opinions on medication management

[DynamicDidactic]

But arguing that we should replace active drug with placebo for the large population of individuals who are either too depressed or simply unwilling to engage in therapy, or who don't have access to effective psychotherapy, is not defensible.

I think this is what separates individuals that base their views on science rather than belief (e.g., anti-pharma folks). To view this issue as dichotomous (drugs are good or bad) is unwise. Medications have likely, above and beyond placebo, helped countless people. Unfortunately, it has also harmed some and for many doesn't do much. The goal is to reduce the harm without removing all the efficacy. I am not saying anyone on here is saying that but there are plenty of people in the world that think this way.

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[beginner2011]

I think this is what separates individuals that base their views on science rather than belief (e.g., anti-pharma folks). To view this issue as dichotomous (drugs are good or bad) is unwise. Medications have likely, above and beyond placebo, helped countless people. Unfortunately, it has also harmed some and for many doesn't do much. The goal is to reduce the harm without removing all the efficacy. I am not saying anyone on here is saying that but there are plenty of people in the world that think this way.

Believe me, I was well-trained in the "combined pharmacotherapy and psychotherapy is the gold standard of care" orthodoxy that's all the rage. However, the more I look into the actual studies and results the more smoke I see. Take, for example, panic disorder:

Recent guidelines (2019) concluded that pharmacotherapy and psychotherapy have similar effects: Pharmacological Therapy in Panic Disorder: Current Guidelines and Novel Drugs Discovery for Treatment-resistant Patient

"Both pharmacotherapy and CBT were found to be superior to placebo and neither treatment showed superior efficacy compared to each other. In addition to the meta-analysis mentioned above, a recent meta-analysis also found similar efficacy between the pharmacotherapy and CBT."

Then, here's the summary from the 2016 Cochrane review they cite: Psychological Therapies Versus Pharmacological Interventions for Panic Disorder With or Without Agoraphobia in Adults - PubMed

There was no evidence of a difference between psychological therapies and selective serotonin reuptake inhibitors (SSRIs) in terms of short-term remission (RR 0.85, 95% CI 0.62 to 1.17; 6 studies; 334 participants) or short-term response (RR 0.97, 95% CI 0.51 to 1.86; 5 studies; 277 participants) (very low-quality evidence), and no evidence of a difference between psychological therapies and SSRIs in treatment acceptability as measured using dropouts for any reason (RR 1.33, 95% CI 0.80 to 2.22; 6 studies; 334 participants; low-quality evidence).

There was no evidence of a difference between psychological therapies and tricyclic antidepressants in terms of short-term remission (RR 0.82, 95% CI 0.62 to 1.09; 3 studies; 229 participants), short-term response (RR 0.75, 95% CI 0.51 to 1.10; 4 studies; 270 participants), or dropouts for any reason (RR 0.83, 95% CI 0.53 to 1.30; 5 studies; 430 participants) (low-quality evidence).

There was no evidence of a difference between psychological therapies and other antidepressants in terms of short-term remission (RR 0.90, 95% CI 0.48 to 1.67; 3 studies; 135 participants; very low-quality evidence) and evidence that psychological therapies did not significantly increase or decrease the short-term response over other antidepressants (RR 0.96, 95% CI 0.67 to 1.37; 3 studies; 128 participants) or dropouts for any reason (RR 1.55, 95% CI 0.91 to 2.65; 3 studies; 180 participants) (low-quality evidence).

There was no evidence of a difference between psychological therapies and benzodiazepines in terms of short-term remission (RR 1.08, 95% CI 0.70 to 1.65; 3 studies; 95 participants), short-term response (RR 1.58, 95% CI 0.70 to 3.58; 2 studies; 69 participants), or dropouts for any reason (RR 1.12, 95% CI 0.54 to 2.36; 3 studies; 116 participants) (very low-quality evidence).

There was no evidence of a difference between psychological therapies and either antidepressant alone or antidepressants plus benzodiazepines in terms of short-term remission (RR 0.86, 95% CI 0.71 to 1.05; 11 studies; 663 participants) and short-term response (RR 0.95, 95% CI 0.76 to 1.18; 12 studies; 800 participants) (low-quality evidence), and there was no evidence of a difference between psychological therapies and either antidepressants alone or antidepressants plus benzodiazepines in terms of treatment acceptability as measured by dropouts for any reason (RR 1.08, 95% CI 0.77 to 1.51; 13 studies; 909 participants; very low-quality evidence). The risk of selection bias and reporting bias was largely unclear. Preplanned subgroup and sensitivity analyses limited to trials with longerterm, quality-controlled, or individual psychological therapies suggested that antidepressants might be more effective than psychological therapies for some outcomes.

You've got to be kidding me. It's this kind of low quality science using shoddy meta-analytic methods that is probably why more than 12% of the population over the age of 12 took an antidepressant in the last 30 days and all the good behavior therapists in my city don't take insurance and don't even bother keeping a waitlist.

So right now someone comes into their PCP's office and says, "Hey doc, I'm having panic attacks all day and my life is falling apart, what do I do?" The current guidelines are to trial the patient on a series of antidepressant medications. Huh? Looking into the data, that is actually what is supported by the evidence! The RCTs suggest that fluoxetine (Efficacy of Usual Antidepressant Dosing Regimens of Fluoxetine in Panic Disorder: Randomised, Placebo-Controlled Trial - PubMed) has roughly the same effect on PDSS (~50% reduction) that expertly delivered CBT does (Five Sessions and Counting: Considering Ultra-Brief Treatment for Panic Disorder - PubMed).

So, what's going on here? Is this why we've got so many psychologists fighting for prescription privileges so that they can deliver the "gold standard" according to the health care system? Have we been fooling ourselves all along that the greatest success story of behavioral interventions (exposure therapy for panic) is basically the same as daily fluoxetine? To me this looks like smoke, and where there's smoke there's fire.

 

[DynamicDidactic]

@beginner2011
I'm not really sure what you are trying to say in the post above.

I have argued in this thread that combined treatment isn't always better.

The problem with meds for panic is the long term outcomes, which are not discussed in this meta. Not to mention some of the potential harm. Benzos especially, once removed, lead to worsening of symptoms. I do not think anyone is fooling themselves about exposure therapy. The outcomes are very good for panic with interoceptive exposure, especially in light of treatment safety.

For guidelines, I tend to encourage people looking over NICE.

I cannot tell if you are mad at the psychotherapy researchers or the pharmacotherapy researchers? RxP is a rather divisive issue in the field and this forum. What is the smoke you are referring to? We are still at a nascent level of treating disorders. If we can do a little better than placebo, that's great. Hopefully, we keep expanding our research to provide even more effective treatments in the future.

 

[beginner2011]

@beginner2011
I'm not really sure what you are trying to say in the post above.

I have argued in this thread that combined treatment isn't always better.

