April 6, 2010
Dietary intervention and mental illness
Recent results of an epidemiologic study demonstrated an association between habitual diet quality and the high-prevalence mental disorders, particularly anxiety and depressive disorders in women.
Researchers in Australia studied 1,046 women ages 20–93 years randomly selected from the population. After adjustments for age, socioeconomic status, education, and health behaviors, it was shown that a “traditional” dietary pattern characterized by vegetables, fruit, meat, fish, and whole grains was associated with lower odds for major depression or dysthymia as well as for anxiety disorders. In contrast, a dietary pattern comprising processed and “unhealthy” foods (western) was associated with a higher likelihood of psychological symptoms and disorders.
Depression is influenced by genetic, hormonal, immunological, biochemical, and neurodegenerative factors. Diet modulates each of these factors and, as a result, has a plausible impact on the development and course of psychiatric illness.
Adherence to a Mediterranean diet, high in vegetables, fruits, legumes, whole grains, fish, olive oil, and low-fat dairy products, correlates with lower levels of inflammatory markers that have been implicated as a contributing factor in depression as well as other chronic medical illness (specifically some types of cancers and cardiovascular disease).
Robin Stone, M.D.
Insight Psychiatry
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810
For Further Reading:
Kotowitz, and Berk. Association of traditional and western diets with anxiety and depressive disorders in women. American Journal of Psychiatry, March 2010
Molteni R, Barnard RJ, Ying Z, Roberts CK, Gomez-Pinilla F: A high-fat, refined sugar diet reduces hippocampal brain-de¬rived neurotrophic growth factor, neuroplasticity and learning. Neuroscience 2002; 112
January 7, 2010
Not There Yet: Comparing the House & Senate Health Care Reform Bills
On December 24, just as Santa was hitching his reindeer, the Senate passed a historical bill in support of health care reform. The gravity of the bill has been compared to the Social Security Act of 1935. Analysts point out, however, that the current health care reform bill lacks bipartisan support—representatives voted 220 to 215, divided straight along party lines. Furthermore, the differences between the House and Senate bills must yet be negotiated.
This article takes a brief look at some of the differences—potential sticking points—between the bills passed by the House and the Senate.
Individual mandate: Both proposals require that Americans hold a minimum amount of health insurance, or face a financial penalty. The penalties differ slightly between the House and Senate proposals, but both exempt American Indians, people with religious objections, and people suffering financial hardship.
Employer contribution: Both proposals require most employers to contribute to the cost of health insurance for at least some of their employees. The House version requires employers with a payroll of $500,000 or more to provide employee coverage, or pay a federal tax penalty. The Senate version does not stipulate that employers must supply insurance coverage, but companies with 50 or more full-time employees will face penalties if they do not. In the Senate version, employers who do not supply coverage will be required to provide vouchers to low- and middle-income earners who will be expected to buy their own coverage from an insurance exchange.
Insurance exchange: The House proposal supports the creation of a national insurance exchange, whereas the Senate version allows the states to organize their own exchanges. Both proposals are open to individuals who do not qualify for insurance through their employer or a government program. The Senate version allows access to insurance exchanges for employers with less than 100 employees, while the House proposes a graduated approach—twenty-five or fewer employees in the first year of the program, 50 or fewer in the second year, and 100 or fewer in the third year.
Public option: The House supports a public insurance option which would be operated on a non-profit basis by the government. This public insurer would negotiate directly with hospitals, doctors, and pharmaceutical companies. The Senate proposal does not include a public option—rather the government would enter into contracts with insurance companies to offer two national health plans, one of which would be operated as non-profit.
Expand Medicaid: The House proposes to extend Medicaid coverage to everyone with incomes less than 150 percent of the poverty level ($33,075 for a family of four), while the Senate proposes to cover everyone with incomes less than 133 percent of the poverty level ($29,327 for a family of four). In both proposals the federal government would cover around 90 percent of the costs, with the states making up the balance. This works out favorably for the states because they currently contribute 43 percent to Medicaid costs on average.
