The Corpus Callosum

I chose three articles from this month’s edition of Archives
of General Psychiatry
, upon which to comment.   For
those not familiar with it, Arch Gen Psychiatry is
an AMA journal, like JAMA, but for psychiatrists.  It’s an
influential journal.


1. href="http://archpsyc.ama-assn.org/cgi/content/full/65/8/870">Selecting
Among Second-Step Antidepressant Medication Monotherapies
.
 This is their one open-access article, so I will mention it
first.  A little background: We’ve known for a long time that
all antidepressants work for some people, but nothing works for
everyone.  A lot of effort has gone into the task of trying to
figure out ahead of time which drugs will work for which persons.
 That’s called treatment matching.
 

From 2001 to 2004,  a large number (727) of patients were
recruited to a study, the Star*D study.  This was a large,
multi-site study that was intended to resolve a number of important,
practical questions pertaining to the treatment of depression.
 A lot of data were collected.  Several papers
already have been published from that data set.

The paper under consideration here followed from efforts to analyze the
data to see if there were any trends that could be used to facilitate
treatment matching.

The whole article is openly available, so you can read it in its
entirety.  But I will save you the trouble:

Conclusions  Clinical,
demographic, and treatment history were of little value in recommending
1 medication vs another as a second-step treatment for major depressive
disorder. Participants most likely to remit in the second step had less
Axis I psychiatric disorder comorbidity, less social disadvantage, and
at least a response to citalopram in the first step. 

In other words, we are back to where we started with regard to
treatment matching.  The authors were not able to find any
factor that could be used ahead of time to figure out who is more
likely to respond to what treatment.  What they found is that
things that we already knew are good prognostic signs, are, in fact,
good prognostic signs.  Patients who are healthier tend to do
better.  Patients who have more money and more social support
tend to do better.  Patients who already have had a partial
response to one drug are more likely to respond to the next drug.

I don’t mean to be dismissive of the study.  It was worth
doing.  But we had hoped for a little more.

2. href="http://archpsyc.ama-assn.org/cgi/content/abstract/65/8/962?lookupType=volpage&vol=65&fp=962&view=short">National
Trends in Psychotherapy by Office-Based Psychiatrists
.
 Only the abstract is openly  accessible.
 This one was featured in an article in the LA Times:
href="http://www.latimes.com/news/science/la-sci-shrink5-2008aug05,0,7966688.story">

href="http://www.latimes.com/news/science/la-sci-shrink5-2008aug05,0,7966688.story">Medication
increasingly replaces psychotherapy, study finds

Fewer patients are undergoing in-depth treatment as
antidepressants and other drugs are more widely used. The shift is
attributed partly to insurance reimbursement policies.

By Denise Gellene, Los Angeles Times Staff Writer
August 5, 2008

Wider use of antidepressants and other prescription medications has
reduced the role of psychotherapy, once the defining characteristic of
psychiatric care, according to an analysis to be published Tuesday.

The percentage of patients who received psychotherapy fell to 28.9% in
2004-2005 from 44.4% in 1996-1997, the report in Archives of General
Psychiatry said.

That would be a good summary, except that it’s wrong.  The
report does not say that.  The authors did not even look at
that question.  Instead, the authors only looked at trends in
practice among psychiatrists.  It is not possible to day,
based upon the study, whether medication is “replacing” psychotherapy.
 

Instead, what the study says, is that psychiatrists are, on average,
spending a smaller proportion of their time doing psychotherapy.
 It is possible (indeed, likely) that other practitioners are
doing the psychotherapy, while the psychiatrists are devoting more of
their time to medication management.

Here’s the meat of the abstract:

Results  Psychotherapy
was provided in 5597 of 14 108 visits (34.0% [weighted]) sampled during
a 10-year period. The percentage of visits involving psychotherapy
declined from 44.4% in 1996-1997 to 28.9% in 2004-2005 (P <
.001). This decline coincided with changes in reimbursement, increases
in managed care, and growth in the prescription of medications. At the
practice level, the decrease in providing psychotherapy corresponded
with a decline in the number of psychiatrists who provided
psychotherapy to all of their patients from 19.1% in 1996-1997 to 10.8%
in 2004-2005 (P = .001). Psychiatrists who provided psychotherapy to
all of their patients relied more extensively on self-pay patients, had
fewer managed-care visits, and prescribed medications in fewer of their
visits compared with psychiatrists who provided psychotherapy less
often.

Conclusions  There has been a recent
significant decline in the provision of psychotherapy by psychiatrists
in the United States. This trend is attributable to a decrease in the
number of psychiatrists specializing in psychotherapy and a
corresponding increase in those specializing in
pharmacotherapy—changes that were likely motivated by
financial incentives and growth in psychopharmacological treatments in
recent years.

It would be interesting to know if medication management is replacing
psychotherapy, but the study does not tell us that.

