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Lithium was more effective than other maintenance monotherapies in reducing impulsive aggression and the tendency of patients with bipolar disorder to inflict self-harm and unintentional injury, a longitudinal cohort study showed.
In addition, self-harm rates in those prescribed valproate were not higher than in those on other nonlithium maintenance therapies, contrary to the an existing FDA warning, Joseph Hayes, MSc, MBChB, of University College London, and colleagues reported online in JAMA Psychiatry.

After propensity score adjustment to reduce confounding, the study showed that self-harm rates were higher in the 392 patients prescribed valproate (HR 1.31, 95% CI, 1.01-1.70), 409 prescribed olanzapine (HR 1.33, 95% CI, 1.01-1.75), and 582 prescribed quetiapine (HR 1.36, 95% CI, 1.00-1.87) than in the 205 patients prescribed lithium.
Unintentional injury rates also were also higher for those on valproate (HR, 1.32; 95% CI, 1.10-1.58) and quetiapine (HR, 1.34; 95% CI, 1.07-1.69) compared with lithium, but not olanzapine, they reported.
Although suicide rates appeared to be lowest in patients taking lithium, there were too few events to permit accurate estimates or comparisons, the researchers said.
“We found increased rates of self-harm in individuals prescribed valproate, olanzapine, or quetiapine compared with those prescribed lithium,” Hayes and colleagues wrote. “We did not find differences in rates among valproate, olanzapine, and quetiapine. We also found reduced rates of unintentional injury in those prescribed lithium, an important association that has not been widely investigated or found previously. We did not find differences in rates of suicide because of the small number of suicides in the cohort.”
Joseph Stoklosa, MD, medical director of the schizophrenia and bipolar disorder inpatient program at Maclean Hospital in Belmont, Mass., said the study “adds credence to the hypothesis that lithium may have effects on impulsive aggression.”

“These results extend the potential benefits from lithium to these nonsuicidal forms of self-harm and injury,” Stoklosa, who was not affiliated with the study, told MedPage Today. “In many ways, the question to ask ourselves in choosing the right medication for a person with bipolar disorder may be less of which one, so much as ‘Why not lithium?'”
Stoklosa noted that since medications such as anticonvulsants and antipsychotics are commonly used to treat bipolar disorder, comparing the effects of these treatments with lithium — “the gold standard treatment for bipolar disorder” — is important.
“People with bipolar disorder have significant morbidity and mortality from self-harm, unintentional injury, and suicide,” he explained. “We need to continue to study all means to reduce self-harm and unintentional injury through both medication and non-medication modalities. We need to look at medication combinations as well, given that polypharmacy in bipolar disorder is unfortunately more the rule than the exception.”
Restoring patients with bipolar disorder to full function means addressing the ongoing stigma associated with treatment for mental illness, Stoklosa said, “so that people can be increasingly comfortable reaching out for help [and so that] we can get further [away] from reacting and closer to prevention.”
The study looked at primary care data from the electronic records of 6,671 patients with bipolar disorder who had received 2 or more consecutive prescriptions of lithium, valproate, olanzapine, or quetiapine lasting 28 days or longer to stabilize mood. All data were collected by The Health Improvement Network (THIN) system between Jan. 1, 1995 and Dec. 31, 2013. A total of 2,148 patients were prescribed lithium, 1,670 were prescribed valproate, 1,477 were prescribed olanzapine, and 1,376 were prescribed quetiapine.

Data on the association between antipsychotic medication and self-harm are “sparse,” the researchers said. “Small retrospective cohorts have shown no difference in suicidal self-harm in patients taking olanzapine or quetiapine and have demonstrated higher rates of suicide attempts in those prescribed second-generation antipsychotics compared with lithium or valproate.”
Not surprisingly, unintentional injuries associated with bipolar disease have been associated with hypomanic morbidity, they pointed out, “in which case drugs with the strongest anti-unintentional injury properties may not be those with the strongest anti-suicidal effects.”
The researchers acknowledged that despite the use of propensity score adjustment and matching, there may have been residual confounding. In addition, the risk score didn’t capture factors such as educational level and socioeconomic status, which “are likely to be associated with increased risk of self-harm, unintentional injury, and suicide” but shouldn’t influence treatment allocation.

Despite much more insurance coverage than in the past, patients with behavioral health needs are not getting the treatment they need, according to a recent study.
The Patient Protection and Affordable Care Act (PPACA) was supposed to improve access to mental health services by making sure those in need had the insurance coverage to pay for treatment. But there are still barriers that have not been overcome by simply having insurance coverage.

