Thursday, September 30, 2004
Show Me A Drug with No Risk...
The Vioxx issue reminds me of the very-old days when some docs would titrate the dose of a tricyclic antidepressant by repeating an EKG each time the dose was increased. For these docs, the goal was to get the "QT interval" on the EKG to just start to change (widen, actually). It was thought to be a better measure of the blood level of the medication than, well, a blood level.
The thought was that if the patient didnt have a dry mouth, and didnt get a little lightheaded when he stood up, and if the EKG didnt show a bit of a change in the QT interval, well, no way the dose was high enough to help the depression...
The thought was that if the patient didnt have a dry mouth, and didnt get a little lightheaded when he stood up, and if the EKG didnt show a bit of a change in the QT interval, well, no way the dose was high enough to help the depression...
Wednesday, September 29, 2004
Giving Aspirin for a Fulminant Infection
In Tennessee's public health program, the use of antipsychotics in children is skyrocketing, according to a study reported in Psychiatric News. Is it due to improved detection of early onset schizophrenia? No. They're being used to treat behavior problems. The use of these medications for aggression and agitation is quite common, especially in kids who get hospitalized for out-of-control behavior.
Why? It's the push for quick discharges, and it's the lack of funding for the family counseling and case management these children and their families really need. It's treating the symptoms alone, sort of like continuing to hike the dose of aspirin to cover a fever while ignoring (for lack of funding) the underlying infection that you know how to diagnose and treat.
Why? It's the push for quick discharges, and it's the lack of funding for the family counseling and case management these children and their families really need. It's treating the symptoms alone, sort of like continuing to hike the dose of aspirin to cover a fever while ignoring (for lack of funding) the underlying infection that you know how to diagnose and treat.
Tuesday, September 28, 2004
Turning On the Gene for Bad Behavior
A study reported in Psychiatric News suggests that bad boys are bad because of something in their genes. It's sort of like saying they've just got "bad blood," don't you think?
But there is a catch. Something bad has to happen in the child's life in order to switch on a gene tied to serious behavior problems in children. How to switch on the gene? Inconsistent discipline, neglect and exposure to violence will do the trick.
Hmm...
I reckon eventually we're gonna be back to explaining a lot of childhood disorders in a way that ol' Doc Freud would've completely understood. It's just that, nowadays, instead of saying that bad life events lead to psychopathology we'll say bad life events turn on the gene, and then the gene causes the psychopathology.
I'm not sure what the difference is, clinically. How 'bout you?
But there is a catch. Something bad has to happen in the child's life in order to switch on a gene tied to serious behavior problems in children. How to switch on the gene? Inconsistent discipline, neglect and exposure to violence will do the trick.
Hmm...
I reckon eventually we're gonna be back to explaining a lot of childhood disorders in a way that ol' Doc Freud would've completely understood. It's just that, nowadays, instead of saying that bad life events lead to psychopathology we'll say bad life events turn on the gene, and then the gene causes the psychopathology.
I'm not sure what the difference is, clinically. How 'bout you?
Monday, September 27, 2004
Lassie! Get Help!
That's what it says in the first panel of a Danny Shanahan, two-panel comic from the New Yorker in May 1989. Do you remember the second panel? No? Here it is...
Sunday, September 26, 2004
Neuropsychiatric Disorder vs Personality Disorder
Wondering why that medication for "bipolar disorder" isn't helping? Maybe the dosage is wrong. But more likely it's the wrong diagnosis. Lots of folks who used to get diagnosed with personality disorder seem to be coming down with neuropsychiatric disorders nowadays. That's because most of the characteristics of personality disorders overlap with the symptoms of major psychiatric disorders. In making a diagnosis, it is important to keep in mind that fifteen percent of folks have a personality disorder, according to a report in the Journal of Clinical Psychiatry summarized here. That makes personality disorder much more common than most neuropsychiatric disorders. Being poor, divorced or widowed are risk factors for personality disorder. And medications dont fix being poor...
Thursday, September 23, 2004
Walk and Never Get Dementia -- or Depression?
