Ten Ways to Improve Post Partum Psychosis Care in the United States

I have two recent posts on the issue and thought I would add this as a better summary.  The media refrains at this point are tiresome and not helpful.  Just yesterday I heard arguments about how the current Clancy case is or is not an indictment of the mental health system.  That was followed by a poll that said most men consider filicide cold blooded murder and most woman are more sympathetic.  There are of course social media influencers amplifying those extremes to get likes and improve their revenue streams and politicians doing the same. All of this occurs in the context of highly publicized incidents of violence perpetrated by persons with obvious severe mental illness on the streets in New York and other large cities. Those incidents have resulted in loss of life of both victims and perpetrators. 

Any consistent reader of this blog over the years should get the strong message that there is no system of care for mental illnesses in the US and that the system of care for physical illnesses is rapidly going down the same tube. Disproportionate rationing of care for mental illnesses started out as a profit maker for the managed care industry and that has expanded to all medical care.  As a result, there has been an explosion in the number of administrators compared with people doing the work and a transfer of a trillion dollars a year to management.  It is more than profit making at this point. It leads to a current lack of quality care for those who can access it and it is unsustainable.

Here are a few thoughts on getting an actual system in place that might be able to address the real problems rather than focusing on all of the non-functional political rhetoric.    There is some overlap between points.  That is intentional to place more of a focus on postpartum care. 

1:  Improve mental health and the care of mental illnesses in general – The first time the federal government took a direct role in the provision of mental health services was the Community Mental Health Act of 1963 signed by President Kennedy.  The goal was to move mental health care out of asylums and back to communities.  It led to the creation of many Community Mental Health Centers.  Even as late as 1988, I was providing care at a rural hospital so they would not default on a grant they obtained though that original Act.  Since then many CMHCs have been closed.  Some have been assimilated by other non-public systems of care.  New certified community behavioral health clinics (CCBHCs), were established under the Protecting Access to Medicare Act of 2014 rather than continuing the CMHC category.  This changing landscape has made facilities a poor proxy for access to mental health care. 

 Better metrics and the current statistics are included in the table below:

Metric	What it measures	Key statistics	References
1. Treatment rate / minimally adequate treatment	Whether care reached the person and met a guideline-based quality threshold	Of 24.9% of US adults with a past-year disorder, 60.7% received any treatment but only 34.0% received minimally adequate treatment (MDPS, SCID-5). Historically ~47.7% of adults with serious conditions received no treatment; only ~44.8% of adults with any mental illness treated in 2019	[1-3]
2. Workforce supply per population (HPSA)	Provider capacity relative to population; shortage-area designation	>1/3 of Americans live in a behavioral health workforce shortage area; majority of counties lack any practicing psychiatrist, psychologist, or social worker; psychiatrists per 100,000 fell ~10% (2003–2013) while PCP/neurology supply grew	[4-5]
3. Timely access (availability & wait times)	Whether providers accept new patients and how long the wait is	Only 18.5% of sampled psychiatrists available to new patients; median wait 67 days (in-person) vs 43 days (telepsychiatry); worse for Medicaid than private insurance	[6]
4. Two-dimensional geographic access (availability + affordability)	County provider supply per 100,000 AND cost of a treatment course vs disposable income, mapped simultaneously	Reveals counties where providers are physically present but financially inaccessible; income was the strongest predictor of both dimensions; rural and Southern counties carry dual burdens	[7-8]
5. Medicaid acceptance & out-of-pocket burden	Whether existing providers accept Medicaid/new patients and cost-sharing faced by patients	~Nearly half of psychiatrists do not accept insurance due to poor reimbursement eliminates SMI patients who hit benefit limits; SMI care is disproportionately publicly financed	[5]
1:  Edlund M, Guyer H, Ringeisen H, Stambaugh L, Dever J, Carpenter L, Olfson M, First M, Geiger P, Liao D, Peytchev A, Carr C, Zangeneh S, Chwastiak L, Dixon L, Monroe-Devita M, Stroup TS, Swanson J, Swartz M, Gibbons R, Bareis N, Kessler RC. Treatment of Mental Disorders Among U.S. Adults: Findings From the Mental and Substance Use Disorders Prevalence Study. Psychiatr Serv. 2026 Jul 22:appips20250398. doi: 10.1176/appi.ps.20250398. Epub ahead of print. PMID: 42482274. 2:  Olfson M, Wang S, Wall M, Marcus SC, Blanco C. Trends in Serious Psychological Distress and Outpatient Mental Health Care of US Adults. JAMA Psychiatry. 2019;76(2):152–161. doi:10.1001/jamapsychiatry.2018.3550 3: Askari, M.S., Mauro, P.M., Kaur, N. et al. Age, Period, and Cohort Trends in Perceived Mental Health Treatment Need and Differences by Mental Health Severity in the United States, 2008–2019. Community Ment Health J 59, 631–640 (2023). https://doi.org/10.1007/s10597-022-01044-3 4:  Substance Abuse and Mental Health Services Administration. Expanding Behavioral Health Teams in Care Deserts With Community Health Workers and Peer Support Specialists. Publication No. PEP26-07-001. Substance Abuse and Mental Health Services Administration. 2026. 5:   Huskamp HA, Iglehart JK. Mental Health and Substance-Use Reforms--Milestones Reached, Challenges Ahead. N Engl J Med. 2016 Aug 18;375(7):688-95. doi: 10.1056/NEJMhpr1601861. PMID: 27532837. 6:  Sun CF, Correll CU, Trestman RL, Lin Y, Xie H, Hankey MS, Uymatiao RP, Patel RT, Metsutnan VL, McDaid EC, Saha A, Kuo C, Lewis P, Bhatt SH, Lipphard LE, Kablinger AS. Low availability, long wait times, and high geographic disparity of psychiatric outpatient care in the US. Gen Hosp Psychiatry. 2023 Sep-Oct;84:12-17. doi: 10.1016/j.genhosppsych.2023.05.012. Epub 2023 May 25. PMID: 37290263. 7:  Park J, Kim HR, Duffy RD, Vogel D, Keum BT, Lee S, Tomé NL. Two dimensions of access: Availability and affordability of mental health care across the United States. Am Psychol. 2026 Jun 4. doi: 10.1037/amp0001735. Epub ahead of print. PMID: 42241094. 8:  Cummings JR, Allen L, Clennon J, Ji X, Druss BG. Geographic Access to Specialty Mental Health Care Across High- and Low-Income US Communities. JAMA Psychiatry. 2017;74(5):476–484. doi:10.1001/jamapsychiatry.2017.0303