Researchers from Brandeis University and Harvard Medical School analyzed National Survey on Drug Use and Health data from 2005 to 2014 to estimate how many people were likely to face “serious psychological distress,” a specific level of mental health need that the Centers for Disease Control and Prevention estimates affects about 3.3% of noninstitutionalized Americans.
The researchers used that 3.3% figure as a general estimate of how many people need mental illness access care. Then they measured how many people actually received mental healthcare.
Even a single inpatient, outpatient, or pharmacy visit was considered mental healthcare.
The findings were published in Health Affairs this month.
Better Access Seen, But Not for All

There was some improvement in access to behavioral healthcare after the ACA was enacted in 2010, but only for certain groups, said lead author Timothy Creedon, a PhD candidate at the Heller School for Social Policy and Management at Brandeis University.
Racial divisions were significant, with whites the only racial group in which a majority of people needing mental healthcare received treatment. Whites with mental health needs also saw access to mental health services grow significantly, from 50% to 55% after ACA.
For Hispanics and Asians, access to mental healthcare improved after 2010, but only at about the same rate it was growing before the law came into effect.
Access for blacks did not change at all. Across all racial groups, less than half of people with serious psychological distress get the treatment they need, the authors concluded.
How can that be if more people have insurance coverage now?

Creedon said the problem appears to be partly the result of consumers not knowing about or understanding the coverage they have.
“When we ask people with private insurance, as many as 25% to 30% of people will say they don’t know,” Creedon said. “That suggests that simply having the coverage doesn’t improve anything unless the person knows and understands how to take advantage of the services available.”
Treatment Limits a Barrier
Although health plans seem to be complying with the ACA requirements and the Mental Health Parity and Addiction Equity Act of 2008, Creedon said nonquantifiable treatment limits still are getting in the way of treatment for some insureds.
“Provider networks, prior authorization, and things like that may still be levers that are available to health plans to manage care in ways that might dissuade people from getting treatment,” Creedon said. “We also have problems with shortages and distribution of mental health providers, who tend to be located in urban centers and not so much in rural areas. The workforce in mental [health] tends to be relatively homogenous and not necessarily reflective of the demographics of the people seeking treatment, and that can be a deterrence.”

Creedon also noted that psychiatrists are the physicians least likely to accept insurance.
He noted, however, that the research period came before the Medicaid expansion and state-based health insurance exchanges, and both may have improved access to mental healthcare, he said.
Health plans also are recognizing the disparity in coverage and treatment, Creedon said.
“We’re seeing some health plans offer more case management and integrated care, which can help people get access to mental health [services] through their primary care office, and some plans are offering more reimbursement for that kind of thing,” Creedon said. “I think if we see more financial encouragement of integration, that will be one way to get needed care to people.”
This report is brought to you by HealthLeaders Media.

Spending for treatment stagnates in face of burgeoning opioid abuse

While financing for mental health conditions by private insurers, Medicaid, and Medicare has increased over the past 30 years, funding for substance use disorder treatment remains stagnant, according to a recent study in Health Affairs.

A team of researchers from IBM’s Truven Health Analytics unit analyzed numerous data sets to measure spending on services treating mental health and substance use disorders since 1986.

They found that the share of treatment expenditures for mental health disorders funded by Medicare, Medicaid, and private health insurers increased from 44% in 1986 to 68% in 2014. But the corresponding figure for substance abuse treatment remained unchanged at 44% throughout this period. The rest of funding that is not covered by insurers comes from patients’ pockets or from other state or federal programs.
Additionally, from 2004 to 2013, the percentage of adults using mental health treatment increased from 12.6% to 14.6%. In contrast, only approximately 1.25% of adults received substance use treatment in inpatient, outpatient, or residential settings despite a surge in opioid-related addictions in this period.
The study’s lead author, Tami Mark, PhD, MBA, of Truven Health Analytics, explained to MedPage Today that the paper “counted spending based on which was the primary diagnosis treated in a particular healthcare encounter.” For example, if the outpatient visit primarily addressed substance use, and secondarily mental health illness, it would fall into the substance use disorder-spending bucket.
She emphasized that the study is “more descriptive than evaluative. We focused on the trends in spending by payer and provider type and use of services.” And, she noted, “there isn’t good data to track whether the quality of mental health and substance use disorder treatment is improving.”
Mark identified two key messages in the findings. First, while the share of financing for mental health coming from standard insurance is increasing over time, it hasn’t yet been felt in treatment of substance abuse disorders. This is likely because “mental health disorders are being more mainstreamed in terms of delivery and financing than substance abuse disorders, which are still heavily stigmatized,” she said.