Here's what I think is unfair about those studies in JAMA this week saying that walking holds off dementia: Why is it that walking 90 minutes per week does the trick for women, but men have to walk a couple of miles per day? How fair is that?
In the study on women, those on antidepressants tended to exercise less. My guess is that the medications weren't working for many of them. I've long believed that it is virtually impossible to retain a vigorous exercise routine and a depressive episode at the same time.
In the study on women, those on antidepressants tended to exercise less. My guess is that the medications weren't working for many of them. I've long believed that it is virtually impossible to retain a vigorous exercise routine and a depressive episode at the same time.
Wednesday, September 22, 2004
Euthymia In the Water
In some parts of the West, I am told, they dont need child psychiatrists. "That's what whippin' posts are for," I am told.
And I hear that there are places that dont need psychiatrists, either, because there is naturally so much lithium in the water.
Now comes this study from the United Kingdom about the high level of Prozac showing up in their drinking water.
Some critics say it is a failure of government water pollution policy. Others say it represents overprescription by British family docs. But since one out of four people will have a major depressive episode some time in their lives, and since no disorder causes more lost productivity than depression, and since Prozac is now generic, perhaps leaving "secondary" Prozac in the water supply simply represents good public health economics...ya reckon?
And I hear that there are places that dont need psychiatrists, either, because there is naturally so much lithium in the water.
Now comes this study from the United Kingdom about the high level of Prozac showing up in their drinking water.
Some critics say it is a failure of government water pollution policy. Others say it represents overprescription by British family docs. But since one out of four people will have a major depressive episode some time in their lives, and since no disorder causes more lost productivity than depression, and since Prozac is now generic, perhaps leaving "secondary" Prozac in the water supply simply represents good public health economics...ya reckon?
Tuesday, September 21, 2004
The Search for Genes that Cause Mental Illness
There is a series of Brief Reports in this month's American Journal of Psychiatry attempting to link specific gene alleles to specific neuropsychiatric disorders. While exciting, I worry that these studies will hit up against a fundamental limitation in my business: all of our diagnoses are descriptive (not pathological) in nature, and (worse) they are based upon a description of symptoms that need only occur over a relatively short period of time. That leaves too much room for diagnostic overlap and misdiagnosis. From a clinical perspective, studies like the one mentioned here that seek to tie medication efficacy to an allele seem more promising in the short-run.
Monday, September 20, 2004
Are Patients Cost Unconscious?
Imagine that you are in line at the grocery store and the guy behind you buys the same box of Cheerios for half of what you just paid. The store manager would get called in a flash.
That's the problem in healthcare economics. It is not about the payor, nor about the high cost of advances in diagnostic testing and pharmaceuticals.
Robert Dodge argues (correctly, in my mind) in the Dallas Morning News that the problem with healthcare costs is that patients don't even know what their services cost. He cites an American Enterprise Institute comment about healthcare: "This is the only major sector where consumers do not know prices."
Mr Dodge suggest that we require doctors, hospitals and other providers to disclose prices. It'd be more effective if we asked patients to directly pay their bills, seek reimbursement from a savings account (with a stop-loss insurance policy) -- and let them keep everything unspent from that account.
That's the problem in healthcare economics. It is not about the payor, nor about the high cost of advances in diagnostic testing and pharmaceuticals.
Robert Dodge argues (correctly, in my mind) in the Dallas Morning News that the problem with healthcare costs is that patients don't even know what their services cost. He cites an American Enterprise Institute comment about healthcare: "This is the only major sector where consumers do not know prices."
Mr Dodge suggest that we require doctors, hospitals and other providers to disclose prices. It'd be more effective if we asked patients to directly pay their bills, seek reimbursement from a savings account (with a stop-loss insurance policy) -- and let them keep everything unspent from that account.
Sunday, September 19, 2004
The Original Special Education Program
Here's an interesting position statement on education: "There are many...who feel that too much is demanded of children in school at the present time. There are many who are sure that the game is not worth the candle, since so many of the modern fads in education bear little relation...to success in life..."