The problem with meds for panic is the long term outcomes, which are not discussed in this meta. Not to mention some of the potential harm. Benzos especially, once removed, lead to worsening of symptoms. I do not think anyone is fooling themselves about exposure therapy. The outcomes are very good for panic with interoceptive exposure, especially in light of treatment safety.

For guidelines, I tend to encourage people looking over NICE.

I cannot tell if you are mad at the psychotherapy researchers or the pharmacotherapy researchers? RxP is a rather divisive issue in the field and this forum. What is the smoke you are referring to? We are still at a nascent level of treating disorders. If we can do a little better than placebo, that's great. Hopefully, we keep expanding our research to provide even more effective treatments in the future.

I appreciate your patience. I muddled together a number of thoughts and arguments in my last post, in part out of frustration.

I'll do my best to gather my thoughts and summarize:

1. Medication does seem to improve outcomes over and above placebo.
2. Placebo also improves outcomes, has less risk of harm to the patient, and lower cost to the health care system.
3. Evidence suggests that meds alone are more costly to the HCS than either psytx alone or combined psytx + meds. (e.g., Panic: Cost-effectiveness of CBT, SSRI, and CBT+SSRI in the Treatment for Panic Disorder - PubMed)
4. Psytx + placebo have not been seriously considered, even though it has less risk of harm to pt and lower cost to the HCS. (smoke: why not?)
5. After looking more closely at the evidence, I am highly skeptical of the meta analyses (e.g., Cochrane review) on the comparative effectiveness of meds. (smoke: antidepressants = psytx for panic?)

In my opinion, high quality psytx is vastly superior in the long-term to meds for many mood/anxiety disorders (e.g., MDD, SAD, Panic). I’m mad because I don’t see clear evidence that psytx researchers have done a good job demonstrating the relative value of psytx, and I think this is due to two main issues: (1) perverse incentives for pharmacotherapy researchers and (2) a lack of unification around what I consider to be “high quality” psytx.

As I see it, the unfortunate consequence of these issues is that:

(1) Meta-analyses (e.g., Cochrane) compare goosed-up effect-sizes for meds to watered-down effect sizes for psytx. As @WisNeuro noted in a previous post:
"the collapsing of both wide ranges of disorders, and treatments, into very heterogeneous groups. We know that different disorders respond differently to treatment in general, as well as types of treatment. Collapsing these just erases these effects, so of course things look similar."

(2) The HCS doesn’t value psytx, so insurance companies reimburse psytx at a standard rate (regardless of quality of intervention) at about $100/hr.

(3) Psytx providers who are top of their field and provide high quality psytx (time-limited EBT) end up cash only in order to be appropriately compensated for their services ($200+/h). Often their clinics are so full they don’t keep a waitlist (and if they do it goes out multiple months).

(4) People in the community with mood/anxiety disorders don’t have access to high quality psytx unless they are both wealthy and lucky.

 

[tr]

I appreciate your patience. I muddled together a number of thoughts and arguments in my last post, in part out of frustration.

I'll do my best to gather my thoughts and summarize:

1. Medication does seem to improve outcomes over and above placebo.
2. Placebo also improves outcomes, has less risk of harm to the patient, and lower cost to the health care system.
3. Evidence suggests that meds alone are more costly to the HCS than either psytx alone or combined psytx + meds. (e.g., Panic: Cost-effectiveness of CBT, SSRI, and CBT+SSRI in the Treatment for Panic Disorder - PubMed)

You are neglecting the extremely important variable of *which* health care system. The cited study is from the Netherlands, which has high-quality universal health care. That analysis won't necessarily translate to the US, where we have an opaque and perversely incentivized for-profit health insurance system.

The van Apeldoorn results are dominated by the productivity loss result (Table 1, bottom row), which wash out everything else including the much higher cost of psychotherapy as compared to medication. A health care system run by the government may care about the productivity loss because it affects the other sectors. A private health insurance company does not, because it doesn't affect their bottom line and is therefore out of their purview. Their interest is to provide the lowest-cost intervention they can get away with. That's medication alone (Table 1, top row - I don't know why it inserted twice and I can't fix it because I'm old and technologically impaired).

4. Psytx + placebo have not been seriously considered, even though it has less risk of harm to pt and lower cost to the HCS. (smoke: why not?)

I dunno but that pilot trial you linked didn't look so encouraging.

5. After looking more closely at the evidence, I am highly skeptical of the meta analyses (e.g., Cochrane review) on the comparative effectiveness of meds. (smoke: antidepressants = psytx for panic?)

As pointed out by @DynamicDidactic, the problem with meds is not that they don't work in the short term. It's the problems they create in the long term. Benzodiazepines work absolutely wonderfully for panic disorder. It's immediate and effortless relief. If all you look at is efficacy then the benzo wins hands down. The problem is that if you keep taking that drug, pretty soon you'll get tolerant, and then it doesn't work so well any more. Then you need to start taking more and more of it, and then you get dependent on it, and after a while it still isn't working that great but if you stop taking it your anxiety goes through the roof and you can't sleep at night. Then if you keep taking it for 40 years you get dementia. So it's not a long-term solution. But it absolutely wins the short-term efficacy race.

In my opinion, high quality psytx is vastly superior in the long-term to meds for many mood/anxiety disorders (e.g., MDD, SAD, Panic). I’m mad because I don’t see clear evidence that psytx researchers have done a good job demonstrating the relative value of psytx, and I think this is due to two main issues: (1) perverse incentives for pharmacotherapy researchers and (2) a lack of unification around what I consider to be “high quality” psytx.

As I see it, the unfortunate consequence of these issues is that:

(1) Meta-analyses (e.g., Cochrane) compare goosed-up effect-sizes for meds to watered-down effect sizes for psytx. As @WisNeuro noted in a previous post:
"the collapsing of both wide ranges of disorders, and treatments, into very heterogeneous groups. We know that different disorders respond differently to treatment in general, as well as types of treatment. Collapsing these just erases these effects, so of course things look similar."


(2) The HCS doesn’t value psytx, so insurance companies reimburse psytx at a standard rate (regardless of quality of intervention) at about $100/hr.

From the point of view of the for-profit health insurance company, the psychologist is going to take 12 face-to-face hours to deliver the intervention, whereas the physician is going to deliver the intervention in two 15-minute med checks. The health insurance company has no interest in the long-term well-being of the patient. The only point that matters to them is that if they pay $300 for the med checks instead of $1200 for the therapy, they will pocket the other $900.

(3) Psytx providers who are top of their field and provide high quality psytx (time-limited EBT) end up cash only in order to be appropriately compensated for their services ($200+/h). Often their clinics are so full they don’t keep a waitlist (and if they do it goes out multiple months).

This is not at all unique to psychology. I have both insured and private pay patients. Insurance reimburses 1/3 to 1/2 of the private pay rate.

(4) People in the community with mood/anxiety disorders don’t have access to high quality psytx unless they are both wealthy and lucky.

People in the US IN GENERAL don't have access to high quality HEALTH CARE unless they are wealthy and lucky. Welcome to the land of the free.