 

The data for postpartum depression in various clinical settings is that only 6.3% of women with the disorder receive adequate treatment and only 3.2% of that cohort achieve remission (1).  Similar rates are not available in those populations for postpartum psychosis, but there is no reason to expect the numbers would be better.  In a study of postpartum psychosis where all of the cases were identified as a cohort treated by the same research group the remission rate was 82-94% (2) illustrating the rates of treatment response with a comprehensive program.

The first metric is the clearest indicator of a non-system.  Less than half of anyone with a serious mental disorder or any mental disorder receives minimally adequate care in this country. For some conditions like depression that number goes as low as 10% when considering effective treatment for depression. With those numbers it should not be surprising that people with acute symptoms are obvious at times. Metrics 2 – 5 explain why the gap exists (capacity, timeliness, geography, and financing).  There are concrete ways to address every one of those problems.

2:  Develop state of the art guidelines for treatment - the existing system has evolved to ration access and shift costs to non-mental health care settings like jails, shelters, and county detox units.  This impedes access to medical providers with the most resources and access to referrals.  The standard crisis approach at most hospitals creates a boarding situation in emergency departments (ED), excessive congestion, and slows access to mental health care.  Many people end up leaving without treatment.

3:  Develop adequate inpatient units for care – bed requirements to produce the same wait time and access to care that medical and surgical patients get have been determined.  States and health care systems have been reluctant to build and staff those adequate numbers and there is some indication that medical and surgical beds are also in short supply.  Granted there is more ambulatory care than in the past – but it clearly has been inadequate at alleviating pressure on both the ED and hospital admissions.  Many outpatient mental health providers use the ED for after hours crisis referral and in many cases it is the only way to access more intensive services like electroconvulsive therapy.  The ED services that I am familiar with do not provide crisis care.  They provide a decision about whether a person should be admitted to the hospital or not and the bias is on the not side.