Nope, it's not from a 2004 campaign stump speech. It's from the Journal of the American Medical Association -- in 1904.
It's part of an article reporting on a novel way to help children with learning disorders -- by giving them extra help. One hundred years later, it too often still feels like pulling teeth to get this kind of help for some children in need. It's a shame, too, because I cannot tell you how many cases misdiagnosed as ADHD I have "cured" by getting a learning disabled child into a classroom setting where he is not frustrated, and therefore does not need to act out that frustration in bad behavior. (This is especially common among children with verbal delays. If it's difficult for you to talk about how frustrated you feel, you're more likely to show it behaviorally.)
Nope, it's not from a 2004 campaign stump speech. It's from the Journal of the American Medical Association -- in 1904.
It's part of an article reporting on a novel way to help children with learning disorders -- by giving them extra help. One hundred years later, it too often still feels like pulling teeth to get this kind of help for some children in need. It's a shame, too, because I cannot tell you how many cases misdiagnosed as ADHD I have "cured" by getting a learning disabled child into a classroom setting where he is not frustrated, and therefore does not need to act out that frustration in bad behavior. (This is especially common among children with verbal delays. If it's difficult for you to talk about how frustrated you feel, you're more likely to show it behaviorally.)
Friday, September 17, 2004
How to Stop Smoking
You can't stop a patient from smoking just by recommending it. According to a study by the Surgeon General reported in JAMA, patients need counseling and medication (Welbutrin or a nicotine replacement regimen) if they are likely to successfully stop.
Comorbid psychiatric disorder makes it harder to quit smoking. So here's one of those cases where a little psychiatric treatment now can facilitate the goal of cessation, and perhaps eliminate the need for expensive medical care down the line for the sequelae of cigarette smoking.
Comorbid psychiatric disorder makes it harder to quit smoking. So here's one of those cases where a little psychiatric treatment now can facilitate the goal of cessation, and perhaps eliminate the need for expensive medical care down the line for the sequelae of cigarette smoking.
Thursday, September 16, 2004
The Original Low-Carb Diet?
From a letter to the editor by Dr Ruth Berkelman of Emory University, in JAMA last week:
"Excerpts from an English manual of home medicine in 1892: Mr Banting's widely read "Letter on Corpulence" . . . tells us that for years he struggled in vain against constantly augmenting fatness [Banting is described as being aged 66 years, about 5'5" and 202 lb in 1862]. At last . . . he almost abandoned the use of bread, butter, sugar, beer, and potatoes, eating freely and fully, however, of other kinds of food. In this way he . . . lost in thirty-eight weeks thirty-five pounds in weight . . . he improved wonderfully in general health...."
Daniel Pinkwater (and scroll down) insisted this week on NPR that he'd lost 50 pounds doing exactly what his father told him to do years ago to lose weight: no white bread, no white rice, no desserts.
"Excerpts from an English manual of home medicine in 1892: Mr Banting's widely read "Letter on Corpulence" . . . tells us that for years he struggled in vain against constantly augmenting fatness [Banting is described as being aged 66 years, about 5'5" and 202 lb in 1862]. At last . . . he almost abandoned the use of bread, butter, sugar, beer, and potatoes, eating freely and fully, however, of other kinds of food. In this way he . . . lost in thirty-eight weeks thirty-five pounds in weight . . . he improved wonderfully in general health...."
Daniel Pinkwater (and scroll down) insisted this week on NPR that he'd lost 50 pounds doing exactly what his father told him to do years ago to lose weight: no white bread, no white rice, no desserts.
Wednesday, September 15, 2004
Another Approach to Health Care Cost Control
There was an article and editorial in JAMA last week about the Swiss health insurance system. Apparently the Swiss require working folks to buy a minimum insurance policy. Insurance companies have to offer the base package, but it sounds like they make their money only on add-ons to it.