 

[beginner2011]

First, I want to say thank you for taking the time to respond. I am acutely aware with all of this stuff that I have a lot to learn. I really appreciate you making the effort to follow up and continue this conversation with me.

You are neglecting the extremely important variable of *which* health care system. The cited study is from the Netherlands, which has high-quality universal health care. That analysis won't necessarily translate to the US, where we have an opaque and perversely incentivized for-profit health insurance system.

The van Apeldoorn results are dominated by the productivity loss result (Table 1, bottom row), which wash out everything else including the much higher cost of psychotherapy as compared to medication.

Point taken. However, if you look at the two rows that are NOT productivity loss (Time costs, Informal care), the SSRI-only column totals around 450, whereas the two columns with CBT total around 200. So, any way you slice it the cost is substantially larger for SSRI.

I dunno but that pilot trial you linked didn't look so encouraging.

Bottom two lines of the table below: The Contribution of Active Medication to Combined Treatments of Psychotherapy and Pharmacotherapy for Adult Depression: A Meta-Analysis - PubMed

Effect size of psytx+placebo = ~1.5
Effect size of psytx+meds = ~1.7

HAM-D-17 effect size comparing psytx+placebo to psytx+meds: d = 0.16

The contribution of active medication to combined treatments of psychotherapy and pharmacotherapy for adult depression: a meta-analysis - PubMed

Active medication has a small but significant contribution to the overall efficacy of combined treatments.

pubmed.ncbi.nlm.nih.gov

As pointed out by @DynamicDidactic, the problem with meds is not that they don't work in the short term. It's the problems they create in the long term. Benzodiazepines work absolutely wonderfully for panic disorder. It's immediate and effortless relief. If all you look at is efficacy then the benzo wins hands down. The problem is that if you keep taking that drug, pretty soon you'll get tolerant, and then it doesn't work so well any more. Then you need to start taking more and more of it, and then you get dependent on it, and after a while it still isn't working that great but if you stop taking it your anxiety goes through the roof and you can't sleep at night. Then if you keep taking it for 40 years you get dementia. So it's not a long-term solution. But it absolutely wins the short-term efficacy race.

I agree with you, and also want to point out that the Zulfarina2019 article I cited earlier actually makes claims in opposition to what you're arguing here. Pharmacological Therapy in Panic Disorder: Current Guidelines and Novel Drugs Discovery for Treatment-resistant Patient

" Concerning the pharmacological interventions, licensed selective serotonin reuptake inhibitors (SSRIs) are considered as first choice pharmacological treatment, but tricyclic antidepressants (TCAs) could also be prescribed. According to the NICE guidelines, benzodiazepines should not be prescribed because they are associated with less favorable outcome in the long term plus the effectiveness of serotonin and norepinephrine reuptake inhibitors (SNRIs) venlaflaxine was not acknowledged.23) However, a number of meta-analysis have demonstrated similar efficacy between antidepressants and benzodiazepines,26,27) between SSRIs and TCAs,27–29) between benzodiazepines, SSRIs and TCAs,23) though benzodiazepines have better tolerability than antidepressants26,27) while SSRIs have better tolerability than TCAs.27,29) Several recent studies also demonstrated evidence that SNRI venlaflaxine is an effective treatment for PD,9,30) and should perhaps warrant an appraisal of the current NICE guideline to include SNRIs and benzodiazepines as standard treatment for PD. "

From the point of view of the for-profit health insurance company, the psychologist is going to take 12 face-to-face hours to deliver the intervention, whereas the physician is going to deliver the intervention in two 15-minute med checks. The health insurance company has no interest in the long-term well-being of the patient. The only point that matters to them is that if they pay $300 for the med checks instead of $1200 for the therapy, they will pocket the other $900.

My understanding of the Apeldoorn article provides some preliminary evidence that contradicts this. The SSRI condition had substantially increased "informal care" costs and "medication" costs relative to the CBT condition. My conclusion is that this reflects the failure of psychology as a guild to adequately advocate for our relative value to the HCS, and the relative success of the pharmaceutical industry to advocate for their interests.

I don't blame psychiatrists or the AMA -- they're just doing whatever the research says is best practice, most effective, and the most lucrative. For reference, you might compare the relative power of the "psychotherapy industry" to the power of the "pharmaceutical industry" when considering how funding priorities are set and a research agenda is formed (e.g., NIMH).

This is not at all unique to psychology. I have both insured and private pay patients. Insurance reimburses 1/3 to 1/2 of the private pay rate.

CMS hourly fees for psychiatirists have been estimated at about $350-$450 per hour doing 30m med-check appointments. Are many independent practicing psychiatrists really charging $1350/hour (450*3)? I find that hard to believe, but I am admittedly naive in this area.

People in the US IN GENERAL don't have access to high quality HEALTH CARE unless they are wealthy and lucky. Welcome to the land of the free.

Couldn't agree more. I think this is what makes me more mad than any of the rest of this stuff. I feel stuck, torn in multiple directions by many competing values.

 

[clausewitz2]

[

I agree with you, and also want to point out that the Zulfarina2019 article I cited earlier actually makes claims in opposition to what you're arguing here. Pharmacological Therapy in Panic Disorder: Current Guidelines and Novel Drugs Discovery for Treatment-resistant Patient

" Concerning the pharmacological interventions, licensed selective serotonin reuptake inhibitors (SSRIs) are considered as first choice pharmacological treatment, but tricyclic antidepressants (TCAs) could also be prescribed. According to the NICE guidelines, benzodiazepines should not be prescribed because they are associated with less favorable outcome in the long term plus the effectiveness of serotonin and norepinephrine reuptake inhibitors (SNRIs) venlaflaxine was not acknowledged.23) However, a number of meta-analysis have demonstrated similar efficacy between antidepressants and benzodiazepines,26,27) between SSRIs and TCAs,27–29) between benzodiazepines, SSRIs and TCAs,23) though benzodiazepines have better tolerability than antidepressants26,27) while SSRIs have better tolerability than TCAs.27,29) Several recent studies also demonstrated evidence that SNRI venlaflaxine is an effective treatment for PD,9,30) and should perhaps warrant an appraisal of the current NICE guideline to include SNRIs and benzodiazepines as standard treatment for PD. "

The follow-up for the meta-analyses showing "long term" equivalence between BZDs and SSRIs/TCAs have a modal follow-up of 8-10 weeks. BZD tolerance is very real but it does take a while to develop for many people. Looking a year out would be much more relevant, though this is a pervasive problem in the pharmacology literature.

My understanding of the Apeldoorn article provides some preliminary evidence that contradicts this. The SSRI condition had substantially increased "informal care" costs and "medication" costs relative to the CBT condition. My conclusion is that this reflects the failure of psychology as a guild to adequately advocate for our relative value to the HCS, and the relative success of the pharmaceutical industry to advocate for their interests.

