Tag:

Prescriptions

NAMI Illinois Rejects Psychologists’ Attempts to Gain Prescription Privileges

by John M. Grohol, Psy.D. 7/13/2024

NAMI Illinois Rejects Psychologists' Attempts to Gain Prescription Privileges “Insanity is doing the same thing over and over again but expecting different results.”
~ Rita Mae Brown

Ya have to admire psychologists who endlessly lobby state legislatures for the right to extend prescription privileges to their profession (with a little additional training). They won’t take repeated defeat as a sign that perhaps their efforts are… insane?

Illinois is the latest state to hand psychologists seeking prescription privileges a defeat, with NAMI Illinois siding on the side of not supporting the bills in front of the Illinois legislature. After intense lobbying by both sides of this issue, they concluded, “NAMI Illinois opposes SB 2187 and HB 3074 in its current form to expand prescriptions privileges to psychologists.”

When will psychologists learn?

7/13/2024 38 comments

Should Psychotherapy Notes Be a Part of Your Electronic Health Record?

by John M. Grohol, Psy.D. 4/3/2024

By John M. Grohol, Psy.D.

Should Psychotherapy Notes Be a Part of Your Electronic Health Record? A story last week caught my eye about a patient, Julie, who was surprised to discover that her psychotherapy notes became a part of her electronic health record at the hospital system that administered her care — Partners in Boston.

She found out that any doctor within the Partners system could access her record — including her sensitive psychotherapy notes — with no reason whatsoever. And she only discovered this privacy issue because her new internist initially refused to prescribe her needed medication because of “concern” about her psychiatric history — a history he had access to and read without the patient’s prior knowledge.

There’s a couple of problems here. But it’s a teaching moment for others implementing system-wide electronic health records. Psychotherapy notes enjoy special status in the health care community, and that special status should continue even in the age of electronic access.

4/3/2024 15 comments

Antidepressants Overprescribed in Primary Care

by John M. Grohol, Psy.D. 12/13/2023

By John M. Grohol, Psy.D.

Antidepressants have long enjoyed a reputation as being a quick and “easy” treatment for all types of depression — from a mild feeling of being a little down, all the way up to severe, life-debilitating depression.

But like all medications, they have side effects and instances where they should not be prescribed. Hence their continued need for a prescription after seeing a doctor.

So what does it mean when primary care physicians are handing them out like candy?

It suggests that your family doctor doesn’t really understand how antidepressants work, or what they are approved to treat. In short, it suggests that antidepressant medications are being over-prescribed by well-meaning doctors who are simply not using very good judgment.

12/13/2023 10 comments

Psychiatry Doesn’t Do Psychotherapy Anymore

by John M. Grohol, Psy.D. 10/13/2023

By John M. Grohol, Psy.D.

Psychiatry Doesn't Do Psychotherapy Anymore Despite a trend that started as early as the late 1980s, Gardiner Harris writing in The New York Times yesterday seems to bemoan the fact that most psychiatrists don’t practice psychotherapy any longer.

Perhaps Harris should have interviewed Dr. Danny Carlat, who nearly a year ago wrote about his experiences as a modern psychiatrist (in the The New York Times Magazine, no less). Psychiatrists nowadays are generally poorly trained in psychotherapy, so they spend most of their time prescribing psychiatric medications. (Dr. Carlat’s book, Unhinged is well worth the read for further background about modern psychiatry.)

So I wasn’t sure why I was reading this in the “Money and Policy” section of the Times. Surely it’s not news that psychiatry is no longer practicing much psychotherapy — and hasn’t been doing so for decades. What’s the story here?

It appears to really just be a lifestyle piece about Dr. Levin, a practicing psychiatrist who has had to switch gears mid-career from a psychiatrist who was doing a fair amount of psychotherapy earlier in his career, to one who does nothing but medication prescriptions.

10/13/2023 40 comments

Middle-Age Suicides Continue to Rise

by John M. Grohol, Psy.D. 6/7/2023

By John M. Grohol, Psy.D.

Middle-Age Suicides Continue to Rise Suicides amongst the middle-aged — 45 to 54 year olds — continued to rise for the second straight year in a row, from 2006 to 2007 (the last year we have the final government data on). This means this age group enjoys the highest suicide rate in the U.S. The rate in 2007 was 17.6 per every 100,000 people, up from 17.2 per 100,000 people in 2006.

