Success Rates In Psychiatry

 

Today's comment is on a brief editorial in JAMA Psychiatry about the evidence of success of psychiatric treatments (1). The authors present an even handed argument for establishing systems that would allow for the determination of success rates of psychiatric care. They point out the obvious limitations of developing these systems in the United States but may not have gone far enough. In the US - our healthcare data is considered proprietary by the health care company who owns the electronic medical record that the data is recorded in. Patients often find themselves in varying negotiations in order to get access to their own records. They may find some data is not accessible at all. If they venture into another system of care that uses the same electronic health record (EHR) – they may have to repeat significant portions of their record (current medication list, allergy list, immunization record, test results) that should have easily transitioned. Within a typical metropolitan area in the US – there may be many EHRs that cannot communicate with one another at a level that would allow determination of success rates. As a result, the authors conclude most of the success rate data in psychiatry comes from clinical trials.  That data is limited by selection biases and brief periods of treatment.

The authors also look at Specific Success Rates (SSR) and Aggregate Success Rates (ASR) as population-based quality measures. To the best of my knowledge there are no corporations currently using these measures. That lack of usage is based more on medical tradition than usefulness of quality measures. Current hospital and clinical measures typically sample worst possible outcomes or so-called sentinel events. This is the business approach to mortality and morbidity conferences in medicine and surgery that were detailed discussions of deaths and complications. The thinking has typically been to learn from worst case scenarios or your colleagues’ obvious mistakes. The problem with those conferences is that they provide little guidance about the best treatment for most other patients.  For many years Medicare used the same system.  I was a Medicare Quality reviewer for 2 states and their focus was on process rather than outcomes and success rates were never discussed.  Major quality events like a death on a psychiatric unit would trigger a detailed quality review.

As a long time follower of the work of Tiihonen, the first flaw that I noticed was that none of his work was referenced.  Tiihonen has a long track record of looking at outcomes using observational studies (2-12) and has commented on both the limitations and advantages of these studies (17). One of the critical advantages of doing research in Scandinavian countries is access to nationwide databases or registries that include the usual demographic patient information but also diagnoses, treatments, medications and outcome data.  Those data include hard outcomes (suicide, all cause mortality, disability) and soft outcomes (drug discontinuation, rehospitalization, symptom checklists, side effects checklists, psychosocial outcomes).  Similar data is available in other studies such as long acting injectable (LAIs) antipsychotic medications back to the 1980s, treatment cohort studies (Schou, Winokur, Guze, Angst) from similar periods and various sampling studies that look at surveys of medical clinics.  There are also the statistics from the 19^th century protopsychiatry era.  My favorite one is from Luther Bell (15) describing the outcomes of delirious mania:

“A subsequent case series published by Luther Bell in 1849 described 40 patients with the condition among 1700 admissions to McLean Hospital (Bell, 1849). He reported a mortality rate of 75% in these patients."

Today - nobody dies from delirious mania or the more common forms of mania that frequently led to deaths from congestive heart failure during the protopsychiatry era.  That is an improvement in mortality on par with any other medical specialty and it is due to improvements in psychiatric care.

But nothing can replace the rigor and data of registry studies from Scandinavia. By rigor I mean the results of treatment of unselected real-world patients in real world systems of care, very large data sets, and no missing data. Clinical trials can't compare when as many as 80% of real-world patients are omitted from consideration (16) and those patients may be at higher risk for morbidity and mortality outcomes.

Psychiatric treatment success rates are available if you look for them.  I am not as negative about observational or registry studies when I consider the advantages about knowing real world outcomes and how they diverge from relatively brief randomized controlled trials that do not choose real world patients and are biased at times to the point of being irrelevant by drop outs over time. Additional considerations in terms of the goals of this post include experienced psychiatrists themselves are the typically the best critics of the field. Critics who maintain a specific obvious viewpoint will generally continue to repeat the same criticisms they have been repeating for decades and cannot be considered reliable.  All psychiatrists have varying experiences clinically, in research, and in the literature of the field. An extensive review of psychiatric outcomes over time would seem to be indicated – but there is a lot of applicable research out there right now.  In terms of generating more thorough success rates several biases described above need to be overcome including viewing the necessary data as proprietary or the disingenuous application HIPPA regulations that seem to allow mass marketing of patient data but not allow adequate population-wide quality measures.  I would go as far as establishing a nationwide pharmacosurveillance/pharmacovigilance system to get adequate real world pharmacology data. 

