Market competition is not going to fix US health care

Imagine you are getting your car serviced. You bring it to the shop, you get an estimate. When the work is done the shop presents you with a bill. It may be a little more or less than the estimate was, but either way that's what you'll be paying. Now imagine that instead of paying the bill as it's presented, you tell the shop: No, I don't think your work is worth this much. In fact I think it's only worth half this much, and that's what I'll pay. You pay half the bill and walk out, leaving the mechanic with his mouth open.

Sound out of line? This is exactly what happens every day to health care providers across the country. I recently made two visits to a specialty practice group at a large public academic hospital. Here are the services I received:

2 ultrasounds: ~40 minutes of time with each of 2 ultrasound techs and ~20 minutes of time with an attending radiologist (+resident but she was just observing)
~20 minutes of counseling with a pediatric surgeon
~20 minutes of counseling with a high-risk OB

Don't forget all the overhead costs and behind-the-scenes work like maintaining the ultrasound, scheduling the appointments, dictating and transcribing the reports, discussing the case, etc.

The cost for all of this work was $994. I have to say this doesn't sound unreasonable to me, though perhaps others' views may differ.

The insurance company, however, decided the work was worth only $477.12. That left the hospital $516.88 in the hole. But since they have an agreement with my insurance company, I'm not being held responsible for the difference. The hospital is presumably going to eat the cost. (I'm planning to call the practice group and offer to pay the difference, because I got excellent service, I was treated incredibly well, and I feel terrible that my insurance company is screwing over the hospital like that. But that's a side issue.)

In any other line of business you'd be stuck paying the sticker price, regardless of what you thought was fair. Only in health care does a third party get to decide what a provider's services are worth. The doctor or hospital can say ahead of time, we will work with Insurance Company A or we won't; but once they agree to work with that insurance company they are bound to accept whatever the insurance company decides is fair reimbursement.

Surprised at the cost of your health care? Remember that if you or your health insurance company pays in full, you're subsidizing all the people who don't have health insurance, or whose insurance (like mine, or like MediCare) doesn't pay the full cost of the services provided.

This is just one of the many ways that the insurance system divorces the health care system from the competitive forces of the free market.

Here's another one to wrap your brain around: Basic market principles imply a cost for a product or service. The better your product or service, the more you can charge for it and (in a perfect world) the more money you make. Right? Not down the rabbit hole of health insurance. Insurance companies make money by *refusing* the service they ostensibly provide - payment for health care. The more claims they deny, the bigger their profit margin. This completely subverts the competition principles of the free market. It also results in insurance companies spending a lot of money to pay people who figure out how to deny claims. Hence (among other, more complex reasons) why private insurers in the US have three times the overhead of MediCare, which doesn't waste effort figuring out how to deny people's claims.

Check out also this comparison of overhead costs in the privatized US system versus the centralized Canadian system (Woolhandler et al., NEJM 349:768-775):

And hence why placing blind trust in the power of the free market is, at least in this instance, a terrible idea.


In fact, not only is the health insurance system divorced from the principles that make free markets successful, it's divorced from its own founding principle of spreading the risk.

The whole point of insurance is that you have a large number of people at risk for an adverse event. These people all pay into a pool that will cover the small number who actually experience the adverse event. Somehow insurers decided it was OK to start divvying people up into risk pools, so that people who are less at-risk pay less, and people who are more at-risk pay more (or are blocked from getting insurance entirely). Sounds reasonable at first, but it's a slippery slope. As we find out more about ways to predict risk, we can charge sick (or risky) people more and more and healthy (or low-risk) people less and less. Soon you have a system where all the sick people are blocked from participating, or are paying the costs of their own health care with no participation from the healthy community. That's not spreading the risk. You might as well just pull out your checkbook and pay your doctor his fee. Except then you wouldn't be generating profits for the insurance companies.

The only way health insurance is going to work is if we go back to the basics:
If you want to use a risk-spreading model, everybody needs to participate. Young, old, sick, well. No excluding people and no basing premiums on expensively-generated risk profiles. Practically, the only way I can see to do this is a single-payer system. Whether the government wants to do the job itself or contract out to a private company is its own business; but however it's done, everybody (or almost everybody) has got to be enrolled to make it work.

This is why the Obama-Biden health care plan is not going to work.