Typically, according to the article in the New York Times, the eldest segment of the population — those 80 and older — suffers the highest suicide rate. Men typically commit suicide nearly four times as often as women, and most people who contemplate suicide would carry a depression diagnosis.

Since 2000, the age-adjusted death rate for suicide has increased by 8.6 percent, according to the U.S. National Center for Health Statistics.

We don’t know what causes these bumps in suicide rates. While there are lots of theories — 2007 was the year the real estate market really began to tumble — nobody knows for certain.

6/7/2023 13 comments

Are Antidepressants Really That Ineffective?

by John M. Grohol, Psy.D. 3/28/2023

By John M. Grohol, Psy.D.

Are Antidepressants Really That Ineffective? The more researchers delve into the research behind antidepressants — the class of drugs commonly prescribed to treat depression — the more they find that perhaps the majority of antidepressants’ treatment effect is based upon the simple belief that the drug will help.

Newsweek’s Sharon Begley has a lengthy article discussing the growing body of evidence that calls into question decades’ worth of prescriptions. It’s a story that we’ve covered previously, that TIME covered nearly a year ago, and that Therese Borchard had a response to. It seems to be journalists’ favorite “go to” story now in mental health, because there’s a black-and-white controversy — do antidepressants work or don’t they?

People mistakenly believe that one type of research is somehow superior to another form of research. However, data is data and research is research. All things being equal, if it’s done in as objective a manner a human being can do it, then it’s all good and informative. A study conducted 20 years ago is just as valid today, as long as the design of the study was solid and unbiased. And a single-case experimental design, while not very generalizable, can still lead — and has led — to valuable insights into human behavior.

So I get a little concerned when we do give more weight to the most recent study, or the most recent meta-analysis. They have their place, but their place is in context — understanding the body of research as a whole. (Because meta-analyses never take into account the entire body of research on a drug or topic — they always have inclusion and exclusion criteria, criteria that can directly impact the results they find.)

To see another article about this issue go ’round and ’round the bend with both sides, but not really bringing anything new to the discussion, is a little frustrating. I think it’s pretty obvious that if a drug was supposed to help people, but didn’t, people would stop taking it and doctors would eventually stop prescribing it. Since it’s unethical to prescribe placebos to patients outside of a research study, what choice do doctors and patients have — the drug works. (Well, not always, of course, but in many people who take it, and who keep trying a different antidepressant if the first one doesn’t work, according to the results of the STAR*D study.)

Why antidepressants work is an important academic question. If it’s mostly the “placebo effect,” then that’s a sign that a lot of research is wrong. A lot. Drug studies that found significant clinical differences (not just statistical differences) have to be better explained. And those that found virtually no clinical differences need to better see the light of day. We certainly need to understand why we’ve been prescribing an entire class of medications for decades if we honestly believe they are no better than a sugar pill.

But back to the article… As I said, it’s basically a rehash of this question — Are antidepressants effective or not? — which I suspect we’ll see appear in a mainstream media outlet from now on at least once or twice a year. The answer is simple — yes, they can be effective. But perhaps not always for the reasons we thought.

Begley also seems a little confused, telling readers that only psychiatrists conduct psychotherapy (when, of course, there are psychologists, clinical social workers, marriage and family therapists, and a host of other professions that provide psychotherapy):

It’s all well and good to point out that psychotherapy is more effective than either pills or placebos, with dramatically lower relapse rates. But there’s the little matter of reality. In the U.S., most patients with depression are treated by primary-care doctors, not psychiatrists. The latter are in short supply, especially outside cities and especially for children and adolescents. Some insurance plans discourage such care, and some psychiatrists do not accept insurance. Maybe keeping patients in the dark about the ineffectiveness of antidepressants, which for many are their only hope, is a kindness.

This would have also been a great time to mention the mental health parity act that just went into effect, guaranteeing that most insurance plans can no longer “discourage” psychotherapy treatment. But this wouldn’t be the first time Begley doesn’t quite understand what she’s talking about when it comes to mental health. She’s the journalist who took the Association for Psychological Science’s press release about a new training model they were advancing (in the form of a journal article in one of their own journals) and turned it into an uncritical look at Why do psychologists reject science?. We had a far more critical take on this pseudo-science.