The article claims that the system is consumer-driven. But I agree with the commentary: it is much too regulated to be considered consumer-driven. However, it at least gets employers out of the business of managing patient benefits, because in Switzerland it's the patient who buys the insurance policy, not her company. The ideal plan (and I say "ideal" because it would take a massive overhaul to make it work) would have insurance companies out of the business of managing benefits, as well, and return them to managing risk. In that ideal plan, the patient (not the insurance company) would pay the doctor.
The article claims that the system is consumer-driven. But I agree with the commentary: it is much too regulated to be considered consumer-driven. However, it at least gets employers out of the business of managing patient benefits, because in Switzerland it's the patient who buys the insurance policy, not her company. The ideal plan (and I say "ideal" because it would take a massive overhaul to make it work) would have insurance companies out of the business of managing benefits, as well, and return them to managing risk. In that ideal plan, the patient (not the insurance company) would pay the doctor.
Tuesday, September 14, 2004
Why Can't Children Vote?
When experts cite the existence of dementia as the rationale to start competency testing for voting rights (as they do in this JAMA article), then the question that comes to mind for me is this: why not let competent children vote?
Proposed standards include understanding what voting is, showing capacity of choice among candidates, and ability to register. Wouldn't most older children meet those standards?
Proposed standards include understanding what voting is, showing capacity of choice among candidates, and ability to register. Wouldn't most older children meet those standards?
Teen Suicide and Antidepressants
In one report, FDA officials say that none of the research they are using to condemn antidepressant use reaches statistical significance. There is only evidence of "leaning" toward more suicidal thoughts and behavior in teens on these medications.
Another thought I've had about this: I can't tell you how many so-called "treatment failures" I've been asked to consult upon among teens on antidepressants for whom I could not discern why the patient was on the medication in the first place. So it makes me wonder if one factor is wrong diagnosis. Perhaps docs are attempting to treat children with mild or variable depressive symptoms plus dangerous and/or impulsive behaviors (including suicidal behaviors) with a medication intended for severe depression.
Another thought I've had about this: I can't tell you how many so-called "treatment failures" I've been asked to consult upon among teens on antidepressants for whom I could not discern why the patient was on the medication in the first place. So it makes me wonder if one factor is wrong diagnosis. Perhaps docs are attempting to treat children with mild or variable depressive symptoms plus dangerous and/or impulsive behaviors (including suicidal behaviors) with a medication intended for severe depression.
Monday, September 13, 2004
Teen Sex and TV
I just saw a Daniel Drezner post from September 8th on the above topic. He cites a study in Pediatrics that says that teen sex goes up as watching sexual content on TV goes up.
The American Academy of Child and Adolescent Psychiatry (AACAP) has written several "Facts for Families" on this topic, especially this one.
I keep wondering: where are the parents? "Active parenting can ensure that children have a positive experience with television," says AACAP.
We want to blame TV programmers, but I still wonder if the bigger social issue is the long hours parents have to work nowadays to make ends meet. It means less parental supervision; that is, less "active parenting."
I am reminded again of the study in JAMA that I mentioned here about the impact that getting out of poverty has on disruptive behavior problems. I am sure the same applies to sexual behavior problems.
The American Academy of Child and Adolescent Psychiatry (AACAP) has written several "Facts for Families" on this topic, especially this one.
I keep wondering: where are the parents? "Active parenting can ensure that children have a positive experience with television," says AACAP.
We want to blame TV programmers, but I still wonder if the bigger social issue is the long hours parents have to work nowadays to make ends meet. It means less parental supervision; that is, less "active parenting."
I am reminded again of the study in JAMA that I mentioned here about the impact that getting out of poverty has on disruptive behavior problems. I am sure the same applies to sexual behavior problems.
Saturday, September 11, 2004
A Decrease in Conduct Disorders?
A Center for Disease Control report in the latest JAMA says that violence among high school students is significantly down over the past ten years. It speculates that preventative programs have been effective.
I speculate that zero-tolerance since Columbine is the more likely explanation. The data shows most of the decline occurred when you compare 1993 to 1999 (which is the year Columbine took place). Levels were steady between 1999 and 2003.