Obama wants to let people opt out of the national program if they like their own insurance - or if they are simply healthy and don't want to participate. In fact, with a guaranteed-issue plan available there is no reason to buy insurance until *after* you get sick. This would result in healthy people refusing to buy insurance, and the system cannot remain solvent without that crucial population of people who pay in more than they take out.

If people want to opt into private insurance in addition to the national plan, fine, but they can't be let out of the risk pool of the national plan.

The good news is, if everyone is insured, and health care providers can be assured of getting paid in full every time they perform a service, then they won't need inflated sticker prices to cover all the nonpayers and underpayers.

If people want to yell "Socialist!" when they hear these arguments that's fine, but what are they going to do about maintaining solvency in the health care system? If you want to stick to your capitalist guns then your only viable option is laissez-faire, fee-for-service, truly free-market health care. (And if that's what you want you'd better be prepared to see a lot of poor people dying of treatable diseases.)

Because what we have now is not working, and for the reasons detailed above neither are any of the other half-cocked hybrid attempts to apply competitive market principles to a system that turns them on their heads.

depression that isn't

What do you do with a healthy patient who wants to die?

Ms K was 95. Her face was only softly lined, and her ash-white hair was smooth and silky as a girl's. She was in what one might call quite good health, having survived both a heart attack and a cancer many decades ago. Save a matched pair of titanium hips, her body parts were all factory originals.

By all accounts, her life was still a full one. She was close to her children and their spouses. She had a cadre of friends and neighbors who queued at the door to her hospital unit. She was possessed of an adoring younger husband, a stripling of 89. Indeed, he treated her to an extremely long, lingering kiss with evident tongue, in full view of the medical team as well as of their son (who sighed, "This is like a bad romance movie!" as he edged out the door).

And yet, she was decided on death. Quite decided. One day she declared that she would no longer eat, and that was that. "I'm 95 years old," she said, "and it's time." No coaxing, wheedling, or caviling; no gnashing of teeth and no rending of garments could dissuade her. After a few days of this, her distraught family brought her to the ER. After it was duly determined, via the usual sequences of poking, prodding, and sticking with needles, that she suffered from no medical illness, psychiatry was called.

After much ineffective discussion, Ms K was diagnosed with depression (though she professed no sadness) and brought into the hospital. She lay there for days refusing food and medications, even basic nursing care. Far from the etheral candle flame near snuffing out, Ms K held court from her bed, directing her frantic relatives to fulfill various social obligations and execute a litany of domestic chores.

Stymied, the psychiatry team consulted the hospital ethics board. The ethics board was equally flummoxed. Its concern was to rule out the possibility that Ms K was acting in her right mind, and not out of a reaction to depression or pain. A meeting was held with the physician team, the patient, her husband, and her son and daughter-in-law.

According to the family, this desire for death wasn't like Ms K at all. Generally she was quite life-loving and had never expressed a wish to die. At the same time they admitted that she seemed quite of sound mind otherwise, that her personality was pretty well unchanged and her mind continued to be the steel trap it had always been. They did note that she had always been very pain-averse, that she was at the beginning of a long course of physical therapy to recover from a hip replacement, and that she'd been pretty well exhausted by the physical therapy for the replacement of her *other* hip a few years ago.
Of course the very fact that she'd undergone the second hip surgery - and that her surgeon felt her 95-year-old hip was appropriate for replacement - suggested that both she and the surgeon had expected her to have quite some life left to make use of it.

The best we could figure out was that she'd just decided she would rather die than go through more physical therapy. But that seemed a bit... dramatic, didn't it? Then again, from what her family said, Ms K was nothing if not dramatic.

As an aside, I'm not opposed to the choice of a dignified, peaceful, planned exit when it's the only choice over an imminent and pain-filled one. That doesn't sound like mental illness to me. But that is pretty different from this. It's pretty different when a dying patient chooses the time and the means, versus a healthy - but aged - one choosing to end her life for no clear reason. Especially when she's nested in a network of people who would be devastated by her passing, but unspeakably more so by her *intentional* passing. When you think about it from that perspective, it starts to sound a little bit selfish in a way.

What to do about Ms K? A masterful ethicist managed to convince her that in order to let her have her wish of self-starvation, we would first have to be convinced that she was not depressed. And one way for us to do that would be for Ms K to give us a trial of... eating. And taking an antidepressant. In order to prove that her course of action was entirely voluntary, she'd have to show us she could change it.

Somehow this made sense to Ms K, and she agreed to take the antidepressant - but not to eat. So there she was, dutifully tossing back a Lexapro every morning but steadfastly refusing to eat while her desperate family surrounded her bed, alternately threatening and cajoling her.