But it’s that last line of that paragraph that is especially troubling and paternalistic. People should know whether the treatment they are receiving has research data to back up its effectiveness. But then they should also know and be able to put that into some kind of context. Like the fact that a lot of common medical procedures are only now starting to gain an evidence base, yet they continue to be done (and have been done for decades) with little scientific evidence that they work. Why hold mental health to the fire, when health care in general has been lacking a scientific evidence base for nearly all of the last century?

As for Kirsch, he insists that it is important to know that much of the benefit of antidepressants is a placebo effect. If placebos can make people better, then depression can be treated without drugs that come with serious side effects, not to mention costs. Wider recognition that antidepressants are a pharmaceutical version of the emperor’s new clothes, he says, might spur patients to try other treatments. “Isn’t it more important to know the truth?” he asks. Based on the impact of his work so far, it’s hard to avoid answering, “Not to many people.”

Let’s get real. People choose antidepressants over psychotherapy because antidepressants — placebo or not — take 2 seconds to take and require virtually no thought as a treatment. Psychotherapy, on the other hand, takes an hour every week out of your schedule, and requires not only thought, but active, often difficult changes to be made in the way you think and feel. It’s hard work. That’s why most people will continue to opt for the pill, no matter it’s effectiveness — it’s easier and for those who benefit from its effects, it works.

I am, of course, all in favor of more people giving psychotherapy a try. But I’m also a pragmatist and know that many people have already given psychotherapy a try, and unfortunately it didn’t work out for them. Whether it was due to a bad therapist, a misunderstanding of the expectations of therapy, or whatever. People don’t only want options — they need them.

So yes, let’s figure out the important question of why antidepressants work. But let’s also continue to give people the treatment options they need, and not pretend there’s a single answer to someone overcoming depression. There isn’t.

Read the full article: The Depressing News About Antidepressants

3/28/2023 27 comments

Bremner’s False Claims about Postpartum Depression

by John M. Grohol, Psy.D. 12/2/2022

By John M. Grohol, Psy.D.

Bremner's False Claims about Postpartum Depression Psychiatrist J. Douglas Bremner has weighed in on the Melanie Blocker Stokes MOTHERS Act, an effort to provide voluntary screenings to pregnant women to help identify postpartum depression before it becomes overwhelming. I’ll let Bremner speak for himself:

The problem with this is the attitude that being a mother is a risk factor for a psychiatric disorder. First of all, there is no evidence that women without a prior history of anxiety and depression have any increased risk of getting post partum depression. So to screen all moms as if giving birth is a risk factor for depression is ridiculous.

My BS alert goes off whenever someone tries to change the argument from a reasonable effort to help increase education and information about a stigmatized mental health issue, to hyperbole, suggesting that a piece of legislation is trying to turn motherhood into a psychiatric disorder. It goes off again when a professional makes an extraordinary claim like, “there is no evidence that women without a prior history of anxiety and depression have any increased risk of getting post partum [sic] depression.” Really? Absolutely no evidence? That’s quite a strong statement, and easily proven false with a literature review.

Where shall we begin? (I have limited space and you have a limited attention span, so I’ll just highlight a few studies…)

Ross & Dennis (2009), for instance, in a literature review found that both substance use and current or past experiences of abuse are associated with increased risk for postpartum depression (PPD).

In urban South African women, Ramchandani and colleagues (2009) found the strongest predictors of postnatal depression were exposure to extreme societal stressors (e.g., witnessing a violent crime/danger of being killed) and reporting difficulties with their partner.

Robertson et al. (2004), in a large meta-analysis of research to-date, found that a previous history of depression and anxiety (not just during pregnancy) was predictive of postpartum depression. But they also found that simply experiencing a stressful life event during pregnancy or low levels of social support (e.g., not having any emotional support from your friends or family) could also lead to postpartum depression.

Beck’s (2001) meta-analysis of 84 studies found:

13 significant predictors of postpartum depression: prenatal depression, self-esteem, childcare stress, prenatal anxiety, life stress, social support, marital relationships, depression history, infant temperament, maternity blues, marital status, SES, and unplanned/unwanted pregnancy. 10 of the 13 risk factors had moderate effect sizes while 3 predictors had small effect sizes.

Look at all of those factors which are not depression or anxiety — I count 9. Even if 3 of those are small-effect size factors, that still leaves 6 factors which are not depression or anxiety.

What about the argument that if depressed women are the most at-risk, we should simply focus on them?