I speculate that zero-tolerance since Columbine is the more likely explanation. The data shows most of the decline occurred when you compare 1993 to 1999 (which is the year Columbine took place). Levels were steady between 1999 and 2003.
Friday, September 10, 2004
Patient Family Members Who Blog
Outside of mentally-ill patients themselves, nobody has endured more stigma than the parents of those who suffer from neuropsychiatric disorders like schizophrenia and severe bipolar disorder.
For thousands of years, society considered severe/persistent mental illness to be some sort of moral problem: If you would just get right in your relationship with God, you wouldn't have this disease.
Then in the late 1800's, Freud developed some profound and useful theories that were profoundly misinterpreted by most of society. Society no longer considered severe/persistent mental illness to be a problem between you and God. Now it was a problem between you and your parents: If you would just get new parents, you wouldn't have this disease.
In spite of all of the contemporary evidence suggesting a mostly-genetic etiology for diseases like schizophrenia, parents of the mentally ill still endure stigma and guilt from a society that still tends to point the finger in their direction.
NAMI and its chapters continue to fight this stigma.
In addition, some family members have been willing to talk about their experiences online, and I have added links to some of their weblogs, as well.
For thousands of years, society considered severe/persistent mental illness to be some sort of moral problem: If you would just get right in your relationship with God, you wouldn't have this disease.
Then in the late 1800's, Freud developed some profound and useful theories that were profoundly misinterpreted by most of society. Society no longer considered severe/persistent mental illness to be a problem between you and God. Now it was a problem between you and your parents: If you would just get new parents, you wouldn't have this disease.
In spite of all of the contemporary evidence suggesting a mostly-genetic etiology for diseases like schizophrenia, parents of the mentally ill still endure stigma and guilt from a society that still tends to point the finger in their direction.
NAMI and its chapters continue to fight this stigma.
In addition, some family members have been willing to talk about their experiences online, and I have added links to some of their weblogs, as well.
Thursday, September 09, 2004
Weblogs by Patients
I have added links to a number of patient weblogs. I did so after a recent personal trip to the emergency room. It occurred to me how hard it is for any physician, but particularly for an emergency room physician, to consistently maintain the high level of empathy that most patients (or at least this patient!) demands in a patient-physician encounter.
Perhaps most docs think it would be easier for a psychiatrist, and especially a child psychiatrist, to maintain that coveted empathy patient after patient. But in an era when payors incentivize the 10-minute med check over the clearly-more-efficacious 50-min meds-plus-psychotherapy visit, even psychiatrists are seeing 50 or more patients in a day (especially in the public sector).
So an experience from the patient's side of the encounter was helpful for me. So are the views expressed in these patient weblogs.
Perhaps most docs think it would be easier for a psychiatrist, and especially a child psychiatrist, to maintain that coveted empathy patient after patient. But in an era when payors incentivize the 10-minute med check over the clearly-more-efficacious 50-min meds-plus-psychotherapy visit, even psychiatrists are seeing 50 or more patients in a day (especially in the public sector).
So an experience from the patient's side of the encounter was helpful for me. So are the views expressed in these patient weblogs.
Wednesday, September 08, 2004
Is it Juvenile Bipolar Disorder or ADD?
Experts in the field have not yet agreed on all diagnostic criteria of juvenile bipolar disorder.
Evidence suggests that bipolar disorder does occur in children, and that it is distinct from attention deficit hyperactivity disorder. That is, there is a syndrome in children characterized by poor regulation of emotions.
But - there is no clear evidence that the syndrome is related to adult bipolar disorder at all. And the fact that poor treatment response and recurrence are common leads many to believe that while underdiagnosis may have been a problem in the past, overdiagnosis is now more prevalent.
Evidence suggests that bipolar disorder does occur in children, and that it is distinct from attention deficit hyperactivity disorder. That is, there is a syndrome in children characterized by poor regulation of emotions.
But - there is no clear evidence that the syndrome is related to adult bipolar disorder at all. And the fact that poor treatment response and recurrence are common leads many to believe that while underdiagnosis may have been a problem in the past, overdiagnosis is now more prevalent.