4: Adequately fund treatment maternal care including replacing the Medicaid funding that has been cut - Medicaid is the largest single payer of maternal care, mental health and substance use treatment – even before additional funding is considered.  The current administration cut this funding source by $1trillion over the next decade.  Even before those cuts directly impact all of those millions of individuals – hundreds of rural and safety net hospitals and other facilities will be closed.  In the process all health care premiums will increase fueling the ongoing cycle rationing and cost-shifting to increase corporate profits.  Safety net hospitals are generally critical components of the treatment of severe mental illnesses and psychiatric emergencies.  Every hospital with a large obstetric component needs mental health consultants that know about perinatal care.   

5:  Educate medical professionals about the disorder – most of the physicians I have discussed this disorder with have encountered some form of maternal mental disorder that compromised the safety of the mother or child at some point in their training and career.  In my experience it first happened during my clinical rotation though obstetrics and gynecology (OBGYN) in medical school.  At that time there was no discussion of the mental disorder or what care was necessary. Even as a psychiatric resident, I saw patients with the disorder but there was no discussion of specific evaluation or treatment.   I did not start to see that information until about a decade into clinical practice.  My next post will have the top groups worldwide studying this disorder as well as some of the top references.   

6:  Promote maternal mental health as a necessary subject in primary care and psychiatric specialties – the full array of psychiatric disorders associated with the peripartum state has become a lot clearer with research. It is a frequent topic at psychiatric research and continuing education conferences.  All primary care specialists need to have a good idea about necessary care and available resources.  The psychopharmacology of these disorders is also a necessary topic and the experts in that area do not necessarily overlap with postpartum psychosis experts (3).

7:   Prioritize prophylactic treatment of severe mental disorders before and during pregnancy – in woman with known preexisting psychiatric disorders there is a lot known about effective prophylaxis that is safe at all stages of pregnancy.  Pregnancy is a known cause of rapidly worsening pre-existing mental disorders and there should be a plan in place to prevent that disruption.  

8:  Educate the general public about the disorder – in one of the studies I referenced in a previous post the partner involved was unaware of pregnancy related mental health disorders and was often concerned about the loss of the relationship or future with the woman involved.  All of that can be addressed in education about peripartum and postpartum care and the appropriate educational materials made available.

Social media is a very poor format for these discussions because of the level of misinformation out there about psychiatric disorders as well as the political posturing involved.  That has resulted in moralistic positions being taken that have no basis in reality.  And yes – I am saying as a psychiatrist that mental conditions can affect consciousness, insight, judgment, and agency to the point that a person will make a decision that they would not otherwise make in the commission of a crime.  And further I am saying that is a qualitative change and not a quantitative one.  In other words it is not getting excessively angry or emotional in the heat of the moment, it is an entirely different state of mind.   

9:  Adequately fund research on the disorder – like most people reading this I do not have a scorecard on what research programs or scientists were cut doing research on this disorder.  I think there is a general bias with the new political movement against women up to an including the criminalization of pregnancy complications in some states.  Those laws place the lives of women at risk and the careers of professionals trying to treat them at risk. With that level of overt bias against women, I would not be shocked to see research grants in this area defunded.  After reading some of the research from groups with organized research efforts – I do not want to see that happen.  

10:  Add postpartum psychosis and depression to the DSM – this was an ongoing debate in the research I reviewed for my posts on the topics.  As noted in the graphic at the top of this post – ICD has discrete diagnoses for both postpartum depression and postpartum psychosis. The DSM uses a “peripartum” specifier for 11 pre-existing categories most of which are mood disorders.  There is always debate about what codes to include in a DSM – but my reading of the literature suggests that there are clearcut cases that only occur postpartum and that is a critical distinction in terms of whether maintenance medication is required.  The only non-mood disorder diagnosis in the DSM with a peri-partum specifier is brief psychotic disorder. Based on the cases I have seen and treated my speculation is that the group of women in that category who are postpartum is extremely small.

A section on women’s mental health in the DSM listing these disorders and other considerations would be a welcome addition.  It fulfills the goal of mapping onto the ICD codes and could be a valuable source of education about these disorders.

These are a few of the thoughts I have about what is needed to improve mental health care in the US. I am painfully aware of the The Mental Health Parity and Addiction Equity Act (MHPAEA) and its unfulfilled promise. It also illustrates that as long as governments allow for profit businesses to run the healthcare system – the only expectation should be continued deterioration in care and higher expenses.  The current stance of most companies denying care is they will ignore you until you either get a national news organization to look into their care denial or you sue them.

That is not a way to run an ethical healthcare company or have an actual system of care.

