Evidence--Based Medicine

‘Gray Areas’ in Psychiatric Treatment

I recently heard parts of a lecture by a healthcare provider (not a psychiatrist), who was speaking to a group of general practitioners about psychiatry.  She answered questions about the best approach for treating depression, anxiety, and other psychiatric disorders by relating anecdotes from her own experience and suggested by her favorite mentor.  “Add a little of this, and if that doesn’t work, try adding some of that” she said.  “Psych is all a gray area.  You can be creative.”

Now THAT’S crazy.  Her recommendations, sadly, will likely be followed in a number of actual patients.  No wonder patients coming to treatment often have a distrust for psychiatry, or a sense of being a ‘guinea pig’ during earlier treatments for psychiatric conditions.

At some point over the past decade, we began using the term ‘evidence-based medicine.’ The term is likely over-used for marketing purposes, but the original concept of evidence-based medicine is of great value, particularly in psychiatry.

Medical scientists, i.e. practitioners who have training in conducting and interpreting scientific research, know the risks of letting personal experiences guide treatment approaches.  They know that human beings have a natural tendency to assign greater importance to personal observation than to the experiences described by others, even if the personal observation involved one patient, no blinding, and no control group. Even people with advanced degrees, who recognize the value of blinded studies and appropriate control groups, tend to rationalize that they know, in THIS case, that their observations are valid.

Evidence-based medicine encourages practitioners to ignore their own experience, and to instead anchor practice patterns to those supported by peer-reviewed research.  Practitioners should know the difference in predictive value for comments by a mentor, the findings in a case report, and the results of a large, prospective clinical trial.  Practitioners should appreciate the perils of using their knowledge of basic science to extrapolate findings from one set of conditions, to a case where some variables differ.

These distinctions are especially important in an era where insurance companies increasingly try to influence treatment patterns.  For example, there is considerable evidence that Abilify effectively augments the antidepressant effects of SSRIs.  Insurance companies often refuse to cover Abilify, instead demanding substitution with risperidone, a less-expensive medication from the same general class of ‘atypical antipsychotics.’  But there is no good evidence that risperidone provides any benefit for depression.  There are a number of similar situations where insurers require ‘prior authorization’ for the treatment best-supported by clinical evidence.  Many insurers even require a period of treatment failure with a bad medication, before they will consider the best medication. Insurers would argue that they recommend medications that are much less expensive, at the cost of ‘minor’ side effects.  But practitioners who use evidence-based approaches to treatment know that the insurer’s medication selections are influenced by cost to a much greater extent than efficacy.

Back to the original discussion, those who practice evidence-based medicine know that someone who views psychiatry as a ‘gray area’ is someone who didn’t have a strong education in psychiatry or neuroscience, and who doesn’t read much of the psychiatric literature.  To a Board Certified Psychiatrist, the field of endocrinology is a ‘gray area.’  But when treating depression, the psychiatrist knows—or should know– that adding a ‘one milligram sprinkle’ of Abilify has no scientific basis for treating major depressive disorder, whereas a dose between 2 and 15 mg has been effective in controlled, clinical trials. Nothing gray about it.

Patients treated for depression or other psychiatric conditions should be aware of efforts to increase the use of evidence-based medicine in psychiatry.  How does your treatment measure up?

ADD Treatment at Fond du Lac Psychiatry

While raising three children through elementary school, high school, and college, I often struggled with the question whether I was doing all I could to make certain my children had the same chance to succeed as their classmates.  If my children had a condition that made school more difficult and I did nothing to help them, I thought I would be shirking my role as parent.

focus 300x229 ADD Treatment at Fond du Lac Psychiatry

ADD affects the course of one’s life

Untreated attention problems place children at greater risk of failure in school, lessening the chance they will eventually gain a sense of control over their destiny in a career they enjoy.  Children who fail in school are more likely to reject authority, and more likely to engage in behaviors that cause problems down the line, including smoking and experimentation with drugs and alcohol.  Many adults treated for attention deficit disorder say ‘if I knew about this earlier, I would have gone to college.’   Unfortunately, by the time of that discovery the pathway is often out of reach, after a history of low test scores and failures– and the impact of failure on self esteem.

How do we know if our children have a condition that impacts their performance, that might benefit from treatment?  For that matter, how do we know if we ourselves have such a disorder?!  Given such difficult questions, most people take the path of doing nothing, and letting the chips fall as they may.  In this post I will discuss the considerations that are made for a diagnosis of ADD, the process for treating ADD, and the costs of such treatment at my practice.

For as long as I can remember, news stories have decried the increased number of people diagnosed with attention deficit disorder (ADD) or the syndrome’s hyperactive cousin, ADHD.  Growing up in the 1960′s and 1970′s, I remember overhearing discussions between teachers about students who ‘took medication’.