Informal care appears to be things friends and neighbors are doing to help out patients, apparently, and the productivity costs are based on illness-related time off of work. Both of these things seem to me to likely to be hugely impacted by the differences in social structure between the Netherlands and the US, as well as relevant differences in disability law. The gap is not so wide that I think we can have any confidence in transferring these results from, say, Utrecht to Utica.

CMS hourly fees for psychiatirists have been estimated at about $350-$450 per hour doing 30m med-check appointments. Are many independent practicing psychiatrists really charging $1350/hour (450*3)? I find that hard to believe, but I am admittedly naive in this area.

Insurance payments vary wildly depending on market, but it's not super unusual for some insurances to pay something around ~100 for a 99124. This is only going to yield the range you estimate for CMS fees if you do the dreaded 15 minute check. In my area I am lucky that there are commercial payers who actually pay more than medicare, but the CMS estimates are way off in my area if we are assuming two appointments per hour. Medicare here pays at most 116 dollars per 99124 and 156 for 99215. Routinely billing 99215s is a really excellent way to get audited. The most generous commercial plans are shelling out something like 200 for a 99215 and more like 130 for 99214. If you were doing 2 99214s per hour (probably the modal billing code for private practice psychiatrist around here) that gets you 260 from insurance per hour. Cash psychiatrists around here charge 300-400 dollars for a 60 minute appointment. And that's the ones that openly advertise their rates .

Couldn't agree more. I think this is what makes me more mad than any of the rest of this stuff. I feel stuck, torn in multiple directions by many competing values.

I want to again emphasize I definitely share your anger at the state of things and in no way want to undermine the importance of therapy. Your earlier point about heterogenity goes both ways, though - I am not sure there is a principled reason to expect MDD being a wastebasket category to differentially reduce estimates of psychotherapeutic effectiveness and differentially increase estimates of psychopharm effectiveness. I would naively expect "real" group membership to effect estimates for both in both directions on average.

 

[tr]

Point taken. However, if you look at the two rows that are NOT productivity loss (Time costs, Informal care), the SSRI-only column totals around 450, whereas the two columns with CBT total around 200. So, any way you slice it the cost is substantially larger for SSRI...

My understanding of the Apeldoorn article provides some preliminary evidence that contradicts this. The SSRI condition had substantially increased "informal care" costs and "medication" costs relative to the CBT condition. My conclusion is that this reflects the failure of psychology as a guild to adequately advocate for our relative value to the HCS, and the relative success of the pharmaceutical industry to advocate for their interests.

Yes yes, but those are all non-medical costs, i.e., costs that will not be seen or shouldered by a private health-insurance company, but are instead part of the 'societal burden of illness,' with which for-profit health insurance companies need not concern themselves.

CMS hourly fees for psychiatrists have been estimated at about $350-$450 per hour doing 30m med-check appointments. Are many independent practicing psychiatrists really charging $1350/hour (450*3)? I find that hard to believe, but I am admittedly naive in this area.

Yes, you are naive. @clausewitz2 seems to be practicing in a relatively lower COL area than I am.

 

[beginner2011]

Yes, you are naive. @clausewitz2 seems to be practicing in a relatively lower COL area than I am.

What are your thoughts on the additive benefit of active medication compared to placebo (in the combination of psytx+) being estimated at d = .16 for HAM-D? (For reference, that's an estimated mean reduction of about .8 in raw HAM-D units in a sample with a pooled SD of 5.)

How do you make sense of the fact that there are private practice psychiatrists charging ~$1350/hr to provide d = .16 to patients?


As we've mentioned, it's probably unfair to reduce all that a psychiatrist does and is capable of to antidepressants, but it does seem to be an extremely common element of treatment provided for most mood/anxiety disorders. If we're looking at cost/benefit to the HCS and to society, I'm beginning to think that the focus on medications is actually a waste of the potential value of psychiatrists. I wonder if the pharmaceutical industry (or "market forces," if you prefer) has transformed the psychiatrist into primarily pill dispensers when they would benefit the HCS more by providing primarily high quality psychotherapy to particularly complex cases who need more than antidepressant meds (e.g., psychotic dx, bipolar dx, etc.)

 

[tr]

What are your thoughts on the additive benefit of active medication compared to placebo (in the combination of psytx+) being estimated at d = .16 for HAM-D? (For reference, that's an estimated mean reduction of about .8 in raw HAM-D units in a sample with a pooled SD of 5.)

I think that the summative value of psychiatric treatment is much more than the value of pill dispensing. I don't find it at all surprising that the relative proportion of treatment benefit for depression/anxiety that can be ascribed to medication is small. Psychiatrists also provide diagnostic services, treatment or referral for contributing medical conditions, behavioral counseling, motivational discussion, psychotherapy, and referral to neurostimulatory modalities or other specialized treatments as appropriate. (Not to mention the many other disorders for which medication is much more necessary - I wouldn't suggest treating psychosis with placebo.) I work with many patients who are not on medication at all (actually patients in my primary area of specialization are highly incentivized to avoid it). The elements of good placebo response are also part of the treatment, actually they are inextricable from important elements of treatment like a warm and nonjudgmental manner, listening ear, air of expertise, etc.

That doesn't mean that we should go ahead and replace an efficacious aspect of the treatment with an element that is explicitly not efficacious. Why should we do that? Seems silly.

How do you make sense of the fact that there are private practice psychiatrists charging ~$1350/hr to provide d = .16 to patients?

I don't make sense of it at all. I think it's ridiculous and I think we should have a national health plan and remove the profit motive entirely from the provision of health care. It doesn't belong there. I am a card-carrying member of Physicians for a National Health Plan (pnhp.org).

By the way, nobody is paying four figures to see a Prozac machine. That price is for boutique treatment (again, all those important placebo elements) and/or specialist expertise.

As we've mentioned, it's probably unfair to reduce all that a psychiatrist does and is capable of to antidepressants, but it does seem to be an extremely common element of treatment provided for most mood/anxiety disorders. If we're looking at cost/benefit to the HCS and to society, I'm beginning to think that the focus on medications is actually a waste of the potential value of psychiatrists. I wonder if the pharmaceutical insurance industry (or "market forces," if you prefer) has transformed the psychiatrist into primarily pill dispensers

FTFY. The pharmaceutical industry has limited power over individual prescribers who don't wish to be seduced by its charms. Pharma only has carrots (lunches, pens, and the like). It's the insurance giants who carry the power of the pocketbook. We may hate them but we have to play by their rules - or go cash only, as half of the psychiatrists in the US do.

Fewer Psychiatrists Seen Taking Health Insurance (Published 2013)

Psychiatrists are less likely than doctors in other specialties to accept insurance, researchers have found, complicating the push to increase access to mental health care.

www.nytimes.com

You're much more likely to see a pill dispenser if you need to use your insurance. Psychiatrists who work for cash owe nothing to pharma.

when they would benefit the HCS more by providing primarily high quality psychotherapy to particularly complex cases who need more than antidepressant meds (e.g., psychotic dx, bipolar dx, etc.)