 

George Dawson, MD, DFAPA

 

Supplementary 1:  I have posted my experience in his area many times on this blog and therefore did not include it in the above post.  When I started working at a major medical center in 1989, the department heads were all physicians who were doing clinical work, teaching, and research.  The only business people present were business managers who answered to the head of the department. Over the next 20 years – department heads were physicians in name only who mostly did administration.  There was still a business manager.  And now there was an entire tower of executives managing all of us by basically giving us the message that we were not working hard enough.  We were routinely called up to implement bad ideas from management.  When I tried to contact the tower directly I was told: “You should think of a firewall between the clinicians and us”.   Translation: don’t ever call us – just listen to us through your physician/manager and business manager.

Supplementary 2:  I will have a major post out in the next few weeks looking at all of the top research groups in the world on postpartum psychosis and a few of their references.  I will have a separate post on peripartum psychopharmacology since I have attended several of these meetings and have first hand knowledge of many of these researchers.

 

References:

1:  Cox EQ, Sowa NA, Meltzer-Brody SE, Gaynes BN. The Perinatal Depression Treatment Cascade: Baby Steps Toward Improving Outcomes. J Clin Psychiatry. 2016 Sep;77(9):1189-1200. doi: 10.4088/JCP.15r10174. PMID: 27780317.

2: Kamperman AM, Veldman-Hoek MJ, Wesseloo R, Robertson Blackmore E, Bergink V. Phenotypical characteristics of postpartum psychosis: A clinical cohort study. Bipolar Disord. 2017 Sep;19(6):450-457. doi: 10.1111/bdi.12523. Epub 2017 Jul 12. PMID: 28699248.

3:  Bourke CH, Stowe ZN, Owens MJ. Prenatal antidepressant exposure: clinical and preclinical findings. Pharmacol Rev. 2014 Feb 24;66(2):435-65. doi: 10.1124/pr.111.005207. PMID: 24567054; PMCID: PMC3973612.

Photo Credit:  Rick Ziegler - sunset over Lake Superior March 2024

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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.

The Problem With Making Medical Information More Like Financial Information

I have been an interested reader of financial information for the the past 40 years.  My uncle was an avid stock market investor when I was a kid and he got me interested in reading the Value Line investment  survey.  I still read it and base some of my decisions on it.  Over the years I have had some degree of success in investing, but it hasn't all been good.  One of my greatest successes was a defensive maneuver that resulted in me not losing anything during the stock market crash of 2008.  I have been a subscriber at one time or another to most of the significant investment magazines and newspapers in the United States.

It has been interesting to observe what has happened to what has come to be known as the financial services industry over my investing career because it has implications for the increasing business control over medicine.  I have already alluded to many on these implications on this blog including treating knowledge workers like production workers and creating an unhealthy work environment that results in a lack of empathy for the patients being treated.  But there are even larger implications.  Financial services industry friendly legislation has probably been the single largest contributor to the idea that the privacy of individuals is relative to the advantages gained by establishing credit reporting.  Credit reporting agencies were born out of the idea that data could be collected under a Social Security Number and released to any financial institution without the consent of the person behind that SSN.  That single idea violated a previous promise by Congress that SSNs would not be used as any type of national identifier and was single handedly responsible for creating a multi-billion dollar industry that basically buys and sells credit information and the identity theft industry - both the criminal side and the services to protect people from the criminals.  It is much harder to be an identity thief in a world that does not have credit information centralized on a SSN.

The driving force behind businesses everywhere is to create leverage that results in people needing to buy a product or service and make it so they can't get it anywhere else.  We hear a lot about competition and its importance in capitalism, but there is plenty of evidence that capitalism is not only lacking but that measures are often in place to severely restrict it.    It results in an industry that is set up to optimize gain from consumers while keeping them all at risk.  As an example, one of the "low risk" strategies for investing with some of these companies is to investment in index funds.  As retirement nears, the recommendation can be to put funds into an annuity or with an advisor who can determine withdrawal rates, reallocation, and future investment decisions.  In many cases the retiree is charged up to 1% for that service on top of whatever service charges and transaction fees are associated with the funds that are invested in.  There is always the disclaimer that there is no guarantee of income from the account and this is compounded by the fact that interest on cash and money market funds is at an all time low.  Very few investors can fund their retirement by interest on so-called safe investments and in the last decade we have witnessed the first losses on money market funds.  All things considered, regulation at all levels seems like it is clearly set up to favor the financial services industry.  They have a license to warn you that you can lose money even though you may be paying them to protect it - and that's OK.  In some extreme examples, investment banks have recommended purchases to customer that they were actively betting against.