Meanwhile, we called in the pain team. Ms K had never really complained of pain to us, but given the recent hip surgery and the trepidation about physical therapy, we wondered if there was more than she was letting on. The pain team came up with an improved regimen for her, and that did seem to improve things.

So how did this all turn out? After a week or so without food but snappy as ever, Ms K realized this undertaking was going to last longer than she'd bargained for. It looked as if starvation was going to be more trouble than it was worth. One day she asked for breakfast, and that was that. I suspect the pain from the hip surgery was the real problem; but Ms K never let on. She just acted as if this was a temporary redirection and she was going to find a better method of suicide sometime soon. But she didn't seem acutely dangerous, and her family promised to keep a close eye on her; so after she'd gotten her electrolytes back in balance we discharged her from the psych unit.

You never really do know what's going on with most patients until you've been with them a while. One of my psychiatry preceptors has said that the reason the patient gives for coming in is almost *never* the real problem. At the time I thought that was exaggerated but I'm starting to come around. I guess if psychiatry were more straightforward it wouldn't be nearly as interesting.

Open Letter of Apology to the Patient I Saw Last Night

You came into the hospital hoping to deliver a baby. In fact you weren't pregnant, but you wouldn't believe that; so the ER called me. We had a pretty nice conversation. I didn't challenge your belief that you were pregnant despite a negative urine pregnancy test and an ultrasound showing a normal nongravid uterus; and in turn you loosened up just a little bit. You were still clearly mistrustful - and who wouldn't be in your situation? as you said you'd been in and out of psychiatric hospitals more often than you could remember - but you were willing to talk. You definitely didn't want to come into the hospital, you said.

I was ready to send you home, really I was. Sure you were delusional, but it was a pretty benign delusion, as delusions go. You weren't suicidal. You weren't homicidal. You had a place to stay and seemed reasonably well groomed and nourished. I wasn't worried about your ability to take a cab back to your apartment, the same way you had come. You even had a psychiatrist, you knew your medications and doses (unlike 95% of the patients who come through the ER), you were carrying the pills in your purse, and you had an appointment in less than a week. There are thousands of people out there with worse delusions than yours - more severe, more pervasive, more dangerous - who manage to survive from day to day and to find a little pleasure in life, which is about all anyone can ask for anyway.

Unfortunately for you, things weren't that easy. Since I'm still a resident, I work under the supervision of an attending physician. At night the attending physician is at home, offering advice by phone; but she bears the ultimate responsibility for the patient care decisions that we make. See where this is going? I made you sound as good as I could - as good as you were - but she wasn't having it. She said you were delusional and wouldn't be safe at home, and that unless we could find someone to come get you at 4 AM, we would have to bring you into the hospital even though you didn't want to come.

But you didn't have anyone who could come get you. Like a lot of mentally ill people, you'd burned your bridges. You weren't close with your family, and the 'friend' you named at first turned out to be someone you hadn't spoken with in ten years. And while I was calling around to area hospitals trying to find a case manager, a psychiatrist, someone - anyone - who knew you and could help you out, or at least vouch for your ability to care for yourself - you decided you'd been waiting around in the ER long enough and it was time to leave.

After that things happened quickly. Four big ER security guys pounced on you to stop you from walking out the door. I heard your screams from the doc-box where I was dialing number after unresponsive number, and my heart sank. By the time I got out there you were already in restraints. At that point I was boxed in, and I had no choice but to write out a legal hold.

It was clear you'd been through this before. Other than telling me you hoped I'd die in a traffic accident, you took it all pretty calmly - much more calmly than I would have in your position. You were evidently familiar with the laws governing this kind of thing. You pointed out that you weren't dangerous to yourself or to others and that the legal basis for me to keep you was pretty thin. There wasn't really anything I could say. I acknowledged that you had a point, apologized to you and thanked you for staying (comparatively) calm. I told you I had no choice but to admit you to the hospital. Then I wrote out some weak excuse for the legal hold, which I knew probably wouldn't stand up to the judicial review that would likely take place in a few days. I hoped someone with more power than I had would let you out before then.