In ending this note I will say that the editorial generated predictable rhetoric.  I typically find myself responding to rhetoric on this blog – but in this case another blogger stepped in and did the heavy lifting.  For anyone interested in the rhetorical side I refer you to the commentary by Awais Aftab, MD who provides excellent responses. Psychiatrists are trained in critiquing their own literature and provide the best legitimate criticism.  A lot of critics outside the field basically repeat what they have been saying for decades.  Those responses tend to be impervious to criticism reflect a general lack of knowledge about the field.  The original editorial by Freedland and Zorumski has merit. It was not intended as a blanket condemnation of the field.  I hope to have fleshed it out a bit in this post and suggested both sources of current data and next steps.

 

George Dawson, MD, DFAPA

 

Supplementary 1:  I am very interested in a large review of psychiatric outcomes.  If you have similar interests and expertise – send me your favorite references or suggestions on how we can collaborate.

 

References:

1:  Freedland KE, Zorumski CF. Success Rates in Psychiatry. JAMA Psychiatry. 2023 Mar 22. doi: 10.1001/jamapsychiatry.2023.0056. Epub ahead of print. PMID: 36947055.

2:  Taipale H, Tanskanen A, Mehtälä J, Vattulainen P, Correll CU, Tiihonen J. 20-year follow-up study of physical morbidity and mortality in relationship to antipsychotic treatment in a nationwide cohort of 62,250 patients with schizophrenia (FIN20). World Psychiatry. 2020 Feb;19(1):61-68. doi: 10.1002/wps.20699. PMID: 31922669; PMCID: PMC6953552.

“These data suggest that long-term antipsychotic use does not increase severe physical morbidity leading to hospitalization, and is associated with substantially decreased mortality, especially among patients treated with clozapine.”

3:  Tiihonen J, Tanskanen A, Taipale H. 20-Year Nationwide Follow-Up Study on Discontinuation of Antipsychotic Treatment in First-Episode Schizophrenia. Am J Psychiatry. 2018 Aug 1;175(8):765-773. doi: 10.1176/appi.ajp.2018.17091001. Epub 2018 Apr 6. PMID: 29621900.

“Whatever the underlying mechanisms, these results provide evidence that, contrary to general belief, the risk of treatment failure or relapse after discontinuation of antipsychotic use does not decrease as a function of time during the first 8 years of illness, and that long-term antipsychotic treatment is associated with increased survival.”

4:  Tiihonen J, Wahlbeck K, Lönnqvist J, Klaukka T, Ioannidis JP, Volavka J, Haukka J. Effectiveness of antipsychotic treatments in a nationwide cohort of patients in community care after first hospitalisation due to schizophrenia and schizoaffective disorder: observational follow-up study. BMJ. 2006 Jul 29;333(7561):224. doi: 10.1136/bmj.38881.382755.2F. Epub 2006 Jul 6. PMID: 16825203; PMCID: PMC1523484.

16 yr study

“The effectiveness of first and second generation antipsychotics varies greatly in the community. Patients treated with perphenazine depot, clozapine, or olanzapine have a substantially lower risk of rehospitalisation or discontinuation (for any reason) of their initial treatment than do patients treated with haloperidol. Excess mortality is seen mostly in patients not using antipsychotic drugs.”

5:  Taipale H, Lähteenvuo M, Tanskanen A, Mittendorfer-Rutz E, Tiihonen J. Comparative Effectiveness of Antipsychotics for Risk of Attempted or Completed Suicide Among Persons With Schizophrenia. Schizophr Bull. 2021 Jan 23;47(1):23-30. doi: 10.1093/schbul/sbaa111. PMID: 33428766; PMCID: PMC7824993.

6:  Tiihonen J, Mittendorfer-Rutz E, Majak M, Mehtälä J, Hoti F, Jedenius E, Enkusson D, Leval A, Sermon J, Tanskanen A, Taipale H. Real-World Effectiveness of Antipsychotic Treatments in a Nationwide Cohort of 29 823 Patients With Schizophrenia. JAMA Psychiatry. 2017 Jul 1;74(7):686-693. doi: 10.1001/jamapsychiatry.2017.1322. PMID: 28593216; PMCID: PMC5710250.

7:  Heikkinen M, Taipale H, Tanskanen A, Mittendorfer-Rutz E, Lähteenvuo M, Tiihonen J. Real-world effectiveness of pharmacological treatments of alcohol use disorders in a Swedish nation-wide cohort of 125 556 patients. Addiction. 2021 Aug;116(8):1990-1998. doi: 10.1111/add.15384. Epub 2021 Jan 14. PMID: 33394527; PMCID: PMC8359433.