The other key finding is that increases in spending on mental health appear to have been driven heavily by greater use of medications. “This also raises questions about access to non-medication services,” Mark said.
Andrew Kolodny, MD, a psychiatrist who serves as chief medical officer for the addiction treatment chain Phoenix House, commented that the paper “points to a disturbing trend. We are in the middle of a severe epidemic but spending on addiction remains flat.”
According to Kolodny, “Treatment providers are not making the treatment available because the reimbursement is so low from insurers.” This means that people often have to go out of pocket even when covered by insurance, which is not something you see for other conditions. “This is likely because addiction is highly stigmatized, and insurers take advantage of this and provide little reimbursement.”
He also argued that, when treatment is provided, often it’s the wrong kind. “There is a lot of inappropriate prescribing of medications,” he said. For example, providers may prescribe less effective alternatives such as antidepressants to treat substance use disorders than more effective medications such as buprenorphine. Furthermore, he worried “that there is not enough spending on the psychosocial aspects of mental health.”
Mark agreed, noting that funding for substance use disorders may be lagging because “people don’t appreciate the effectiveness of their treatments, including medications such as methadone and buprenorphine.” She added that psychosocial interventions, such as cognitive behavioral therapy, brief motivational interviewing, and intensive outpatient therapy, are “useful and cost-effective [but] unfortunately, psychosocial services may not be utilized as much as they should.”

Jeanmarie Perrone, MD, of the Perelman School of Medicine at the University of Pennsylvania wondered how the data would look if the study authors counted both primary and secondary diagnoses in substance use disorders and mental health, such as depression with substance abuse.
She said she had seen escalation in overall funding for substance abuse treatment, but “it is still challenging to obtain treatment for these patients.”
Mark said several policies now in place may boost mental health/substance abuse funding. These include the Mental Health Parity Act and provisions in the Affordable Care Act that define mental health and substance use disorder treatment as essential benefits.
Furthermore, a new emphasis on using early intervention to slow the progression of mental health and substance use disorder conditions, as well as pharmacological advances in medications to treat addiction, “are likely to further enhance the effectiveness of mental health and substance abuse treatment,” Mark said.
LAST UPDATED 07.01.2016

The number of practicing psychiatrists in the U.S. has stalled over the last decade, in contrast to an upward trend among many other specialties, researchers found.

Co-author Harold Pincus, MD, of Columbia University and New York-Presbyterian Hospital, told MedPage Today that more medical school students were going into psychiatry in the 60s and 70s, but there’s been a “generational shift and this proportion has declined. Thus, psychiatrists are not being replaced at a sufficient rate.”
He offered two potential reasons for this shift: “First, psychiatrists are one of the lowest compensated specialties,” he said. “Secondly, there are a greater number of other professionals providing behavioral health services, such as mid-level providers and counselors.”
Bishop and colleagues looked at data from 2003 to 2013 from the Area Health Resources Files, a county-level database maintained by HRSA.
In addition to the overall totals, they saw a 10.2% decline in the median number of psychiatrists per 100,000 residents in hospital referral regions — compared with a 15.8% per capita increase for neurologists, and stable per capita proportions for primary care doctors and all practicing physicians.
In further analyses, they also found that both the percentage of high school graduates and the median household income was significantly and positively associated with the per capita number of psychiatrists in 2013.

The researchers suggested that the decline in psychiatrists might explain “why people report poor access to mental healthcare and why a large portion of psychiatrists are able to sustain practices without accepting insurance.”
“There is nothing being done to increase the number of psychiatrists right now,” Pincus told MedPage Today. He suggested that “compensating them more appropriately” might increase interest. However, even if this stimulated interest, it would take a long time to see an increase due to the length of psychiatrist training, he said.
Petros Levounis, MD, chair of psychiatry at Rutgers Medical School, who wasn’t involved in the study, noted that there have been policy efforts to increase reimbursement for mental health services, such as the Mental Health and Substance Use Disorder Act of 2008 — but its implementation “has been slow,” he said.
“Reimbursements are very low,” Levounis added. “Thus, many psychiatrists don’t accept insurance, such as those in the greater New York area.”
From his perspective as a medical school instructor, Levounis said that medical students “are initially interested in mental health and addiction. However, as their education progresses, their interest drops significantly.”