Insurance regulations: Both proposals prohibit insurers from denying coverage or charging higher premiums because of a person’s medical history or health condition. The House proposal goes further, however, by outlawing price fixing and bid rigging, and removing the current exemption of insurance companies from antitrust laws. The House is also more generous in limiting premiums for older people to no more than double that of younger people, while the Senate proposes a cap on premiums that are no more than three times higher for the elderly. The Senate also requires insurance companies to devote more of their income to medical claims by reducing their administrative overheads and spending at least 85 cents in every dollar on medical reimbursements.
Illegal immigrants: The House proposal allows illegal immigrants to purchase coverage from insurance exchanges, while the Senate version does not.
Abortion: In the House proposal, insurance plans can choose to cover abortion, but insurance exchange and public plans will exclude it. In the Senate proposal, health plans may choose to include abortion coverage, but states may elect to ban it. Moreover, people who do choose a plan that includes abortion will be required to pay the abortion component as a separate premium.
Out-of-pocket expenses: Both proposals limit out-of-pocket spending—in the House version, $5000 for individuals and $10,000 for families; in the Senate version, $5950 for individuals and $11,900 for families. These limits would be reduced for people with income less than 400 percent of the poverty level—around $88,000 for a family of four.
Paying for it: The House proposes to pay for reform via a 5.4 percent tax on very high income earners (families with a combined income of $1 million or more, and individuals earning more than $500,000), plus a 2.5 percent tax on medical devices sold in the United States, combined with savings in reduced aspects of Medicare. The Senate proposal is more complicated: a 40 percent tax on “Cadillac” insurance premiums, annual fees for pharmaceutical, medical device and insurance companies, savings against reduced aspects of Medicare, and a 10 percent tax on indoor tanning services.
In both cases, the proposed legislation is intended to be fully implemented by around 2014. The next step, however, is to reconcile the differences between the bills passed by the House and the Senate. Republicans and lobby groups are also expected to make the passage difficult.
Robin Stone, M.D.
Insight Psychiatry
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810
Further reading:
Murray, S & Montgomery, L 2009 Senate passes health care bill, must now reconcile it with House, The Washington Post.
Pear, R 2009 Senate Passes Health Care Overhaul on Party-Line Vote, The New York Times.
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
Posted by at 11:12 AM | Permalink | Leave your Comment here (0) | TrackBacks (0)November 12, 2009
Over The Counter, Under The Radar
When I have a few spare minutes for surfing the web, I wouldn’t normally spend them looking at a website like Bodybuilding.com. But I was there, nonetheless, this afternoon. On the homepage I was greeted by a slideshow of before and after photos. One of the slides was of 55 year old, Ed, a roofing products salesmen from Vancouver, Washington. In his ‘before’ photo, Ed is pale and pudgy in his swimming trunks—almost unrecognizable in relation to the ‘after’ photo where Ed’s big ropey muscles ripple under over-tanned, paper-thin skin. In his bio, Ed says his goal is to reach three percent body fat. He says that his favorite supplements are ‘Elite Whey’ and ‘Instantized BCAA 5000’ (whatever that is).
Which was the point of my visit. On November 3, the Food and Drug Administration (FDA) recalled 65 products sold by Bodybuilding.com as dietary supplements. The FDA has found that some of the ingredients—Superdrol, Madol, Tren, Androstenedione, and Turinabol—should be classified as steroids. They carry the risk of acute liver damage, as well as ‘shrinkage of the testes and male infertility, masculinization of women, breast enlargement in males, short stature in children, a higher predilection to misuse other drugs and alcohol, adverse effects on blood lipid levels, and increased risk of heart attack, stroke, and death’ (FDA 2009).
The recall elevates into public concern, the way in which dietary supplements are regulated in the US. Before 1994, the constituent ingredients of dietary supplements were treated as food additives, and manufacturers were required to prove their safety. But since the passage of the 1994 Dietary Supplement Health and Education Act, dietary supplements are immune from FDA approval, and assumed to be safe.
The act creates a backdoor through which manufacturers can slip badly labeled and contaminated supplement products onto the US market. Some of these contain undeclared and potentially dangerous active pharmaceutical ingredients such as amphetamines, diuretics, and steroids. To date, the FDA has uncovered around 140 contaminated products, and they suspect that around 50,000 unreported adverse events occur each year. While many of the contaminated products are manufactured overseas and sold on the internet, some of them have also made it onto retail shelves. Some manufacturers further attempt to avoid detection by replacing controlled active ingredients with chemical analogues that replicate the actions of the original compound. In addition to potential side effects, most of these analogues are yet to be clinically trialed for use in humans.