Through the 1980′s and 1990′s, people argued whether ADD was a real disorder, or if instead hyperactivity, inability to focus and stay on task, and poor concentration were manifestations of poor parenting.  Studies of large numbers of children showed that ADD and ADHD are not caused by single-parent families or by poverty.  ADD is a biological disorder.  All biological disorders have a genetic component, meaning that children with ADD are more likely to have one or two parents with ADD.  And given the consequences of untreated ADD– poor school function, higher drop-out rates, and all that those things entail–  ADD appears to be more symptomatic of families struggling to get  by.  But ADD is the egg that hatches the dysfunctional chicken– not the other way around.

I don’t consider ADD as much an ‘illness’ as a type of brain function that served people well 200 years ago, but is less efficient in 2013.  Human consciousness is bombarded by sensory input, memories, and emotions.  Some brains have greater control by the frontal lobe to screen out distractions than other brains.  Until recently, a society of humans was best served by a range of frontal lobe function across individuals.  If every member of a tribe focused intently on starting a fire, who would notice the breaking twig that signals predators?  It is only in today’s world, where so many things require reading an owners’ manual or staring through a two-inch screen, that attention and concentration have become important assets for daily function.  And interactive teaching– where teachers interact with students and write on chalkboards during lectures– has been replaced by passive learning and PowerPoint lectures.

Headlines decry the growth in diagnoses of ADD and the increased use of medication.  But at the same time that papers report greater use of ADD medications, experts report that only a small fraction of people with attention deficit disorder are receiving treatment.  I suspect that the nature of ADD causes those who would benefit the most from treatment to be least likely to receive it.

Symptoms of attention deficit disorder or attention deficit with hyperactivity disorder can be found by searching the internet.  People who desire treatment for ADD know exactly which symptoms to describe to doctors.  Tests have been developed to help separate those who actually have ADD from those seeking stimulants for other uses, but the tests have not gained popularity. The ‘gold standard’ for diagnosing ADD consists of assessment by an experienced and competent psychiatrist or psychologist.

If you believe that you or your child has attention deficit disorder, begin with one of the many online screening tools.  If you score high for ADD, consider a treatment ‘trial’, where the person with ADD is prescribed medication for a period of time, followed by an assessment of the response to medication.  There are a number of medications useful for ADD, and the  selection of medication should include a collaboration between patient and doctor. The  medication eventually chosen depends on the presence or absence of other illnesses or psychiatric conditions, insurance coverage for medications, and the experience of relatives with certain medications.  The patient’s daily routine must be reviewed in order to determine the times when coverage with medication is most important.

Patients treated with stimulant medication for ADD should NOT be under the influence of medications that impair attention and concentration, including marijuana, Xanax or alprazolam, clonazepam, or other benzodiazepines.

ADD Treatment at Fond du Lac Psychiatry

Diagnosis and treatment of attention deficit disorder does not require MRI scans or other brain imaging studies.   Diagnosis is made through a discussion of the patient’s symptoms, ideally with the input of at least one other person who knows the patient well.  The initial visit to Fond du Lac Psychiatry begins at the scheduled time and lasts 90 minutes.  The cost for the intake appointment is $322, minus any insurance contribution (I am out of network for all insurers, Medicaid, and Medicare– which may or may not be relevant depending on your deductible.

After thorough evaluation, people who show signs and symptoms of ADD begin a trial of medication.  Patients taking medications that impair concentration will be required to stop those medications before starting medication for ADD.  Most insurance companies cover a range of ADD medications with a small copay.  Patients at Fond du Lac Psychiatry communicate with their doctor by e-mail if side effects or changes in dose need to be considered.  Federal law requires that patients receive at most 90 days of schedule II medication (such as stimulants) between appointments, written on three, 30-day prescriptions.

Patients on medication for ADD are generally seen every 3 months, i.e. 4 times per year.  The cost of treatment, without insurance, is $920 for the entire first year, and $800 for each subsequent year.  That cost may be reduced by out-of-network insurance payments or by HSA’s or ‘Flex-care’ accounts through the patient’s employer,  At first blush, $800 per year is a lot of money. But the cost is a fraction of the cost of other medical interventions.  And the average cost–$2 per day– is a very small investment, particularly if the intervention helps to prevent the pathway of lower school performance, ranging from smoking ($8 per day), addiction (hundreds of dollars per day in many cases), or early pregnancy.  If the intervention does not help, parents rest in knowing that they addressed the issue.  If ADD IS an issue, the cost of treatment will be covered, many times over, through greater potential for educational and professional opportunities.

If you believe you or your loved ones are candidates for treatment for attention deficit disorder, schedule an appointment at Fond du Lac Psychiatry by calling (920) 923-9054.   In most cases, I can schedule an appointment within a week.  Please refer to other blog posts that decribe the extra level of service that I provide, including easy access through email and guaranteed, on-time appointments.