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 19th 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,
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2: Taipale H,
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“The effectiveness of first and second generation
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