The public generally doesn’t understand that these substances may be putting them at serious risk. Surveys have revealed that the majority of people believe that dietary supplements are regulated by the government. The misunderstanding is not limited to the general population. A study involving 300 internal medicine trainees, found that one-third of them believed that dietary supplements require FDA approval (Cohen 2009).
I’ve certainly encountered issues in my practice where patients have misused dietary supplements—weight loss aides and bodybuilding products, in particular. In our society where there’s a pill to fix everything from erectile dysfunction to thinning eyelashes, it’s natural for people to self-medicate with an OTC remedy that promises to help them achieve their goals. The danger, however, is when people are led to believe that they’re taking natural, non-pharmaceutical products. These products don’t come with a prescription yet may contain prescription components, so the opportunity for misuse is rife. And given that dietary supplements fall outside of the FDA’s jurisdiction, there’s also little information about potential interactions between pharmaceutical products and dietary supplements.
Writing in the New England Journal of Medicine, Pieter Cohen (2009) encourages physicians to be mindful that the ingredient list of a dietary supplement may not include all of the active components. He encourages doctors to report any suspected adverse events to the FDA (www.fda.gov/MedWatch/report.htm), even where the ingredient list suggests otherwise. Given that 114 million Americans (around half of all adults) consume dietary supplements, the public risk is significant and doctors are very likely, at some point in their practice, to encounter adverse events caused by a dietary supplement.
It’s surprising that it’s taken the FDA this long to clamp down on the steroids that were being sold as ingredients in some of the dietary supplements available on Bodybuilding.com. During my cursory exploration of the website, I came across a chat forum titled Superdrol for Dummies in which a bodybuilder recommends a dosing regime for the steroid, along with Clomiphene, and Tamoxifen. At one point, he writes, “Clomid has worked excellently for me... It takes care of any testicular atrophy that may arise on [the] cycle” and “…make sure you give a full two month gap between cycles. After all you've got just one liver to use for a lifetime”. ‘Superdrol for Dummies’, indeed!
Robin Stone, M.D.
Insight Psychiatry
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810
Further reading:
Cohen, P 2009 American roulette—contaminated dietary supplements, New England Journal of Medicine, Oct 7.
United States Food & Drug Administration (FDA) | Safety | Recalls | BODYBUILDING.COM Is Conducting a Voluntary Nationwide and International Recall of 65 Dietary Supplements That May Contain Steroids; November 3, 2009.
November 4, 2009
Antidepressants implicated in male factor fertility
A recent study (Tanrikut, et al) implicates SSRI’s, specifically paroxetine, with male fertility issues. The research builds on a litany of information about the effect of antidepressants on women during and after pregnancy, and begins to fill the void about how these medications affect fertility, especially in men.
In an earlier study, researchers found that patients on SSRIs experienced decreased sperm count, impaired motility, and abnormal sperm form. The comforting news is that improvements were recorded within one to two months of stopping medication.
In the most recent study, the same team took 35 healthy males aged 18 to 65, and examined the effect of paroxetine (Paxil) on their semen. Paxil was chosen because 1) it has a relatively short half-life, and 2) it’s associated with erectile dysfunction and delayed ejaculation.
The subjects’ semen remained within normal ranges for physical characteristics such as volume, motility, and concentration. But when the researchers examined DNA fragmentation in the sperm, they found that it had increased from an average 13.8 percent before taking Paxil, to 30.3 percent after four weeks of therapy. The percentage of patients with abnormal levels of sperm DNA fragmentation rose from 9.7 percent to 50 percent.
The researchers theorize that sperm DNA damage increases with antidepressant medication because SSRIs slow sperm transport during production. This effect may be more pronounced with Paxil than other SSRIs because Paxil has a strong affect on delayed ejaculation. The finding is concerning because sperm DNA damage is associated with reduced fertility. According to the study, rates of sperm DNA fragmentation at 30 percent or higher are correlated with reduced rates of conception. It’s some consolation, however, that semen parameters, DNA fragmentation, erectile dysfunction, and ejaculation returned to normal levels within one to two months of cessation of antidepressant treatment.