I don't know how many people can see the trend, but it is pretty obvious to me.  As medical information gets more like financial information - it moves farther away from any reality basis and it becomes a vehicle for manipulation.  The whole point of collecting data from a medical and scientific standpoint is to look at underlying meaning specifically implications for health care.  The best example is lab data.  If I look at a patient's CBC with differential count and chemistry profile,  I have about 40 data points, any one of which could have significant health implications for the care of that individual.  If I look at various quality markers and screening scores that are being collected for business purposes that data varies from questionable to clearly invalid and yet physicians are being held "accountable" for what is essentially business quality data.  In other words, data that has no scientific basis and can be manipulated for a specific result.  The usual intent is to maximize business profits and make it seem like the business is much more critical to the provision of health care than the health professionals it hires.  As absurd as that last sentence looks, it is without a doubt one of the goals of most health care businesses.

Business information collected and manipulated for the sake of furthering business interests in the health care industry is no more valid than  what happens in the financial services industry.  Both types of information have evolved to place the consumer at risk all of the time and give them no clear reason for a making a decision in their own interest.  And in both cases, consumers have no choice but to participate.  We have a government mandated retirement industry that provides a windfall to financial services.  We now have a government mandated health care industry that is set to provide a windfall the large health care and pharmaceutical companies.  In both cases it is underwritten by the American consumer who is placed at financial risk all of the time in an economy of stagnant wages and significant unemployment.

George Dawson, MD, DFAPA

National Behavioral Health Quality Framework - Ultimate Oxymoron?

As I pointed out in a previous post, the Substance Abuse and Mental Health Services Administration (SAMHSA) a branch of the U.S. Department of Health and Human Services is currently working with the managed care industry.  They are also the object of criticism by E. Fuller Torrey in his recent editorial and upcoming book for promoting non evidence based care of people with severe mental illnesses and in fact at many levels dismantling existing care.   With that kind of a backdrop, their e-mail to me this morning suggesting that I should review the National Behavioral Health Quality Framework (NBHQF) and provide comments as an interested member of the public should not have been very surprising.  I thought I would put that commentary here rather than letting it be buried on a government website that nobody would read.

To set the appropriate tone for my comments, the introduction section of this document identifies the major entity that the government is working with here as the managed care industry.  I consider the NCQA (or NQF) to be a proxy for the managed care industry.  That is their history as I recall it and I am not aware of any physician professional group that says otherwise.  In fact, I cannot find the American Psychiatric Association as a member of the NQF, but I am fairly certain that they used to be a member of NCQA..

Getting back to the document - six goals are identified with a page each dedicated to currently available measures and a second page that is described as "future targeted measures that are deemed important to advancing the behavioral health quality measurement."  An example of what that involves is illustrated in "NBHQF Goal 1: Effective - Promote the most effective prevention, treatment, and recovery practices for behavioral health disorders."  Not to be too much of a stickler here, but I don't really know what a "behavioral health disorder" is.  The most precise definition would be "whatever mental or psychiatric disorder that a managed care company has decided that they will pay for".  Behavioral health is basically a business term with no medical or psychological meaning.  As far as I can tell, it was designed to disenfranchise psychiatrists and other mental health providers and yet the rationale for denying treatment was always proprietary "medical necessity" criteria.   Moving beyond that we basically see a number of screening interventions for "Provider/Practitioners", a number of completely unproven interventions and quality markers, and at least 30% of the cells in the matrix are left "intentionally blank".  What exactly is there to comment on?  In the second page "payers using payment incentives to increase the use of EBP (evidence based practices)" is actually considered a quality marker.  That is a conflict of interest much greater than any pharmaceutical company scandal.  To translate, that means that managed care companies nation wide have another way to deny payment and save money based on what they consider to be an "evidence based practice." but they are rationalizing it as a quality marker.

Let me suggest how the depression assessment and screening should be done in this matrix.  First of all the screening test in this case the PHQ-9 does need to be validated as a diagnostic and outcome measure in populations.  The  current literature is extremely limited and there is no evidence that population screening for depression accomplished anything other than exposing a lot of people to antidepressants that the FDA has identified as potentially arrhythmogenic.  The cost of prescribing SSRIs to a large population as well as the electrocardiogram abnormalities is unknown.