We walk the line between safety and liberty every day. When is it justified to deprive someone of his personal liberty? I think the law has it about right in theory - you should be physically dangerous or unable to assure your own care and safety. Seems straightforward; but in practice the latitude is wide and depends heavily on the judgement of the individuals involved. To me, this case lay far over on one side of the line; to my attending, it was far to the other. This time, the unfortunate patient got caught in the middle.

a science in need of a theory

I've had a number of people wonder why, as someone with a research background, I'd be interested in psychiatry. There's a tendency to view psychiatry as 'fluffy' and not something that would be interesting to a person who has spent years getting down and dirty with cells and proteins.

In my view, psychiatry is truly biomedicine’s last frontier, and no medical specialty could be more fascinating for someone who loves unanswered questions.


Medical science can speak knowledgeably on a molecular and tissue levelabout the causes of diabetes, asthma, and cardiovascular disease. We can trace Type I diabetes from the death of a specific cell type (pancreatic beta-cells) through the loss of their hormone product (insulin) to the immediate result (inability to use and store food energy) to the final result (death, before insulin was widely and cheaply available). We could tell you another good story about heart disease: fatty deposits build up inside the arteries that feed the heart, narrowing their cavities until they can be clogged by small bits of clotted debris, starving the heart of blood and resulting in the death of its muscle tissue - a heart attack. (Yes neither story is so simple, in a nod to the endocrinologists and cardiologists out there - but let's not get bogged down in details.)


However, the DSM-IV lists not one disease for which such a clear pathophysiological chain of events has been established. When faced with depression or schizophrenia, medical science begins to wave its hands, to stutter and mumble vaguely about deficits or excesses of this or that neurotransmitter. In this sense, psychiatry is truly biomedicine’s last frontier.

Sure, we have some vague hypotheses about things. Take for example the 'dopamine hypothesis' of schizophrenia. That's the hypothesis that schizophrenic patients have too much dopamine in the frontal cortex (resulting in positive symptoms like hallucinations and delusions) and not enough in the subcortical areas (resulting in negative symptoms like social isolation and flattened affect). That explains why dopamine-blocking drugs improve the positive symptoms but aren't so great at fixing the negative ones.

That's a nice finding, and it is likely accurate to a degree; but it's not what you would call pathophysiology. That's like saying the problem with my computer is that it's got too much electricity in the hard drive and not enough in the disk drive. The computer doesn't work by bathing its various parts in electricity, and neither does the brain work by bathing its various parts in neurotransmitter soup. The important thing for each of them is the patterns in which the circuits are communicating with each other, and naming the medium of that communication - be it electricity or dopamine - isn't anything like the answer to a question about why the system is broken.

But nonetheless, psychiatry continues to offer explanations like "Too much dopamine!" or "Not enough serotonin!" to questions about why people have various psychiatric illnesses.

Many of these answers are based on reverse-engineering from medication effects. We've got this drug that increases serotonin transmission, and it fixes depression, so therefore depression must be the result of insufficient serotonin. We've got this other drug that blocks dopamine transmission, and it fixes schizophrenia, so therefore schizophrenia must be the result of too much dopamine.

The obvious problem with this reasoning is that a drug isn't a perfect reversal of a disease process. A disease has some complex effects, and a drug has some other complex effects, and some of the drug effects work to cancel out some of the disease effects, but the overlap is in no way perfect and doesn't necessarily offer us any information about the root cause of the disease.

When John Snow removed the handle of the Broad Street pump to halt the 1854 cholera epidemic in London, did that mean that working the pump handle gives a person the cholera? No, and neither does 'fixing' your depression with more serotonin mean that depression is ultimately caused by 'not enough serotonin.' Serotonin is playing a role in there somewhere but a 'serotonin deficit' is overly simplistic as a cause of anything so complex as a psychiatric disorder.

So the drugs do a bunch of things, and symptom relief is only part of the picture. I don't really think they're fixing whatever the underlying problem is, only pushing the brain into a more manageable state (not quite a normal one). Although some schizophrenics are quite pleasant and normal when they're appropriately medicated, lots of others are still evidently off.

So what would a theory of psychiatric disease look like - a real one? Don't look at me, I'm just the critic. But this very interesting and timely article in the New York Times describes a couple of authors who have developed something that's much more along the lines of a Good Theory than any of the other vagueness I've heard. I'm not certain I agree with their lumping of psychosis and mood disorders as fundamentally similar, but I like the way they think.

fear of hell

The screech of my pager jolted me from sleep. A soft-voiced nurse informed me that they were having some trouble with one of the patients and his behavior was very disruptive to the others, so could I come by and see him, please?

