QD: News Every Day

ACP Internist's daily digest of primary care in the news continues with legislative jockeying for health care reform, public rejection of flu vaccination and primary care's dominance of mental health prescribing.

Health care reform
Legislation proceeds apace, with congressional members jockeying and pushing for the House and Senate bills to reach their respective chambers by mid-month. Abortion restrictions were defeated, as were other provisions. But there are many hurdles to clear as legislators threaten to cancel the Columbus Day break to get the legislation finished by either Thanksgiving or the end of the year.

Meanwhile, former Senate Majority Leader Tom Daschle said lawmakers were “flummoxed” when attempting to craft specific reform legislation, so Gary R. Gibson, FACP, has created an algorithm to help them understand it.

Flu prevention
Consumer Reports says only a third of Americans plan to get the H1N1 vaccine. More than half of adults with risk factors don't know what complications the flu could cause. They're worried about risks from the vaccine itself, or they're not confident of its efficacy. Or, they just don't think they'll get the flu.

In an NEJM perspective, authors say there's a pressing need for research into whether N95 masks work better or worse than surgical masks to prevent spreading the flu. So JAMA obliged with a study finding that surgical masks work just as well. An accompanying editorial notes that other preventive measures, such as vaccinating health care workers and hand washing, are critical but overlooked.

In case you missed it:
Mental health issues affect 1 in 4 Americans, 1 in 17 severely. Mostly, they go to their primary care clinicians for help, says the Agency for Healthcare Research and Quality.

Fifty-nine percent of U.S. mental health drug prescriptions are written by family doctors, reports Researchers from Thomson Reuters and the U.S. Substance Abuse and Mental Health Services Administration. They examined 472 million prescriptions written for psychotropic drugs from August 2006 and July 2007 and found general practitioners prescribed 62 percent of antidepressants and 52 percent of stimulants, mainly drugs for treating attention deficit hyperactivity disorder.

Labels: flu, H1N1, health care reform, mental health, mental illness, QD

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posted by Ryan DuBosar at 12:54 PM   0 Comments

How depression breaks the heart

It's been known for quite some time that depressed patients have a higher risk of heart problems than those who are mentally healthy. What's been unclear is why-- till now.

A new JAMA study finds that, in depressed patients with coronary heart disease, most of the higher risk of CV events can be chalked up to a lack of exercise.

The study followed more than 1,000 outpatients with CHD for nearly 5 years. Patients reporting symptoms of depression had a 50% greater risk of CV events. Adjusting for comorbid conditions and cardiac disease severity lowered the risk to 31%, but adjusting for lack of exercise pretty much wiped out the association completely (along with a few other "health behaviors," like diet). Put another way, not exercising was associated with a 44% higher rate of CV events-- almost the same as the depression association.

So now the real question is: how do you get those depressed patients to exercise? (Which, by the way, is likely to improve their mood.) That's a whole other study in and of itself. For now, the Mayo Clinic has these tips on motivating depressed patients.

Labels: cardiology, depression, heart, mental health

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posted by Jessica Berthold at 4:00 PM   0 Comments

Is JAMA psychic?

Just two days after JAMA ran an article that found long-term psychotherapy works better than short-term for the complex mentally ill, Congress passed (and Pres. Bush signed) a bill that would effectively require many insurers to cover longer-term treatments.

So does JAMA have some sort of psychic on its payroll? (NEJM has already informed us there are psychic cats that can predict when people will die; perhaps JAMA has a psychic hedgehog that predicts the outcome of legislation?)

In all seriousness, this mental health parity legislation-- which was attached to a big bailout bill you may have heard about-- was a long time coming. To be clear, it doesn't tell insurers they must cover mental illness. It just says that if they already offer mental health coverage, it has to be equal to that of other medical coverage. In other words, treat schizophrenia like you would heart disease.

For years, mentally ill patients have paid higher copays and deductibles, and had lower visit limits, than people with other kinds of illness. This makes it difficult for internists to do anything with these patients other than write them a prescription, because doctors know that a referral to psychotherapy means a limited number of sessions-- if any at all. (An issue we addressed in a story about parity last year.)

Medication is useful, but research has shown the best approach for certain disorders, such as severe depression, is medication plus therapy. And the Oct. 1 JAMA study shows it can take quite a bit of that therapy to make a dent in complex disorders like depression and anxiety.

Specifically, the study found that patients who had at least one year or 50 sessions of psychodynamic psychotherapy were better off than 96% patients who had shorter durations of other therapies, including cognitive-behavioral and behavioral therapies. (Psychodynamic therapy focuses on the patient-therapist relationship-- not the same as the Freudian stuff.)

Study author Falk Leichsenring told the Washington Post that the ideal number of sessions varies by patient, but that most patients with acute distress will do well with 25, while those with chronic distress need about 50, and those with personality disorders need about 200.

Until the parity legislation, most insurance plans covered 20-30 sessions per year, at best.

So what do you think? Will you be more likely to refer your mentally ill patients to therapy, once this law kicks in on Jan. 1, 2010 (for most plans)?

Labels: mental health, mental illness, parity

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posted by Jessica Berthold at 1:30 PM   0 Comments

A new day for mental health parity

Last September, we wrote a story about how the House and Senate were each crafting bills to require that employers and insurers institute mental health parity-- coverage for mental health equal to that of physical health (a flawed definition, I realize, because it implies the two are discrete).

Well, it appears the two sides have reached a compromise on a bill. According to the WSJ, its components include:

• Employers who offer mental health coverage must make it equal to physical health coverage, meaning they cover the same number of doctors' visits and hospital stays, and require the same co-pays and deductibles. (The 1996 parity law already requires that annual and lifetime dollar limits be equal for mh and physical health) Out-of-network coverage, if offered, must be the same as well.
• It doesn't require employers to offer mental health coverage, however. Basically, if you offer it, you have to offer it all the way...or not at all.
• Employers with 50 or fewer employees are exempt from parity requirements.
• It doesn't mandate which specific mental illnesses are covered.

The recently-passed Medicare bill (you know the one, right?) included a provision that would gradually reduce the existing 50% copays for Medicare patients' mental health services to 20%-- the current copay for physical services. Experts hope that not having to chase down patients for half the bill will encourage more psychiatrists (which are in short supply) and psychologists to accept Medicare patients.

Labels: mental health

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posted by Jessica Berthold at 1:14 PM   0 Comments