Tuesday, September 07, 2004
When Hearing Voices is Normal
A worried mom brought in her four-year-old to see me because the child has an imaginary friend with whom he talks and even seems to see. His friend also tells the child things to say - usually bad things about his mom!
The question was: normal, or early-onset schizophrenia?
When we are very little it is hard to own all the bad feelings that we have toward our parents. After all, when you are very little it seems dangerous to risk angering the people who feed you and keep you safe. So, one of the ways children handle those feelings is to attribute them to someone else - even if they have to imagine that someone!
But seeing and hearing imaginary friends is normal behavior for a four-year-old. It is not the same as when an adult suffering from schizophrenia hears voices.
The question was: normal, or early-onset schizophrenia?
When we are very little it is hard to own all the bad feelings that we have toward our parents. After all, when you are very little it seems dangerous to risk angering the people who feed you and keep you safe. So, one of the ways children handle those feelings is to attribute them to someone else - even if they have to imagine that someone!
But seeing and hearing imaginary friends is normal behavior for a four-year-old. It is not the same as when an adult suffering from schizophrenia hears voices.
Monday, September 06, 2004
At-Risk Parenting
A group of researchers had the hypothesis that children born to very young mothers would be at higher-than-average risk for disruptive behavior disorders as they grew older.
In a report in Acta Paediatrica, the researchers tell us they were right -- sort of.
Regression analysis showed that the real risk factors were family adversity and the mother's parenting style. It's just that young mothers live in tougher circumstances, and were "inadequate, restrictive and more negative...with their toddlers."
But it adds credence to the notion that, as much as we'd like to see many of these disorders as purely biological, it is true that parenting is important in their etiology, as well.
In a report in Acta Paediatrica, the researchers tell us they were right -- sort of.
Regression analysis showed that the real risk factors were family adversity and the mother's parenting style. It's just that young mothers live in tougher circumstances, and were "inadequate, restrictive and more negative...with their toddlers."
But it adds credence to the notion that, as much as we'd like to see many of these disorders as purely biological, it is true that parenting is important in their etiology, as well.
Sunday, September 05, 2004
Making Sure "Terrible Twos" Doesn't Become "Terrible Teens," Too
The control battles that occur during the toddler years can leave everyone feeling terrible. That's why they call them the "terrible twos!"
And the battles don't come to a screeching halt just because a child turns three -- just ask the parents of any teenager! So, just because you still see remnants of the terrible twos in your three-year-old (or, for that matter, your thirteen-year-old) does not mean that there is something wrong with you or with your child. This is a normal phase of child development.
But keep in mind that the tone you set at age two will last throughout childhood and adolescence. So it is important to make it clear that you mean business when you set a limit. That means following through with your limit-setting every, single time - even if it means physically restraining your child to ensure compliance.
I know that it can be time-consuming and exhausting to make a decision and follow it through to the end. But the trick is to get the battles over with while your child is still very young. It's a lot easier to keep a three-year-old in a time-out chair than to do so with a thirteen-year-old, right? If your child gets the message early on, then the battles in adolescence (although they won't go away!) will be must less intense.
And the battles don't come to a screeching halt just because a child turns three -- just ask the parents of any teenager! So, just because you still see remnants of the terrible twos in your three-year-old (or, for that matter, your thirteen-year-old) does not mean that there is something wrong with you or with your child. This is a normal phase of child development.
But keep in mind that the tone you set at age two will last throughout childhood and adolescence. So it is important to make it clear that you mean business when you set a limit. That means following through with your limit-setting every, single time - even if it means physically restraining your child to ensure compliance.
I know that it can be time-consuming and exhausting to make a decision and follow it through to the end. But the trick is to get the battles over with while your child is still very young. It's a lot easier to keep a three-year-old in a time-out chair than to do so with a thirteen-year-old, right? If your child gets the message early on, then the battles in adolescence (although they won't go away!) will be must less intense.
Saturday, September 04, 2004
What Makes Ritalin Work?