Ingram & Taylor (2007) found it wasn’t just a woman’s pre-birth depression severity that was important — poor emotional support and women who had more negative descriptions of their own childhood were additional risk factors that played a role in increased risk for postpartum depression. Who’s going to screen for these things, the obstetrician?

Well, no, because the obstetrician is already not doing a good job at screening for postpartum depression, even in high-risk women. Hatton et al. (2007) found that, among high-risk women, obstetric care providers may be overlooking up to one fifth of women with current major depression. Not exactly great numbers there. If obstetric care providers can’t deal with the obvious cases, I can only imagine how well they do with the more complex or less obvious ones.

Monk et al. (2008) sums the state of our knowledge on PPD:

Depression is relatively common during the perinatal period (Gavin et al. 2005; Ross and McLean 2006). Approximately 8.5 — 11% of women experience either a major or minor depression during pregnancy (Gaynes et al. 2005). Nearly 20% of women have a minor or major depression in the first 3 months following delivery (Gavin et al. 2005).

So up to 1 in 5 women have depression after giving birth, and this isn’t something worth noting or screening for? (For comparison’s sake, 1 in 10 men and women in the general population might have depression at any given time.) Giving birth doubles your risk of depression, and this isn’t an issue? Amazing.

But don’t just take my word for it. Zajicek-Farber’s (2009) study conducted on high-risk women for postpartum depression concluded that:

These findings provide additional supportive evidence that more efforts are needed to identify and assess women’s depressive symptoms to promote health and safety of young children.

These are objective researchers calling for more screenings. Not politicians. And not people (or professionals) with a political agenda.

Now, I understand Bremner’s point — let’s not medicalize and catastrophize ordinary motherhood. I agree. And of course a woman’s pre-birth depression or anxiety is strongly correlated to postpartum depression. But not exclusively, as Bremner claims.

Bremner claims, with no evidence, that all mental health screenings are simply pharmaceutical sales tactics to help increase prescriptions. That’s ridiculous. When I worked in community mental health, we ran annual mental health screenings in the clinic — with no funding from any pharmaceutical company — because it reduces stigma, decreases misinformation and increases education about mental health issues in the general population.

Sorry, but most people don’t have time to keep up with a dozen blogs or read monthly journals on the latest research in mental health. Most people know what they know about mental health largely through mainstream media, or their own first-hand experiences with an issue. How is the promotion of more information and education about mental health issues a bad thing?

Bremner uses teens as an example of screening gone wrong, but conveniently fails to mention the facts about teenagers and mental health. Teens are an “at-risk” population, hence the reason they are sometimes targeted for screenings. Teens are notorious for being limited in their treatment options (especially in the U.S., where their treatment may be covered by their family’s health insurance, meaning a talk with their parents about their mental health issues), and for peer pressure limiting their ability to accept or seek help. (Yes, sorry, if you’re seeing a therapist for depression as a teen, you’re typically not seen as a “cool” kid.)

Sadly, whether people want to admit it or not, mothers are another “at risk” population. Why? Because society has told mothers time and time again that giving birth is supposed to be a joyous, happy occasion. If you’re depressed after giving birth to a child, there must be something wrong with you. Don’t draw attention to yourself or your problems. Just try and deal with it, try and take care of the baby, and make it through each day. Mothers don’t know they might have something recognized as postpartum depression, much less that they can talk to someone about these feelings or that there’s treatment — psychotherapy or medication — readily available for it.

So respectfully, I disagree with Bremner’s assessment of the MOTHERS act and its need in today’s society. And if you’re not going to bother to do the legwork and just make general (false) pronouncements about what the research actually shows (or worse, suggest the all research that disagrees with you must be in pharma’s pocket), then that’s a lazy person’s argument. There are too many logical fallacies at work here to list, so I’ll just suggest that I expect more reasoned and professional arguments –based upon the actual research — about such important legislation.

Psych Central continues to support the Melanie Blocker Stokes MOTHERS Act because the research shows it would help in the efforts to increase education and correct mis-information about postpartum depression.

References:

Beck, C.T. (2001). Predictors of postpartum depression: An update. Nursing Research, 50(5), 275-285.

Hatton, D. C., Harrison-Hohner, J., Matarazzo, J., E.P., Lewy, A. & Davis .L. (2007). Missed antenatal depression among high risk women: A secondary analysis. Archives of Women’s Mental Health, 10(3), 121-123.