Ahem, it may be overreach to suggest we are the appropriate providers of 'high quality psychotherapy for particularly complex cases.' I refer you to this recent thread of your colleagues beating us down for our paltry therapeutic expertise.

Do psychiatrists provide psychotherapy?

Hello, What is the main role of psychiatrists? Are any mainly clinical focused? Interested in medicine but want to provide more therapy over anything.

forums.studentdoctor.net

All that aside, personally I feel reasonably good about my ability to provide CBT for depression, anxiety, and (if necessary) insomnia. When I have patients who need CPT for PTSD, DBT for emotion regulation, CBT for psychosis, IPSRT for bipolar disorder, etc., you bet I am referring them out to a psychologist who specializes in the relevant area.

 

[beginner2011]

The elements of good placebo response are also part of the treatment, actually they are inextricable from important elements of treatment like a warm and nonjudgmental manner, listening ear, air of expertise, etc.

Absolutely! I think there are also important elements of the placebo response which could be induced by formally prescribing an open-label placebo. There are some interesting articles I've come across as a result of this discussion on theories behind mechanisms for placebo response, many of which I don't think are widely known/acknowledged at this point. For example, "uncertainty," "novelty," and the so-called, "Bayesian brain" effect.

http://media.virbcdn.com/files/ea/eedfab5b83678fef-KaptchukPBMOLP2018.pdf

http://media.virbcdn.com/files/01/147bb1aea3d8c05b-Kaptchuk-MillerBMJOLP2018.pdf

http://media.virbcdn.com/files/89/e19dfa6c903a4499-Ongaro-KaptBayesianbrainPAIN2018.pdf

FTFY. The pharmaceutical industry has limited power over individual prescribers who don't wish to be seduced by its charms. Pharma only has carrots (lunches, pens, and the like). It's the insurance giants who carry the power of the pocketbook. We may hate them but we have to play by their rules - or go cash only, as half of the psychiatrists in the US do.

Fewer Psychiatrists Seen Taking Health Insurance (Published 2013)

Psychiatrists are less likely than doctors in other specialties to accept insurance, researchers have found, complicating the push to increase access to mental health care.

www.nytimes.com

You're much more likely to see a pill dispenser if you need to use your insurance. Psychiatrists who work for cash owe nothing to pharma.

My understanding is that insurance industry policy and decisions are influenced by the pharmaceutical industry, but I can see how it would make sense to say the insurance company influences the pharma industry. Seems like a mutually beneficial racket that ultimately cuts out the health care professionals as much as possible -- "Let's make the research say to replace therapy with a pill, and then my buddies in pharma get a big slice of the pie, and my costs go down: win-win." Hyperbole perhaps, but with some truth?

Ahem, it may be overreach to suggest we are the appropriate providers of 'high quality psychotherapy for particularly complex cases.' I refer you to this recent thread of your colleagues beating us down for our paltry therapeutic expertise.

Do psychiatrists provide psychotherapy?

Hello, What is the main role of psychiatrists? Are any mainly clinical focused? Interested in medicine but want to provide more therapy over anything.

forums.studentdoctor.net

I think it's a loss for psychiatrists (and patients, ultimately) that psytx training isn't a larger part of training. My understanding is that psychotherapy was at one point a large part of psychiatry. The vast majority of the psychiatrists I've had candid conversations with about training are pretty open about the desire they have for more psytx training. I remember several years back in grad school I was talking with an R3 psychiatrist about an OCD patient that we shared, and I pointed them to the Div12 website. They were surprised to see the variety of ESTs, and we had a number of follow up conversations afterward about CBT because the principles were hardly addressed at all in their training.

I think it's a tragedy that there's an over-reliance on medication (my opinion) in psychiatry training and practice. Again, to me, an example of industry attempting to cut out providers from the process.

 

[cara susanna]

I'm involved in a psychiatry residency and there's a full course on CBT, as well as seminar series on other types of therapies. So I'm glad that at least we're offering solid psychotherapy training!

 

[DynamicDidactic]

I'm involved in a psychiatry residency and there's a full course on CBT, as well as seminar series on other types of therapies. So I'm glad that at least we're offering solid psychotherapy training!

My internship was at a brand name AMC, which was my only experience working in medicine. The only course that the psychiatry residents, psychology predoctoral interns, and social work students shared was a DBT course that meet weekly for 3/4 months. Unfortunately, it was subpar training or nothing more than an introduction to DBT. I sure hope no one left that course thinking they had any idea on how to do DBT.

 

[tr]

There is already a career path for a specialization in psychotherapy. It's called clinical psychology. I'm not sure what would be gained by reducing psychiatrist training in physiological aspects of diagnosis and treatment in order to turn us into subpar psychologists.

Even in the most psychotherapeutically oriented residency, there's no way that any subset of the 12-15,000 hours of training in the 4y residency is going to equate to 6 y of focused psychotherapy training you would get in a doctoral program.

Obviously I think psychotherapy is an incredibly important skill for any mental health worker to have, but for psychiatrists, we are necessarily less specialized in that because we have the physiological piece to manage. We need to understand basic cross-modality principles of good psychotherapy and learn a few important modalities sufficiently well, and personally I think I received that. I don't need to be expert in every modality. I just need to know enough to practice effectively within my expertise and refer to the right person when outside it.

Regarding issues with existing training in psychotherapy for MDs, I really think the issue is more with quality than with quantity. Bizarrely, despite the obsessive focus on evidence-based practices in the rest of medicine, the use of evidence-based practices in psychotherapy has only recently begun to trickle down to psychiatric training. Where I did residency (and even more so, I believe, where I did med school) many of the available supervisors were these elderly MDs who described themselves as psychodynamically or 'eclectically' oriented who really weren't doing very much at all beyond supportive listening with the occasional 'interpretation,' and were instructing trainees to behave similarly. You could do years of this type of supervision without achieving any kind of mastery or even improvement.

 

[DynamicDidactic]

There is already a career path for a specialization in psychotherapy. It's called clinical psychology. I'm not sure what would be gained by reducing psychiatrist training in physiological aspects of diagnosis and treatment in order to turn us into subpar psychologists.

Agreed.

From my anecdotal experience, some of that time would be better off used to reinforce empathy and warmth. Although, if I had to see the amount of people at the intervals of the typical psychiatrist, I would also have a harder time being caring and empathetic (especially if people are malingering for meds).

 

[hamstergang]

Nice to see you around hamstergang! It's been a minute.

Hi! And now it's been another minute -- things got busy and I lost track of this thread. I sort of hate to bump it, but I had an issue I figured psychologists/psychology students could solve. See below.

Completed suicide is pretty hard to study prospectively. I don't think it's at all a foregone conclusion that just because SSRIs may increase suicidal ideation, they would also increase completed suicide. But I find the healthy volunteer studies in particular quite convincing on this point.