So this begs the question: Where a man taking antidepressant medication is part of a couple struggling to conceive, should he stop taking his medicine for a few months? My professional response is "it depends". Given that untreated depression can be accompanied by serious health risks, it’s not a question that a patient should answer alone. It demands close consultation with a mental health professional who thoroughly understands the patient’s circumstances and the drugs involved.
Robin Stone, M.D.
Insight Psychiatry
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810
Further reading:
Wang, B 2009 Paroxetine may affect sperm quality, Reproductive Psychiatry Resource & Information Center of the Massachusetts General Hospital Center for Women’s Mental Health
Tanrikut C, Schlegel PN. 2007. Antidepressant-associated changes in semen parameters. Urology 69(1):185.e5-7.
Tanrikut C, Feldman AS, Altemus M, Paduch DA, Schlegel PN. 2009. Adverse effect of paroxetine on sperm Fertil Steril (in press).
Posted by at 12:27 PM | Permalink | Leave your Comment here (0) | TrackBacks (0)October 16, 2009
Reforming the 'doctorless' health system
It’s old news by now that the Senate Finance Committee has approved legislation that would attempt to reform our health care system. The major features of the revised Baucus bill would include mandatory health insurance for nearly all Americans, taxes on “Cadillac” insurance plans, the creation of non-profit insurance cooperatives, special taxes on drug/ medical device makers as well as insurance companies, and elimination of “pre-existing condition” exclusions.
Republicans promise to make the bill’s passage through the Senate difficult, and hardline Democrats still have their sights set on a public insurance option. We can continue, therefore, to expect the negotiations to play out with the subtlety and finesse of a prize fight.
The vested lobby groups are certainly swinging harder than ever. The Washington Post revealed that the health sector has been spending money at a rate of $1.5 million a day (yes, a day) in an attempt to influence health care reform legislation. Really, who turns enough profit to invest that sort of money in politics? Apparently the biggest spenders were drug manufacturers, hospitals, and insurance groups. And if $1.5 million a day weren’t enough to buy political favor, the insurance industry also launched an ambush attack the day before the vote by releasing a report that suggested that reform could potentially increase insurance premiums. The Democrats labelled the attack scaremongering, and Obama said it confirmed that the legislation was heading in the right direction.
There’s a lot of talk about the vested interests of pharmaceutical manufacturers and insurance companies (rightly so), but what about the system’s users and providers? Where have the doctors and patients gone? Maybe I’m self-interested because I am a doctor and I work with patients, but I’d like know—while congressional committees are debating over insurance exchanges and gold-plated policies—where are the doctors and patients who collaborate on treatment plans?
Dr. Arnold Relman, writing in the New England Journal of Medicine, makes the obvious, but somehow overlooked, point that it’s doctors that make most decisions about the use of medical resources—the same doctors that have a strong financial incentive to maximize elective services and utilize new, expensive technology. This begs the question: how will the proposed legislation control inflationary health care costs as long as doctors are incentivized to use more services and resources? The existing system has encouraged a creeping entrepreneurial ethic into medicine. Physicians who work in hospital systems are rewarded for doing procedures and tests, and the yield from Medicare/Medicaid is comparatively higher for inpatient vs. Outpatient care. In many instances these programs don’t pay for outpatient wellness visits—only sick ones. Meanwhile, primary care providers may see 41 patients a day and receive little to no reimbursement for time spent educating patients about preventative health care. Likewise, some patients are happy to report to the emergency department, rather than a primary care provider, with an earache or head lice. (Yes, I’ve personally witnessed that). What will incentivize those people to purchase health insurance? A $750 annual penalty, I don’t think so (and then there is the “hardship” clause that would exempt people who are likely to be using the emergency department as primary care).
These are not just administrative issues; this is about the health care culture in our country. Surely cultural change must be pivotal in any real overhaul of our health care system, so shouldn’t the vested interests of doctors and patients—not only drug and insurance companies—be central to the debate?
Robin Stone, M.D.
Insight Psychiatry
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810
Further reading:
Eggen, D 2009 At $1.5 million a day, health sector lobbying far outpaces oil and gas, The Washington Post.