There's a neat little study in the September Journal of the American Academy of Child and Adolescent Psychiatry linking the efficacy of Ritalin to a specific genotype. Hyperactive children with one of the genotypes for "norepinephrine transporter gene G1287A" were less likely to improve on Ritalin than children with the other two genotypes.
We were always taught that Ritalin probably worked by its impact on the dopamine system. Nowadays, lots of people think it impacts norepinephrine, instead.
Interestingly, other research suggest no relationship between this same gene and the presence of hyperactivity. The effect is only on the efficacy of the medication.
It will be good for medical economics and good for patient care when the day arrives in which we can predict medication efficacy through bloodwork, rather than through trial and error.
We were always taught that Ritalin probably worked by its impact on the dopamine system. Nowadays, lots of people think it impacts norepinephrine, instead.
Interestingly, other research suggest no relationship between this same gene and the presence of hyperactivity. The effect is only on the efficacy of the medication.
It will be good for medical economics and good for patient care when the day arrives in which we can predict medication efficacy through bloodwork, rather than through trial and error.
Thursday, September 02, 2004
Should Psychotherapy be First-Line Treatment for Depression?
Thousands of Consumer Reports readers completed a survey to tell what worked for them when they needed help for depression. The results are generally the same as with real research: meds plus therapy works best.
But people who relied "mostly" on psychotherapy seemed to have done pretty much as well as people using the combination approach. Folks who just used medication didnt do quite as well, and it often took a while to find the right medication.
Two-session EAP psychotherapy didn't cut it. Folks who did best were those in therapy the longest.
One caveat: the severity of the depressions being treated was unclear.
But people who relied "mostly" on psychotherapy seemed to have done pretty much as well as people using the combination approach. Folks who just used medication didnt do quite as well, and it often took a while to find the right medication.
Two-session EAP psychotherapy didn't cut it. Folks who did best were those in therapy the longest.
One caveat: the severity of the depressions being treated was unclear.
Wednesday, September 01, 2004
The Problem Is Not The Payor
Grahamazon is correct about the bottlenecks that are consciously or unconsciously set up in public-sector programs to impede access to care: they are there to protect a system perceived as underfunded from imploding.
But is the system underfunded, or is it just terribly inefficient? Remove the bottlenecks (see Goldratt's great business book, The Goal, to learn how to do it), don't increase available dollars, and watch and see.
You'll most certainly find that the primary problem is inefficiency, not underfunding. So, the primary problem is not the payor, it is the management of the system. (If government would pay enough to get superior managers, that would be a first step toward a fix of the public sector problem.)
It does not matter if you have one payor or a dozen. What is needed is competition, and there is virtually none in a public and private medical industry driven by insurance companies that do not compete with one another. There is even less competition in community health care.
The whole problem is exacerbated by the fact that, from a business perspective, the physician's "customer" is the insurance company and not the patient. If anything, the patient (or, at best, the patient's care) becomes the "product."
Give the poor vouchers and give the employed-&-insured free reign to negotiate provider prices directly (and the ability to keep anything they dont spend), and the cost of medical care would drop precipitously, more than enough to care for the uninsured.
But is the system underfunded, or is it just terribly inefficient? Remove the bottlenecks (see Goldratt's great business book, The Goal, to learn how to do it), don't increase available dollars, and watch and see.
You'll most certainly find that the primary problem is inefficiency, not underfunding. So, the primary problem is not the payor, it is the management of the system. (If government would pay enough to get superior managers, that would be a first step toward a fix of the public sector problem.)
It does not matter if you have one payor or a dozen. What is needed is competition, and there is virtually none in a public and private medical industry driven by insurance companies that do not compete with one another. There is even less competition in community health care.
The whole problem is exacerbated by the fact that, from a business perspective, the physician's "customer" is the insurance company and not the patient. If anything, the patient (or, at best, the patient's care) becomes the "product."
Give the poor vouchers and give the employed-&-insured free reign to negotiate provider prices directly (and the ability to keep anything they dont spend), and the cost of medical care would drop precipitously, more than enough to care for the uninsured.