There are some interesting findings.  There still are
psychiatrists who won’t split the care; that is, they will not
prescribe medication to someone who is also seeing a psychologist of
social worker for psychotherapy.  Those psychiatrists will
either provide all of the treatment, or none of it, but they will not
do half of it, while someone else does the other half.  The
proportion of psychiatrists with that practice pattern is shrinking.
 Those who do practice that way, are less likely to accept
insurance.  They are more likely to accept only private-pay
arrangements.

As of 2005, only 28.9% of visits to a psychiatrist included
psychotherapy for more than 30 minutes.  That may be
influenced by the fact that the psychiatrist can make a lot more money
by doing a greater number of short sessions that by dong fewer long
sessions.

As an aside, I once dealt with an insurance company that paid more for
a single 15-minute medication review, than they paid for a single
30-minute session that included both medication management and 
psychotherapy.  

That company went out of business, for unrelated reasons.

3. href="http://archpsyc.ama-assn.org/cgi/content/abstract/65/8/914">Capsulotomy
for Obsessive-Compulsive Disorder
,
 Psychosurgery got a really, really bad reputation due to the
discredited practice of frontal lobotomy.  But a different
kind of psychosurgery still is done.  It is a more refined,
localized, precise surgery, done only in those who are incapacitated by
obsessive-compulsive disorder.  It is not done very often.
 This study reports on the long-term (10-year) outcome in 25
cases.  Here is part of the abstract:

Results  The mean Y-BOCS
score was 34 preoperatively and 18 at long-term follow-up (P <
.001). Response (defined as ≥35% reduction at long-term
follow-up compared with baseline) was seen in 12 patients at long-term
follow-up. Nine patients were in remission (Y-BOCS score, <16)
at long-term follow-up. Only 3 patients were in remission without
adverse effects at long-term follow-up. Response rates did not differ
significantly between surgical methods. A mean weight gain of 6 kg was
reported in the first postoperative year. Ten patients were considered
to have significant problems with executive functioning, apathy, or
disinhibition. Six of these 10 patients had received high doses of
radiation or had undergone multiple surgical procedures. Results of our
magnetic resonance imaging analysis in 11 patients suggest that the OCD
symptom reduction may be increased by reducing the lateral extension of
the lesions, and a reduction in the medial and posterior extension may
limit the risk of adverse effects (ie, smaller lesions may produce
better results).

Conclusions  Capsulotomy is effective in
reducing OCD symptoms. There is a substantial risk of adverse effects,
and the risk may vary between surgical methods. Our findings suggest
that smaller lesions are safer and that high radiation doses and
multiple procedures should be avoided.

The patients all had surgery between 1998 and 2000.  

The study suggests that people who get smaller lesions (that is, less
drastic surgery) not only have a lower risk of adverse effects, but
they have greater reduction in symptoms.  The risk-benefit
balance is not very favorable: only 3 patients (12% of the sample)
experienced long-term remission without impairment of cognition.
 

Clearly, more study would be necessary to refine the technique and to
assess fully the best way to balance the risks and the benefits.
 But it is hard to get the data for more studies, because the
procedure is not done very often.  

All three papers share a common theme.  They illustrate that
it is easy to get data in medical research, but often it is hard to get
the data that you really want, to learn what you really want to know.
 

Comments

  1. #1 Roy from Shrink Rap
    August 30, 2008

    I wasn’t able to find my issue of AGP around the house, so I am wondering about the 2nd article, about psychotherapy. I’m wondering if they used claims data to do this study. If so, then it would be a worthless study.

    For your readers, some brief background: When psychiatrists submit a bill to an insurance company, there are generally 3 types of codes one can use, which are called CPT codes (for Current Procedural Terminology). One is called an E&M code (Evaluation & Management). This would mostly be one of these: 99211, 99212, 99213, 99214, 99215 (each one is more complex or time-consuming than the next, with escalating payments). Use of this code requires a specific type of documentation. A number of insurance companies may either not pay for this code for psychiatrists, or require a preauthorization.

    The next are psychotherapy codes, which are based on time and the main ones are 90805 (20-30 min), 90807 (45-50 min), and 90809 (75-80 min). These also require some specific documentation and payments escalate.

    Finally, there is the medication management code, or 90862. There is no time attached to this one, so whether you spend one minute or one hour with a patient, you can use this one. It is paid about the same as a 99213 and a bit less than a 90805. There are very little documentation requirements and rarely requires a preauthorization, so it is the easiest one to use. Many psychiatrists will use this code, yet still provide psychotherapy to a patient during the session, commonly 15 to 30 minutes long (a few docs may only see pts for 5 or 10 minutes, if the pt is well-known to them, or in a busy clinic, but this is probably not the standard).

    So, since the abstract was unclear on this matter, I thought I’d do some teaching about how it works. If they only look at claims, then this study only truly speaks to the success of managed care policies in paying less and less for psychiatric treatment. Of course, you get what you pay for.

    (Since I went on for so long here, I decided to copy and paste this as a post on Shrink Rap.)