Relman, AD 2009 Doctors as the key to health care reform, New England Journal of Medicine, 24 September, vol.361, no. 13.
October 1, 2009
Reflections on Psychotherapy
Health care reform highlights more than the changing nature of medicine—it highlights that social change is underpinned by ideologies that vie against each other in a competitive marketplace of ideas and values. I explored that topic in my last blog. In this blog, I reflect on the transformation of psychotherapy in psychiatric practice. I want to begin by acknowledging that sometimes change manifests as a schism between old and new—a sudden break from the past that throws our modes of acting and thinking into disarray. But revolutionary change is extremely rare—there are usually too many stakeholders invested in the existing order of things. The current health care debate is a good example. More often than not, then, change is evolutionary or environmental—we change because we adapt or because the constant drip, drip, drip of external factors wares us into a different form. In the case of gradual transformation it’s only through reflection that we can make sense of the forces acting on us.
From its inception in the late nineteenth century until very recent times, psychotherapy dominated psychiatry. As a therapeutic model it eloquently combines and addresses the biological, psychological, and social dimensions of illness. It powerfully acknowledges the multi-directional nexus between how we think, feel, and act. And yet, psychotherapy has always been somewhat clouded in conjecture. I think that some of that can be attributed to its popularization in the twentieth century which resulted in entertaining, but inaccurate, stereotypes. Say the word “psychotherapy” and many people will envisage the peculiar dynamic of a patient reclining supine as he relates childhood memories to a therapist who sits behind him, out of view, scribbling notes. In a more recent stereotype, the analyst assumes a social accessory role similar to that of the tennis coach, Pilates instructor, or personal trainer. When the psychiatric profession is so often reduced to a caricature, it’s easy to appreciate why the average person could be intimidated by it.
But since the 1990s the fog has thickened around psychotherapy within the psychiatry profession itself. A national survey of outpatient medical practices from 1996 to 2005 revealed that psychotherapy and pharmacotherapy in psychiatry are increasingly split:
The investigators surveyed 14,108 visits to psychiatrists involving a psychiatric diagnosis. The percentage of visits with at least 30 minutes of psychotherapy decreased significantly over 10 years from 44 percent to 29 percent. For patients with private insurance, the decline was significant (from 50 percent to 25 percent), but not for those in publicly funded programs, where the initial percentage was low (Medicare, from 32 percent to 21 percent; Medicaid, from 22 percent to 13 percent). The percentage was highest among self-paying patients and did not change significantly (from 55 percent to 59 percent). In HMOs, the percentage of visits with psychotherapy decreased significantly to a remarkable degree (from 23 percent to 5 percent) (Dubovsky 2008).
In short, psychotherapy is being eroded from psychiatric practice and, upon reflection, there are a number of environmental causes. The most significant factor is an economic one. Psychiatrists who work within managed care programs administered by insurance companies are discouraged from combining psychotherapy with pharmacotherapy. They’re under pressure to see a large number of patients and work within a system that rewards short consultations. The same study revealed that ‘third-party reimbursement to psychiatrists is 41 percent less for one 45-minute psychotherapy session than for three 15-minute "med checks."’ (Dubovsky 2008).
At the same time, there’s been a paradigm shift in psychiatry that focuses on mental illness as a physiological disease—a biological imbalance that can be chemically corrected. As a consequence, there’s stronger emphasis on drugs in psychiatry—a trend which finds favor with pharmaceutical companies, cost-conscious insurers, and patients looking for fast relief. Anti-depressants are now the most commonly prescribed drug in the US. Indeed, psychotropic drugs have revolutionized psychiatry by strengthening the biological component of the biopsychosocial model—but I’ve also seen, over and over, that pharmacotherapy is rarely a complete solution. People are complicated—more complicated than chemistry alone can account for. They ultimately seek to be understood and to understand themselves, not just to be promised that their neurotransmitters will be set right with a pill. It’s the relationship that heals, and the correct formulation of diagnosis and treatment is powerful in, and of, itself.