I will briefly comment on the additional goals.  "Goal 2: Person-Centered Care".  As previously explained, this is the goal of every physician who has ever been trained in medical school.  It appears here basically as rhetoric that is designed to disenfranchise professionals and make it seem like managed care companies invented individualized care.  "Goal 3: Encourage effective coordination within behavioral health".  What jumps out of the page at me under this sparsely populated matrix is "Ratio of detox to outpatient admissions".  It is well known that managed care tactics have essentially destroyed the availability of medical detox in most communities.  I can recall being told that medical detox was not "medically necessary" by managed care reviewers.  I guess the hope was that the cost of detox could be transferred from managed care companies to non-medical county facilities.  Quality care for addictions means that there needs to be a spectrum of care.  I don't know what ratio is implied by this quality marker but I can assure you that it will favor managed care companies.

"Goal 5: SAFE - make behavioral health care safer."  Suicide, injury and death, treatment for overdoses after hospitalization, and discharges on multiple antipsychotic drugs are suggested as quality markers.  There is no evidence of what it takes to make the assessment and treatment.  To capture any problems in these areas you need a quality process, not a piecemeal check box that can be gamed so that it appears that you are providing quality care.  Measuring these variables in the absence of defining a quality process is meaningless.

"Goal 6: Affordable/Accessible: Foster affordable high quality behavioral health care...".  This continues to be an absurd priority of the partnership between the government and the managed care system. There is no more "cost effective" approach than what passes for behavioral health care.  Mental health treatment in the US has been decimated by 20 years of managed care to the point it is practically non-existent.  During that same time there has been an addition of trillions of dollars in Cardiology, Intensive Care, and Oncology infrastructure.  Even if that were not true, what is the evidence that cost effectiveness has to do with quality?  It is certainly not reflected in the previous specialties that I just listed.

Are there problems with this approach?  It turns out there are major problems and here are just a couple:

1.  Administrative data - administrators have significant biases that seem to impact on so called quality markers across the board.  They don't seem to understand their biases and the major biases include not really knowing anything about medical quality,  thinking that medical quality can be derived from what is basically administrative data (length of stay, readmissions, etc.) and at this point in time having so much political leverage from government backing that they don't really have to pay attention to the considerable number of people out there who know a lot more about quality.  As I have documented on this blog this is a thirty year trend and all of that is captured in the NBHQF.  Any who has followed quality markers over the last two decades will probably have made the observation that business heavy entities like managed care systems are information averse.  By that - I mean that they collect a large amount of data  but it is really not enough data or the right data.  Great examples are HEDIS data and PHQ-9 scores.  Is it really possible to collapse medical quality in to what are really simplified demographic parameters?  No more than knowing that 50% of 85 year old men have coronary artery disease.

2.  Business practices trumping medical practice -  on this blog I have also reviewed these practices and will focus on one this glares in this report - "person-centered care".  For years HMOs and their administrators were focused on "population based care".  They scoffed at the notion that people or patients needed to be treated on an individual basis.  This was at the peak time when they were deciding that everyone with a certain condition should be hospitalized for a the same number of days and it was a "quality problem" if the length of stay in the hospital was too long.  Nobody ever complained if the length of stay was too short.  Many of the thought leaders in managed care go to that position by basically promoting these ideas.  Why is the managed care industry suddenly behind "person centered care".  You won't see the history recorded anywhere but a lot of it goes back to the primary care physician as gatekeeper.  If you assume that you can managed populations of people with the same interventions, you can tell your subscribers that they have to get "referrals" from their primary care physician for any tests or consultations that are viewed outside of the population norm.  This was happening on a large scale in the 1980s and 1990s but subscribers rebelled against it.  After all they were paying good money for insurance coverage and not seeing it back in what they were interested in for health care.  The gatekeeper function disappeared and suddenly even managed care subscribers could directly seek consultations and referrals that they were interested in.  Patient centered care from the managed care industry was basically determined by the market and the failed theory of their thought leaders about managing populations rather than treating individual people.

Physicians have always been taught that patient care is highly individualized.  The question is will they continue to let the government, business entities, and non-evidence based practices masquerade as quality.  Looking at the quality of physician commentary in the media, in journals, and on blogs is not very hopeful.  It is clear that physicians would prefer to blame themselves or one up one another rather than look at the true problems with the health care system and what bureaucrats and businessmen are calling quality.

George Dawson, MD, DFAPA

SAMHSA.  National Behavioral Health Quality Framework (NBHQF)