Also, have you not seen this clinically? It's rare, but if you give out antidepressants regularly I'm surprised you haven't seen it. I have seen it a number of times, always in young adults under 25 (I don't treat adolescents). Most of them describe the thoughts as feeling ego-dystonic, as if they 'came out of nowhere' or 'weren't me,' which is quite unlike how people with depression- or personality-related SI typically describe their thoughts. Also it goes away pretty quickly when you take the obvious step of stopping the med, which is why I'd be surprised if there were any detectable contribution to completed suicide rates.

I basically only treat children and adolescents. I would only rarely start with a new patient who's over 18 and never over 21. I have had patients who report SI after starting a medication, but figuring out if that's actually new or they're just now talking and sharing is a challenge. Not infrequently kids will tell me of some sort of SI they haven't told their parents, so when the parents later see them cutting it gives the impression that the thoughts just developed.

Anyway, I believe that if I could clearly convince parents that SSRIs may increase SI but not at all suicides themselves, I may be able to convince a handful more parents to give them a try. So I wanted to look at national (USA) data to see if there was even a correlation between youth taking antidepressants and suicides. This is certainly not definitive and not perfect, but it could give us an idea if this might even make sense, and it may be able to be displayed graphically (and to be clear, I'm not trying to claim that their potential correlation may imply some causation, but instead that their potential lack of correlation would imply causation to be unlikely).

I had previously gone through the CDC's Vital Statistics and pulled out the suicide rates stratified by age. I now finally figured out how to work SAS's free viewer and so was able to process data from NHANES (the CDC's national health surveys done in 2 year cycles which have a large sample and can give a sense of what percentage of youth are taking medications classified as antidepressants) using help from Excel and Python (it's been a great day off, relearning how to program).

However, I now don't know what to do with the data and Google is failing me. I will attach here what I have; can anyone help to try to understand it? Please note that I am not convinced I got all the NHANES data correctly so the numbers in the attached Excel file may not represent the reality in this country. Plus, the numbers themselves come with some huge caveats. This is just a starting point. Thanks.

 

[beginner2011]

Hi! And now it's been another minute -- things got busy and I lost track of this thread. I sort of hate to bump it, but I had an issue I figured psychologists/psychology students could solve. See below.


I basically only treat children and adolescents. I would only rarely start with a new patient who's over 18 and never over 21. I have had patients who report SI after starting a medication, but figuring out if that's actually new or they're just now talking and sharing is a challenge. Not infrequently kids will tell me of some sort of SI they haven't told their parents, so when the parents later see them cutting it gives the impression that the thoughts just developed.

Anyway, I believe that if I could clearly convince parents that SSRIs may increase SI but not at all suicides themselves, I may be able to convince a handful more parents to give them a try. So I wanted to look at national (USA) data to see if there was even a correlation between youth taking antidepressants and suicides. This is certainly not definitive and not perfect, but it could give us an idea if this might even make sense, and it may be able to be displayed graphically (and to be clear, I'm not trying to claim that their potential correlation may imply some causation, but instead that their potential lack of correlation would imply causation to be unlikely).

I had previously gone through the CDC's Vital Statistics and pulled out the suicide rates stratified by age. I now finally figured out how to work SAS's free viewer and so was able to process data from NHANES (the CDC's national health surveys done in 2 year cycles which have a large sample and can give a sense of what percentage of youth are taking medications classified as antidepressants) using help from Excel and Python (it's been a great day off, relearning how to program).

However, I now don't know what to do with the data and Google is failing me. I will attach here what I have; can anyone help to try to understand it? Please note that I am not convinced I got all the NHANES data correctly so the numbers in the attached Excel file may not represent the reality in this country. Plus, the numbers themselves come with some huge caveats. This is just a starting point. Thanks.

Personally, I would not recommend doing your own epidemiological analysis for a question like this. Epidemiologists receive extensive training over multiple years in order to effectively address this sort of question (control for appropriate confounding variables, select appropriate statistical methods, limit inferences appropriately, etc.), so it's generally a better use of time to find up to date literature and carefully read and interpret findings. This appears to be a good source to address this question:

The Lancet: Comparative efficacy and acceptability of antidepressants, psychotherapies, and their combination for acute treatment of children and adolescents with depressive disorder: a systematic review and network meta-analysis


Edit: I'd highly, highly encourage a full, careful, and close read of the articles themselves. Here are a few selections that stood out to me on a first pass.

From the Lancet:

Two US medical claims databases that contain data on 221028 young people with depression for the period 2004–09 showed that, after accounting for the time varying effect of confounders, the apparent association between antidepressant use and suicide attempts and self-inflicted injury was diminished and not statistically significant. (source)

From the source:

Results of our study revealed that the simple unadjusted and unweighted analysis showed significantly increased risk of suicide attempt and self-inflicted injury when patients were receiving antidepressant treatment for both databases. In both databases, addition of potentially confounding covariates to the model decreased the magnitude of this relationship, but it remained statistically significant. MSM revealed a non-significant relationship between antidepressant treatment and suicide attempt and self-inflicted injury in both databases, with point estimates of 1.05 and 1.21 for LifeLink and MarketScan respectively. These findings suggest that imbalance in both static and dynamic characteristics of patients in terms of the treatment selection process lead to the appearance. of a significant association between antidepressant treatment and suicide attempt and self-inflicted injury. The MSM estimated treatment effects translate to number needed to harm of 1429 and 909 respectively. The question is whether we want to deny treatment to the roughly 1000 patients who have a positive benefit to harm balance (and may become suicidal because of a poorly treated disorder) to avoid harm to one patient who may or may not become suicidal because of treatment. Similar results were obtained when the analysis was restricted to treatment with SSRIs only (point estimates of 1.12 and 1.25 for LifeLink and MarketScan respectively). Our use of MSM combined with good temporal resolution of these data allowed us to adjust for the association between suicidal risk and initiation of antidepressant treatment, and provide a more realistic estimate of any possible relationship between antidepressant treatment and suicide attempt and self-inflicted injury.

There are several limitations of this study. First, suicide attempt and self-inflicted injury may be under-reported in that doctors may treat a suicide attempt or self-inflicted injury but classify it under an unrelated ICD-9 code. However, as noted by Bowie and Shafer22 , “These codes [E950–E959] are used only if the condition is truly deemed a suicide or selfinflicted injury. Use of these codes on an insurance claim can have a devastating impact on how the claim is handled and can have far-reaching effects for a person who tries to obtain insurance in the future.” Second, while we have endeavored to include as many observed confounders as possible, there are likely other unmeasured confounders which may remain unbalanced. Third, just because a prescription has been filled, does not mean that the medication was actually taken and/or taken at the time of the prescription fill. Fourth, we do not have data on completed suicide or mortality during follow-up, and unless the fatal suicide attempt or self-inflicted injury led to hospitalization or treatment, it would go undetected in the medical claims data.