Think of someone who’s never understood why they think, behave, or feel the way they do, and has suffered greatly most of their life. For example, they may have experienced emotional problems, anxiety, interpersonal difficulties, or failed career aspirations. Now interject another person who’s trained to illuminate reasons—taking into account the biological, social, psychological aspects of their circumstances—in a safe, non-judgmental arena, and at the right point in a patient’s life. The key to improved mental health lies in not only alleviating a patient’s symptoms, but in helping them to understand and address the underlying causes of those symptoms. When a patient improves through insight and understanding, they gain a much better sense of control over their disorder. The result is that they experience a more positive prognosis, which might be more aptly described as a better life.
The pendulum is swinging back as mounting clinical research demonstrates that psychotherapy is more effective than drugs alone in treating many mental disorders. (Refer to the American Psychiatric Foundation for further information about clinical findings). The positive effects of psychotherapy can be measured not only by symptom relief, relapse reduction, and patient wellbeing, but by physiological changes in the brain. They key here is that the growing proof for psychotherapy not only appeals to the medical and scientific community, but that it also piques the interest of penny-wise insurance companies!
Robin Stone, M.D.
Insight Psychiatry
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810
References & further reading:
American Psychiatric Foundation 2008 Psychotherapy basics, Mental HealthWorks.
Mojtabai, R & Olfson, M 2008 National trends in psychotherapy by office-based psychiatrists, Archives of General Psychiatry, vol. 65, no. 8.
Dubovsky, S 2008 Psychiatric practice: a march from the brainless to the mindless?, Journal Watch Psychiatry, September 15.
September 10, 2009
Ideology and the Heath Care Debate
In October 2009, Physicians Practice will publish the findings of their annual survey. Nearly 1600 physicians were asked this year about what health care reforms they’d like to see. Among the top ten were ‘get the government out of medicine entirely’, ‘institute a single-payer system that has universal coverage’, and ‘cap insurance and pharmaceutical company profits’. The results highlight the ideological divide between those segments that’d prefer to see more government involvement in our health care system, and those that’d prefer to see less—much less! The ideological divide was no less evident in Washington on Wednesday night when President Obama addressed congress to explain some of the details of his plan for health care reform.
The President’s reforms propose to offer more choice, lower costs, and improved security for people who already have health insurance. Under the proposal, insurance companies would not be allowed to drop or dilute coverage. For the uninsured, the new plan proposes affordable coverage for individuals and small business owners. Among other changes, it’d be unlawful for insurance companies to deny an applicant coverage on the basis of a pre-existing condition. Other proposed reforms include pilot studies for changes to medical malpractice laws.
The President made it clear that, while alternative proposals were welcome, he would not lie down easily on a public insurance option, nor his concept of an insurance exchange. In his words, a public insurance option would provide better choice and competition for consumers. Dr Charles Boustany replied on behalf of the Republicans. He told the press that his party opposes a government-operated insurance agency, and argued that competition in the insurance market could be improved by allowing families and small businesses to purchase their insurance across state lines.
One political commentator described the presidential address as ‘vintage Obama’, highlighting what he saw as a veiled contradiction: ‘Complete command of the issue, excellent cadence and pace. The reach out, as expected, to the GOP to join him half way, while standing firm on his beliefs and denouncing what he saw as the "politics" of division’(Rudin 2009). Another agreed that the President failed to exhibit the attitude of compromise he was demanding. William McKenzie of The Dallas Morning News wrote:
[Under Obama’s plan] there's no guarantee you can keep your health plan. If your company stops offering coverage and you end up on a public plan, you could lose your doctor. Look at Medicare. Washington has been tightening up Medicare payments to doctors, so fewer providers are picking up seniors. The same phenomenon could happen under a public plan. If you end up on it, and your doctor chooses not to participate, you're out of luck. The president wants a public option so consumers can have more insurance choices. Well, they could get more options if he supported letting insurers and consumers connect across state lines. That way, we all could get plenty of choices and wouldn't have to worry about the headaches of creating a federal plan.
All this political crossfire overshadows the facts. The US has the most expensive health care system in the world—around 1.5 times more expensive per capita than the average of other developed nations. For every six dollars an American earns, they spend more than one dollar on health care (Gawande 2009). You’d think, therefore, that our nation would be exceptionally healthy. Instead, we’re ranked 42nd in the world for average life expectancy—just above Mexico—and we have the dreadful honor of being the fattest country on the planet (Ohlemacher 2007). Research reveals that 41 percent of working age adults in the US have a medical debt, or have a problem paying medical bills (Gardner 2008). A study published in the American Journal of Medicine found that nearly two-thirds of personal bankruptcies filed in the US in 2007 were caused by illness and medical expenses. More concerning, most of these people had insurance at the start of their illness, were middle class, university-educated, and owned a home (Healy 2009). Meanwhile, insurance companies and their executives are rewarded for the relentless pursuit of profits.