Psychiatrists may not be inspiring students enough; or, medical and surgical specialists could be perpetuating the impression that mental illnesses are less important than physical illnesses, Levounis said.
He emphasized that the lack of psychiatrists is problematic not just for population mental health, but for its overall health.
“We now realize that the root causes for many physical conditions are linked to mental health disorders,” Levounis said. “For example, lung cancer and COPD are linked heavily to smoking cessation, which is under the realm of psychiatry.”
Pincus suggested that giving psychiatrists a supervisory role to guide other behavioral health professionals, while diminishing their own face time with patients, may be the best path to managing population mental health. But Levounis disagrees: he believes such a move will online increase the need for psychiatrists.
On the other hand, telemedicine may be able to pick up the slack, although it’s “early to tell the success of their outcomes,” Levounis said.
The researchers concluded that “policy makers, payers, and the medical community simultaneously must develop strategies to enhance recruitment into psychiatry and rapidly develop and effectively disseminate new care models to use the psychiatric workforce more efficiently in the near term.”

Yet many on antidepressants may not need them

More than two-thirds of adults with depression don’t receive any treatment for their condition, researchers reported.
In an analysis of data from the Medicare Expenditure Panel Surveys (MEPS), only about 29% of adults who screened positive for depression were being treated for it in 2012-2013, Mark Olfson, MD, MPH, of Columbia University, and colleagues reported online in JAMA Internal Medicine.

At the same time, patients with less serious psychological distress were more likely than those with serious distress to be prescribed antidepressants — and the clinical reasons for that aren’t clear, the researchers said.
The findings suggest there are “problems aligning depression care with patient needs,” Olfson told MedPage Today, and that there is a greater need for “more careful clinical attention to ensure depressed patients receive care their symptoms require.”
Previous work that had indicated that about half of adults with a lifetime medical history of major depressive disorder had never been treated for depression — but there has been a recent spike in antidepressant prescribing over the past few years in the U.S., and more emphasis has recently been placed on depression screening following a recommendation from the U.S. Preventive Services Task Force, the researchers said.
“With the recent increase in prescribing of antidepressants, some physicians may assume that under treatment of depression is no longer a widespread problem,” Olfson said.
To assess depression treatment trends, Olfson and colleagues analyzed data from 46,417 adults who responded to the Medical Expenditure Panel Surveys in 2012 and 2013.

A total of 8.4% screened positive for depression — but only 28.7% reported receiving any treatment for depression, the researchers reported.
Yet among all respondents who were receiving treatment for depression, only about 30% actually screened positive for depression — and only about 22% had serious psychological distress, they found.
“The clinical reasons for this pattern are unclear, but may include a tendency to overestimate the effectiveness of antidepressants in treating mild depression, insufficient time to provide alternative interventions for mild depression, and errors in clinical assessment,” the researchers wrote. “The reported treatment patterns suggest a need to increase routine assessment of depression severity.”
Those with serious psychological distress who were treated for depression were more likely to receive care from psychiatrists (33.4% versus 17.3%, P<0.001) or other mental health specialists (16.2% versus 9.6%, P<0.001) than those with less serious psychological distress.
They were also less likely to receive depression care exclusively from general practitioners, and more likely to receive psychotherapy (32.5% versus 20.6%, P<0.001) — but less likely to receive antidepressants (81.1% versus 88.6%, P<0.001).

The researchers noted that racial and ethnic minorities had a particularly low likelihood of receiving treatment for depression.
They acknowledged that the study was limited because the surveys were based on recall, and because updates on treatment outcomes weren’t available.
Still, they concluded that critical treatment gaps in depression care exist, and it’s important to deliver the right kind of care to the right patient.
“The results underscore ongoing challenges in aligning depression care with patient needs,” Olfson said. “Expanding the use of simple depression screening tools in primary care is a good first step to increase identification of depression and to guide matching patients to appropriate depression treatment.”
Jonathan Becker, DO, of Vanderbilt University Medical Center, who was not involved in the study, said the findings highlight a concern that healthcare professionals and patients have recognized for quite some time — that many people who suffer from depression aren’t receiving the treatment they need.
“[This] is particularly true for minorities and patients with lower incomes, less education, and lack of insurance,” Becker told MedPage Today. “I hope this paper leads to the development of strategies to improve access to treatment for those that need it.”

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