Edit 2:
Also of note, per previous conversations re placebo:

Only fluoxetine plus CBT and fluoxetine were significantly more effective than pill placebo or psychological controls (SMDs ranged from –1·73 to –0·51)

 

[hamstergang]

Personally, I would not recommend doing your own epidemiological analysis for a question like this. Epidemiologists receive extensive training over multiple years in order to effectively address this sort of question (control for appropriate confounding variables, select appropriate statistical methods, limit inferences appropriately, etc.), so it's generally a better use of time to find up to date literature and carefully read and interpret findings.

I mean sure, but it's fun to play around with such things and try to learn along the way. Actually compiling the data, plotting it, and attempting to analyze it gives a different appreciation of the situation than reading other people's work on the topic.

I do appreciate the source and will read through it. My issue with existing research that I've found is that, as with the first quote you provided, much of it focuses on a short time frame. I wanted to see how the data looks over the past 2 decades (well I wanted even longer but could only find such data from 1999).

 

[beginner2011]

Anyway, I believe that if I could clearly convince parents that SSRIs may increase SI but not at all suicides themselves, I may be able to convince a handful more parents to give them a try. So I wanted to look at national (USA) data to see if there was even a correlation between youth taking antidepressants and suicides. This is certainly not definitive and not perfect, but it could give us an idea if this might even make sense, and it may be able to be displayed graphically (and to be clear, I'm not trying to claim that their potential correlation may imply some causation, but instead that their potential lack of correlation would imply causation to be unlikely).

Totally understand the desire to play with data and improve own thinking about an issue. My concern was that when I read the bolded above it sounded like you were planning on generating a graphic to use with patients to inform their treatment decisions. I think that would be unwise.

 

[R. Matey]

So I wanted to look at national (USA) data to see if there was even a correlation between youth taking antidepressants and suicides.

I took a look at your file and there is insufficient data here for this question. You only have the overall rate by calendar year in the U.S., which is basically a single data point per year. You can run an overall correlation across all years, but it would be meaningless. With the data you have, you're better off with a chi-square with a corresponding RR comparing the younger group to the older group broken down by year. This would only tell you the likelihood of completed suicide for a person on anti-depressants compared to the other group, so not exactly what you want.

P.S. While I agree with Beginner that this should just be an academic exercise, I'm not sure what "advanced statistical training" epidemiologists get that we don't. My understanding is that many of the same methods are employed with different research questions. We probably just care a lot more about psychometrics than they do.

 

[beginner2011]

I took a look at your file and there is insufficient data here for this question. You only have the overall rate by calendar year in the U.S., which is basically a single data point per year. You can run an overall correlation across all years, but it would be meaningless. With the data you have, you're better off with a chi-square with a corresponding RR comparing the younger group to the older group broken down by year. This would only tell you the likelihood of completed suicide for a person on anti-depressants compared to the other group, so not exactly what you want.

P.S. While I agree with Beginner that this should just be an academic exercise, I'm not sure what "advanced statistical training" epidemiologists get that we don't. My understanding is that many of the same methods are employed with different research questions. We probably just care a lot more about psychometrics than they do.

I believe @hamstergang is an MD, thus different training backgrounds than you or me (or an epidemiologist).

 

[hamstergang]

Totally understand the desire to play with data and improve own thinking about an issue. My concern was that when I read the bolded above it sounded like you were planning on generating a graphic to use with patients to inform their treatment decisions. I think that would be unwise.

The graphic would be more for me -- I hoped I could plot the two sets of data and clearly see they weren't correlated and then I could tell parents more confidently that the medications wouldn't make their kid kill themselves (I'd have 20 years of data, that's older than the kids themselves and so sounds like a lot). While I can be convinced by studies done by professionals, many parents would be more swayed by "I looked at 20 years' worth of data myself and concluded..."

I took a look at your file and there is insufficient data here for this question. You only have the overall rate by calendar year in the U.S., which is basically a single data point per year. You can run an overall correlation across all years, but it would be meaningless. With the data you have, you're better off with a chi-square with a corresponding RR comparing the younger group to the older group broken down by year. This would only tell you the likelihood of completed suicide for a person on anti-depressants compared to the other group, so not exactly what you want.

As @beginner2011 said, I am an MD. I am the most mathematically minded psychiatrist I know (I have a BS in computer science, I watch math videos for fun) but I don't understand everything you said in this quote. I think this problem is beyond my current capabilities. I think I need to relearn/learn some more stats before returning to this.

 

[hamstergang]

I took a look at your file and there is insufficient data here for this question.

All that aside, what I was initially thinking was that if SSRIs led to suicide, then in the years that a higher percentage of kids were on SSRIs, we would expect to see the suicide rate go up in those years too. Conversely, in the years where a lower percentage of kids were on SSRIs, we would expect to see a lower rate of suicides those years. Is that not valid? Surely there are many reasons we could all think of where this wouldn't be found, but is the concept in general not ok?

 

[WisNeuro]

All that aside, what I was initially thinking was that if SSRIs led to suicide, then in the years that a higher percentage of kids were on SSRIs, we would expect to see the suicide rate go up in those years too. Conversely, in the years where a lower percentage of kids were on SSRIs, we would expect to see a lower rate of suicides those years. Is that not valid? Surely there are many reasons we could all think of where this wouldn't be found, but is the concept in general not ok?

Are you controlling for population increases/decreases, healthcare visits, family history of suicidality, etc? The real problem is, in a very low base rate behavior (completed suicide/hospitalizations for suicide), confounding variables can have huge effects that you cannot assume washout in large samples. I agree with others that the correlation of two variables in any given year is largely a meaningless statistic given base rate problems in this dataset.

 

[hamstergang]

The real problem is, in a very low base rate behavior (completed suicide/hospitalizations for suicide), confounding variables can have huge effects that you cannot assume washout in large samples.

Hmm, oh well. Glad I came here.

By the way, I have to read these much more carefully still, but some of my idea was promoted by this paper:

Duty to Warn: Antidepressant Black Box Suicidality Warning Is Empirically Justified (Front. Psychiatry, 13 February 2020): Duty to Warn: Antidepressant Black Box Suicidality Warning Is Empirically Justified

"some researchers have concluded that the Black Box warning caused severe unintended consequences; specifically, they have argued that the warning led to reduced use of antidepressants among youth, which led to more suicides."

There's at least one study cited here that tried to justify that quote, which is close to what I was trying to do.

Early Evidence of the Effects of Regulators' Suiciadality Warnings on SSRI Prescriptions and Suicide in Children and Adolescents (Am J Psychiatry 1 Sept 2007): Psychiatry Online

 

[tr]

Are you controlling for population increases/decreases, healthcare visits, family history of suicidality, etc? The real problem is, in a very low base rate behavior (completed suicide/hospitalizations for suicide), confounding variables can have huge effects that you cannot assume washout in large samples. I agree with others that the correlation of two variables in any given year is largely a meaningless statistic given base rate problems in this dataset.

Also there may be effects in both directions. Antidepressants may precipitate suicidal ideation in rare cases, but they much more commonly improve depressive symptoms, which could decrease suicide attempts. Both effects could coexist but you'd be hard pressed to figure that out by looking at the low-resolution dataset described.