The Democrats and GOP have agreed on a middle ground when it comes to expanding insurance access for people with pre-existing conditions, and providing health care assistance for very low income earners. But the coming months will further tell if our representatives in Washington are able to conceive of the world in shades of gray by building a bridge of compromise between their ideologies—or if they are only capable of confusing and polarizing the constituency. The danger of not compromising on ideology is that we will continue to compromise our health.
Robin Stone, M.D.
Insight Psychiatry
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810
References & further reading:
Beckel, A & Michael, S 2009 Ten health reforms docs want, Physicians Practice.
Gardner, A 2008 Medical debt sending many over financial brink, US News & World Report.
Gawande, A 2009 The cost conundrum: what a Texas town can teach us about health care, The New Yorker.
Healy, M 2009 Medical bills led to two-thirds of bankruptcies in 2007, study finds, Los Angeles Times.
McKenzie, W 2009 Obama's health care speech got it right and wrong, National Public Radio.
Rudin, K 2009 The President spoke. What did people hear? What will congress do?, National Public Radio.
September 6, 2009
When Healers Need Healing
In the last 30 years, ‘burnout’ has turned from a vernacular idiom into a prevalent psychosocial syndrome—one that’s particularly relevant in current times as the economic recession impacts on lifestyles. Surveys reveal that job cuts and the threat of redundancy are affecting work/life balance. Many people are working longer hours and seriously worrying about their job security.
Professional burnout has many characteristics, not least of which include emotional exhaustion, cynicism, and a loss of interest in one’s work or personal life—the feeling of “just going through the motions”. Burnout cuts a broad swathe across professions, but is especially prevalent where occupational stressors—such as heavy workload and constant pressure—are accompanied by other job demands that lead a person to perceive a lack of control in their life.
It’s little surprise, then, that medical professionals are particularly prone to burnout, especially so given the current health crisis. When physicians are surveyed, up to 40 percent of them report feelings of stress and burnout, while a concerning 70 percent report feeling pessimistic about the future of the health care system (Gundersen 2001).
Burnout can be especially dangerous in medicine because it carries potential consequences for patients. Some studies suggest that burned out physicians have more trouble relating to patients, and the quality of the care they provide may suffer—let alone that an increasing number of doctors contemplate early retirement and alternative professions.
Due to fear of recrimination (licensure issues, shame and guilt, and social stigmatization), physicians often avoid or postpone mental health treatment, or attempt to treat themselves secretly. As a case in point, about a third of physicians do not have their own doctor. A concerning pattern occurs where medical professionals often delay seeking help until they hit rock bottom.
The good news is that there’s a growing movement that recognizes the importance of physician health—not only for the benefit of members of the medical profession, but for the wider good of the community. Wellness strategies include methods of recharging one’s physical and mental capacity, emotional self-awareness, connecting with social support systems, and seeking help before stress begins affecting work performance. Research demonstrates greatly reduced burnout rates and improved job satisfaction in physicians who practice these coping strategies (Spickard et al 2002).
As a fellow medical professional, I understand the pressures that make physicians reluctant to seek care, which is why my practice is designed to protect the professional sensitivities of my patients. At my office, for example, there are two separated waiting rooms. Patients enter and exit from different doors, and discrete parking is provided at the rear of the building. Privacy is a very valid concern for medical professionals seeking mental health support, but it should not be an insurmountable obstacle. We must remind ourselves that ‘doing no harm’ begins with our own well-being first.
Robin Stone, M.D.
Insight Psychiatry
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810
References & further reading:
Gundersen, L. 2001 ‘Physician burnout’, Annals of Internal Medicine, vol. 135, no.2, pp. 145-148.
Spickard, A., Gabbe S., Christensen, J. 2002 , ‘Mid-career burnout in generalist and specialist physicians’, Journal of the American Medical Association, vol. 288. no. 12.
