Lake Norman Psychiatry | Huntersville

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December 17, 2009

Health Care Reform: Time to Stop Digging?

Health care reform leapt back into the spotlight this week when independent Senator Joe Lieberman announced that he wouldn’t support any proposal that includes an expansion of Medicare or a public insurance option. Lieberman agrees with the Republican line that an expansion of Medicare and tougher government controls on insurance providers would not only be inflationary, but analogous to a public insurance option which would potentially drive private insurance companies out of business. The American Medical Association (AMA) also opposes the expansion of Medicare, arguing:

Many physicians have been forced to stop accepting Medicare patients because of the program’s burdensome regulations and unstable payment system. Adding more patients to Medicare will force more physicians to make this difficult decision. Medicare payment rates have failed to keep pace with practice cost increases … Adding a new patient population to the program will only increase the cost shifting, raising premiums and health care costs for other Americans (2009).

Lieberman’s stance comes after the Democrats introduced a bill that attempted to break the current senate impasse by proposing a Medicare buy-in option for people aged 55 and over (currently 65+) and not covered by employer-provided health insurance, as well as a network of government supervised private insurance plans.

Lieberman’s opposition to the proposal deepens the political stalemate and threatens to dilute the reform. Meanwhile, the AMA’s position highlights the following conundrum: How will we, without increasing costs, extend coverage to more people (remember, nearly 46 million Americans are uninsured) while maintaining current health care practices?

One of the answers might lie in eliminating unnecessary waste. The existing health system encourages doctors to order expensive procedures and tests through financial incentives, a culture of defensive medicine, as well as patient pressure on physicians to be overly-thorough. A 2006 study that looked at 4,600 preventative health checkups found that 43 percent of them resulted in unwarranted urine, X-ray or electrocardiogram tests on asymptomatic people (Lagorio 2006). If every American were to undergo these tests at an annual checkup, the costs would run into hundreds of millions of dollars (Pho 2008).

There’s lots of talk about the cost of health reform, but what about the cost of not changing? According to the Urban Institute (2009), a nonpartisan research organization, if we make no major changes to the health system, the best case scenario is that by 2014—only five years from now—the number of uninsured Americans will reach 53 million. The worst case scenario is nearly 58 million. Insurance premiums, which have grown 131 percent in the last decade, will continue to grow. Poor affordability will necessitate an expansion of Medicare/Medicaid and further fragment health services.

What do they say about holes? If you find yourself in one, stop digging?

Robin Stone, M.D.
Insight Psychiatry
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810

Further reading:

American Medical Association 2009 Health system reform bulletin, December 9.

Holahan, J et al 2009 Health reform: the cost of failure, Urban Institute.

Lagorio, C 2006 Needless medical tests costly, CBS News.

Pho, K 2008 My take: just say no to unnecessary tests, KevinMD.com.

December 1, 2009

Complementary &Alternative Medicine? Yes & No…

A national study has revealed that 54 percent of people with self-reported severe depression have used complementary and alternative medicine (CAM) in the last 12 months. Two-thirds of them were also receiving conventional therapies (Saeed et al 2009). The October 2009 edition of Current Psychiatry features a meta-analysis that investigates the evidence base for the use of different CAM options in the treatment of severe depression: yoga, exercise, St John’s Wort, SAMe, fatty acids, L-tryptophan, and acupuncture.

The benefits of exercise in the treatment of depression are well documented, and the meta-analysis confirmed this. Interestingly, however, the analysis also revealed that research into the health benefits of exercise in depression has tended to involve mainly young, physically sound patients, which means there’s little clinical evidence to support the extent of efficacy for older, less physically able patients. Still, the researchers recommend that the side effect profile of exercise is benign if a sensible exercise regime is accompanied by appropriate nutrition and hydration. While some studies have found that rigorous exercise (eg aerobics or resistance training) is more effective in treating depression than moderate exercise (eg walking), the meta-analysis revealed that yoga is just as effective as high intensity exercise in inducing symptom remission in severe depression.

Polyunsaturated fatty acids—most commonly omega-3 and omega-6 oils derived from fish—are being praised lately for all sorts of health benefits for the joints, skin, and cardiovascular system. Research also indicates that they may be beneficial in treating depression, especially in combination with an SSRI (Saeed et al 2009). Some studies have also demonstrated that omega-3 is helpful in relieving symptoms of depression in patients suffering from Parkinson’s disease.

Our bodies make S-adenosyl-L-methionine (SAMe) from methionine, an amino acid found in protein-rich foods. The molecule is a metabolite used in the bio-synthesis of norepinephrine, serotonin, and dopamine. Since the 1990s, it’s been available in the US as a dietary supplement and heralded in the popular press for its benefits in treating depression, arthritis, and liver problems.

Most of the favorable studies for St John’s Wort have come from Europe, whereas American trials have not been able to establish a significant difference between the herb and placebo in treating major depression (Saeed et al 2007). While numerous studies have found that St John’s Wort can assist in inducing remission of depressive symptoms, research conducted by the National Center for Complementary & Alternative Medicine (NCCAM) at the National Institutes of Health (2007) did not find that St John’s Wort was any more effective than placebo. It also has some serious side effects which suggest that it shouldn’t be treated as an innocuous herbal remedy. It can also limit the effectiveness of other drugs including the birth control pill, antidepressants, cyclosporine, digoxin, medicines used to control HIV infection, anticancer medications, and anticoagulants as just a few examples (NCCAM 2007)

L-tryptophan is an amino acid used in the biosynthesis of serotonin. It can be derived from foods or ingested as a dietary supplement. While a couple studies demonstrate benefits in combining L-tryptophan with conventional pharmacology in treating depression, the meta-analysis concluded that little clinical evidence exists to support its use. L-tryptophan is also implicated in causing eosinophilia-myalgia syndrome, which led the FDA to ban the sale of L- tryptophan in 1991. The FDA has since loosened the restrictions, although importation is still banned.

While acupuncture may result in some symptom relief, the meta-analysis found that there’s no clinical evidence to suggest that it’s more effective than placebo. Research to date has been poorly designed and inconsistent. The side effect profile, however, seems to be rather benign.

As always, if you intend to utilize a complementary medical treatment please advise your physician.

Robin Stone, M.D.
Insight Psychiatry
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810

Further reading:

Agency for Healthcare Research & Quality 2002 S-adenosyl-L-methionine for treatment of depression, osteoarthritis, and liver disease, US Deparment of Health & Human Services Evidence Report, no. 64.

National Center for Complementary & Alternative Medicine (National Institutes of Health) | Get the Facts | St John’s Wort & Depression 2007.

Saeed A., Bloch, R., et al 2009 CAM for your depressed patient: six recommended options, Current Psychiatry, vol. 8