 

[WisNeuro]

Also there may be effects in both directions. Antidepressants may precipitate suicidal ideation in rare cases, but they much more commonly improve depressive symptoms, which could decrease suicide attempts. Both effects could coexist but you'd be hard pressed to figure that out by looking at the low-resolution dataset described.

Totally agree, this is the difficulty in these datasets, if you don't accurately control for things, your data will turn out meaningless. Can't analyze these like you would experimental data, particularly RCT type data, where you already control for many of the confounding variables in your setup (hopefully).

 

[allantois]

I would like to bump this thread. Since I've started practicing, I've seen a disturbing pattern where therapists (albeit, I do not work with psychologists), are not referring patients for medication management (we offer both services at our clinics). Now, a lot of things can be managed with therapy alone. However, I am noticing a lot of bipolar patients who are being seen by therapy and are clearly either manic or depressed not even being suggested that they should make an appointment to discuss medication. I am also seeing patients who tell their therapists that they stopped taking their medication and no attempt is made to have the patient follow up for a medication appointment (they just document patient stopped taking their medication). I can think of some other examples of severe depression, high suicide risk patients once again not even being encouraged to have a medication appointment. I have talked to some therapists about these issues, but most it seems genuinely do not see bipolar disorder as requiring medication management as well as not understanding that they don't want to be the only ones seeing high risk suicidal patients.

 

[WisNeuro]

I would like to bump this thread. Since I've started practicing, I've seen a disturbing pattern where therapists (albeit, I do not work with psychologists), are not referring patients for medication management (we offer both services at our clinics). Now, a lot of things can be managed with therapy alone. However, I am noticing a lot of bipolar patients who are being seen by therapy and are clearly either manic or depressed not even being suggested that they should make an appointment to discuss medication. I am also seeing patients who tell their therapists that they stopped taking their medication and no attempt is made to have the patient follow up for a medication appointment (they just document patient stopped taking their medication). I can think of some other examples of severe depression, high suicide risk patients once again not even being encouraged to have a medication appointment. I have talked to some therapists about these issues, but most it seems genuinely do not see bipolar disorder as requiring medication management as well as not understanding that they don't want to be the only ones seeing high risk suicidal patients.

This is probably where a lot of the issues lie. Midlevels are probably more often beholden to ideas that are not supported by data (e.g., EMDR can treat everything under the sun, acupuncture works, etc). Unfortunately, it seems like this is the direction a lot of the larger non-VA healthcare systems are going with populating their therapy clinics with SW and masters therapists.

 

[PsychPhDone]

I would like to bump this thread. Since I've started practicing, I've seen a disturbing pattern where therapists (albeit, I do not work with psychologists), are not referring patients for medication management (we offer both services at our clinics). Now, a lot of things can be managed with therapy alone. However, I am noticing a lot of bipolar patients who are being seen by therapy and are clearly either manic or depressed not even being suggested that they should make an appointment to discuss medication. I am also seeing patients who tell their therapists that they stopped taking their medication and no attempt is made to have the patient follow up for a medication appointment (they just document patient stopped taking their medication). I can think of some other examples of severe depression, high suicide risk patients once again not even being encouraged to have a medication appointment. I have talked to some therapists about these issues, but most it seems genuinely do not see bipolar disorder as requiring medication management as well as not understanding that they don't want to be the only ones seeing high risk suicidal patients.

When my patients tell me they have d/c meds without discussing it with their prescriber, I encourage them to follow their prescriber's recommendations and set up an appt with prescriber and the prescriber gets tagged to the note. (Yes I'm in the VA.)

I have zero interest in trying to do psychotherapy with someone who needs meds and isn't taking them.

Agree with @WisNeuro about people not knowing what they don't know.

 

[R. Matey]

This is probably where a lot of the issues lie. Midlevels are probably more often beholden to ideas that are not supported by data (e.g., EMDR can treat everything under the sun, acupuncture works, etc). Unfortunately, it seems like this is the direction a lot of the larger non-VA healthcare systems are going with populating their therapy clinics with SW and masters therapists.

These orgs are lighting their own money on fire though. Inefficacious treatment is ultimately more expensive because it produces longer and more frequent episodes of care. Not to thread hijack, but given this issue, I'm curious if folks here think midlevels should be supervised by psychologists at least in the same manner as PAs are to MD/DOs since we often advise people who just want to do therapy to get an SW degree.

 

[WisNeuro]

These orgs are lighting their own money on fire though. Inefficacious treatment is ultimately more expensive because it produces longer and more frequent episodes of care.

Well, these places also staff their midlevel managers with people who have never done clinical work, so they only really care about balancing their spreadsheets for the year. They're not looking at intermediate and long-term issues.

 

[R. Matey]

Well, these places also staff their midlevel managers with people who have never done clinical work, so they only really care about balancing their spreadsheets for the year. They're not looking at intermediate and long-term issues.

Sounds like a job for a growth model if anyone actually cared about saving money in the long run.

 

[WisNeuro]

Sounds like a job for a growth model if anyone actually cared about saving money in the long run.

Considering long-term consequences is a wholly un-American point of view.

 

[Sanman]

This is probably where a lot of the issues lie. Midlevels are probably more often beholden to ideas that are not supported by data (e.g., EMDR can treat everything under the sun, acupuncture works, etc). Unfortunately, it seems like this is the direction a lot of the larger non-VA healthcare systems are going with populating their therapy clinics with SW and masters therapists.

In addition, I also wonder how much training these people have in management of more serious MH diagnoses. I see people not trained in the management of more serious MH concerns hired for these positions once they graduate in the name of saving a dollar.

 

[PsychPhDone]

In addition, I also wonder how much training these people have in management of more serious MH diagnoses. I see people not trained in the management of more serious MH concerns hired for these positions once they graduate in the name of saving a dollar.

I specialize in a content area that I think midlevels could reasonably work out ok on the average case...but then I get emails like "hey I'm going to do this treatment in the specialty area that I've never done before since your wait-list is long, can you send me the manual? ... Oh no I don't have a supervisor"

 

[Sanman]

These orgs are lighting their own money on fire though. Inefficacious treatment is ultimately more expensive because it produces longer and more frequent episodes of care. Not to thread hijack, but given this issue, I'm curious if folks here think midlevels should be supervised by psychologists at least in the same manner as PAs are to MD/DOs since we often advise people who just want to do therapy to get an SW degree.

Should they be supervised by a psychologist or otherwise experienced clinician? Yes. Will this be done? unlikely. It is not profitable to provide quality supervision to a licensed clinician and consultation/free advice will only get you so far.

 

[R. Matey]

Should they be supervised by a psychologist or otherwise experienced clinician? Yes. Will this be done? unlikely. It is not profitable to provide quality supervision to a licensed clinician and consultation/free advice will only get you so far.

In education, teachers have instructional coaches who have the job and providing professional development and support to teachers. It would be cool if we could do that for mid-levels. Provided the salary is right, I'd take that job.