intensive review of one’s history in order to develop an “individualized” treatment approach.  How long it takes to get to this point (and whether we can afford it) remains to be seen.

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