8:  Lähteenvuo M, Tanskanen A, Taipale H, Hoti F, Vattulainen P, Vieta E, Tiihonen J. Real-world Effectiveness of Pharmacologic Treatments for the Prevention of Rehospitalization in a Finnish Nationwide Cohort of Patients With Bipolar Disorder. JAMA Psychiatry. 2018 Apr 1;75(4):347-355. doi: 10.1001/jamapsychiatry.2017.4711. Erratum in: JAMA Psychiatry. 2022 May 1;79(5):516. PMID: 29490359; PMCID: PMC5875349.

9:  Puranen A, Koponen M, Lähteenvuo M, Tanskanen A, Tiihonen J, Taipale H. Real-world effectiveness of mood stabilizer use in schizophrenia. Acta Psychiatr Scand. 2023 Mar;147(3):257-266. doi: 10.1111/acps.13498. Epub 2022 Sep 14. PMID: 36065482.

10:  Tiihonen J, Haukka J, Taylor M, Haddad PM, Patel MX, Korhonen P. A nationwide cohort study of oral and depot antipsychotics after first hospitalization for schizophrenia. Am J Psychiatry. 2011 Jun;168(6):603-9. doi: 10.1176/appi.ajp.2011.10081224. Epub 2011 Mar 1. Erratum in: Am J Psychiatry. 2012 Feb;169(2):223. PMID: 21362741.

11:  Tiihonen J, Tanskanen A, Hoti F, Vattulainen P, Taipale H, Mehtälä J, Lähteenvuo M. Pharmacological treatments and risk of readmission to hospital for unipolar depression in Finland: a nationwide cohort study. Lancet Psychiatry. 2017 Jul;4(7):547-553. doi: 10.1016/S2215-0366(17)30134-7. Epub 2017 Jun 1. PMID: 28578901.

12:  Tiihonen J, Lönnqvist J, Wahlbeck K, Klaukka T, Tanskanen A, Haukka J. Antidepressants and the risk of suicide, attempted suicide, and overall mortality in a nationwide cohort. Arch Gen Psychiatry. 2006 Dec;63(12):1358-67. doi: 10.1001/archpsyc.63.12.1358. PMID: 17146010.

13:  Kisely S, Preston N, Xiao J, Lawrence D, Louise S, Crowe E. Reducing all-cause mortality among patients with psychiatric disorders: a population-based study. CMAJ. 2013 Jan 8;185(1):E50-6. doi: 10.1503/cmaj.121077. Epub 2012 Nov 12. PMID: 23148054; PMCID: PMC3537812.

14: McMahon FJ. Prediction of treatment outcomes in psychiatry--where do we stand ? Dialogues Clin Neurosci. 2014 Dec;16(4):455-64. doi: 10.31887/DCNS.2014.16.4/fmcmahon. PMID: 25733951; PMCID: PMC4336916.

15: Bell, L., 1849. On a form of disease resembling some advanced stageof mania and fever. Am. J. Insanity 6, 97–127. 

16:  Taipale H, Schneider-Thoma J, Pinzón-Espinosa J, Radua J, Efthimiou O, Vinkers CH, Mittendorfer-Rutz E, Cardoner N, Pintor L, Tanskanen A, Tomlinson A, Fusar-Poli P, Cipriani A, Vieta E, Leucht S, Tiihonen J, Luykx JJ. Representation and Outcomes of Individuals With Schizophrenia Seen in Everyday Practice Who Are Ineligible for Randomized Clinical Trials. JAMA Psychiatry. 2022 Mar 1;79(3):210-218. doi: 10.1001/jamapsychiatry.2021.3990. PMID: 35080618; PMCID: PMC8792792.

17: Taipale, H. and Tiihonen, J. (2021) “Registry-Based Studies: What They Can Tell Us, and What They Cannot,” European Neuropsychopharmacology, 45, pp. 35–37. doi: 10.1016/j.euroneuro.2021.03.005. 

18:  Lähteenvuo M, Paljärvi T, Tanskanen A, Taipale H, Tiihonen J. Real-world effectiveness of pharmacological treatments for bipolar disorder: register-based national cohort study. Br J Psychiatry. 2023 Oct;223(4):456-464. doi: 10.1192/bjp.2023.75. PMID: 37395140.