Ingram, J. & Taylor, J. (2007). Predictors of postnatal depression: Using an antenatal needs assessment discussion tool. Journal of Reproductive and Infant Psychology, 25(3), 210-222.

Monk, C., Leight, K.L. & Fang, Y. (2008). The relationship between women’s attachment style and perinatal mood disturbance: Implications for screening and treatment. Archives of Women’s Mental Health, 11(2), 117-129.

Ramchandani, P.G., Richter, L.M., Stein, A. & Norris, S.A. (2009). Predictors of postnatal depression in an urban South African cohort. Journal of Affective Disorders, 113(3), 279-284.

Robertson, E., Grace, S., Wallington, T., Stewart, D.E. (2004). Antenatal risk factors for postpartum depression: a synthesis of recent literature. General Hospital Psychiatry, 26(4), 289-295.

Ross, L. E. & Dennis, C-L. (2009). The prevalence of postpartum depression among women with substance use, an abuse history, or chronic illness: A systematic review (PDF). Journal of Women’s Health, 18(4), 475-486.

Zajicek-Farber, M.L. (2009). Postnatal depression and infant health practices among high-risk women. Journal of Child and Family Studies, 18(2), 236-245.

12/2/2022 202 comments

Washington State Allows Assisted Suicide

by John M. Grohol, Psy.D. 9/18/2022

By John M. Grohol, Psy.D.

Those who are terminally ill with less than 6 months to live no longer have to travel to a foreign country or hope they can find a medical practitioner in Oregon who will look the other way and let them die with dignity. Washington state has become only the second U.S. state to allow assisted suicide, otherwise known as a death with dignity law. It’s meant to stop the prolonging of a life simply because we can — medical technology and advances making it possible.

But we still have a ways to go, as the law doesn’t mandate such prescriptions when requested by a patient. Doctors can opt-out of the law’s requirements, meaning one has to doctor-shop to find a physician willing to write the deadly prescription. In fact, entire hospitals will be banning the practice:

Under the Oregon and Washington laws, physicians and pharmacists are not required to write or fill lethal prescriptions if they are opposed to the law. Some Washington hospitals are opting out of participation, which precludes their doctors from participating on hospital property.

They’ve tried to make the law immune to any manipulations or rash, spur-of-the-moment decisions:

Under the Washington law, any patient requesting fatal medication must be at least 18 years old, declared competent and a state resident. The patient would have to make two oral requests, 15 days apart, and submit a written request witnessed by two people, one of which must not be a relative, heir, attending doctor, or connected with a health facility where the requester lives.

Two doctors must certify that the patient has a terminal condition and six months or less to live.

Some doctors who opposed the measure have argued that a six-month terminal diagnosis is never a sure thing.

Well, sure, but that could be said of almost anything in medicine. There are very few “sure things” in medicine, so trying to hold this particular concern to a higher standard not used elsewhere in medicine is irrational and just silly.

Under Washington state’s “Death with Dignity” law, a patient must:

Be at least 18, declared competent, and a state resident.
Be determined by an attending physician and a consulting physician to have a terminal disease and be expected to die within six months.
Make an oral and written request, signed and dated by the patient and witnessed by two other people, one of whom must not be a relative of the patient, entitled to the patient’s estate, anyone tied to a health facility where the patient is being treated or is a resident, or the attending physician.
Repeat an oral request to the attending physician at least 15 days after making the initial oral request. The patient can rescind the request at any time.

Once the request is made, the attending physician:

Determines whether the patient is competent and has made the request voluntarily.
Informs the patient of alternatives, like hospice care and pain control.
Refers the patient to another physician for confirmation of the terminal diagnosis and to ensure the patient is competent and acting voluntarily.
Recommends the patient for counseling if the patient is believed to be suffering from a psychiatric or psychological disorder.
Recommends that the patient notify next of kin.
Dispenses medication directly, or with the patient’s consent, contacts a pharmacist to fill the prescription.

All I have to add is that “pain control” in most cases is a joke if a patient is in serious pain. The vast majority of doctors underprescribe pain medications to patients in severe pain, for fear of being flagged by oversight authorities for “over” prescribing such medications.

I believe in the right to die with dignity and respect. And sadly, our society has to pass these kinds of laws to make this possible, because much of medicine today values quantity of life over quality.

Read the full story: Washington state to allow assisted suicide

9/18/2022 10 comments