I asked for some further details. Apparently he was kneeling on the bathroom floor screaming that Satan was trying to remove his soul through a portal in the back of his head.

Yikes. I quickly pulled up the patient's record for a look. He was a young man in his early twenties with a diagnosis of schizophrenia. History of delusions about the devil. Apparently he had presented voluntarily for help with a chief complaint of "getting schizo again." That sounded like an unusual degree of insight for a severely psychotic patient.

I jogged over to the next building and let myself into the locked unit, jiggling my keys about in apprehension. The unit was quiet. I peered into the empty bathroom on my way to the nursing station.

The nurses greeted me with visible relief. "He's in his room, doctor." I walked down the darkened hall toward a square of fluorescent light spilling across the linoleum. I nodded politely to the patient's silent knife-lipped sitter, and knocked gingerly at the door.

He lay flat on his back in the spare, brightly lit room, arms at his sides. Only his wide, terrified eyes moved to follow me about the room. Pale and trembling in his coat of puppy fat, he looked like a round-cheeked child caught in a nightmare. I asked him what was wrong.

He glanced at me sidelong. "Nausea."

Nausea? "Is that all?" He nodded. "Is it all better now?" Another nod. "Are you sure? Because the nurses told me you were having a lot of trouble a few minutes ago." A third fearful, stiff-necked nod. I paused. "Are you afraid that talking about it is going to make it come back?" A vigorous nod. "Okay," I said. "If you don't want to talk about it, I don't want to make you talk about it. But I might have a better chance of helping you if you could tell me what the problem is."

I'd barely finished my sentence when he burst out, "Satan is talking to me!"

Ah-hah.

"What's he saying?"

The patient shook his head, refusing. Sweat beaded his unlined brow. He looked awful. I took his hand. "Can you tell me what's real?" I asked. He looked at me. "I'm real," I told him. "You're real. The hospital is real. My hand is real." I squeezed his damp chubby hand, and he squeezed back, staring at me, and nodded. "Is Satan real?"

"I can hear him talking right now!"

"Tell him to shut up."

"Shut up!" he screamed vehemently at the empty air to the left of his head, startling the others in the room.

"Good," I coached. "Listen to me. Satan is not real. I know this is frightening. But try to keep reminding yourself that it isn't real. Are you okay?"

He nodded. "Are you okay?"

I was confused. "I'm fine. I want to make sure that you're okay."

"You're all right?" he repeated.

"I'm fine," I reassured him, still unclear about the reason for his concern.

He beamed, for the first time, with relief. "So I can't hurt you with my thoughts?"

I understood. "No, you can't hurt me with your thoughts. That's not real, okay?"

He nodded again. "Sometimes I get confused."

"I know. It's okay. If you get confused you can ask the nurses for help, or you can ask for me to come back. Do you want some medication?"

He nodded again. He was already pushing the limits on antipsychotic dosing for the day but the meds didn't seem to be touching him. "You've already had a lot today," I told him. I'm going to give you something to help you sleep, and just a tiny bit more of something else for the voices. But no more today after that, okay?" He was agreeable. "Is there anything else we can do to make you feel safer?"

"Can someone stay with me?"

"Sure." I gestured toward the implacable sitter at the door. "It's Rose's job to stay here and watch you, and she can help you as well if you get scared again."

"No," he cried, suddenly frightened again. "She's with Satan!"

I looked doubtfully at the sitter, who stared back in frizzy-headed indifference. "No she's not," I reassured the patient. "That's not real, okay? She's here to help you just like everyone else."

"Oh, I'm sorry," he said, addressing himself to the sitter. "I get confused sometimes. I didn't mean to be insulting." She nodded silently.

"It's okay," I offered for her. "Everyone here understands. I'm going to go write for the medication we talked about. Do you need anything else before I go?" He shook his head. "Okay. Just remember to ask for help if things get bad again."

“Thanks,” he said, and I stepped out.

This was definitely not toeing the party line on handling delusions. You’re not supposed to challenge the delusion, or even usually imply that you don’t think it’s real – at least not outside of a structured therapy program. (Cognitive behavioral therapy has been found effective in reducing delusions, but that requires a long-term commitment to treatment and a strong therapist-patient relationship.) Normally what you’re supposed to do in an acute situation like this where you don’t know the patient is simply be supportive and offer medication.


On the other hand, this patient had excellent insight. He knew he was ill, and he found his hallucinations and delusions terribly frightening. My instinct was to offer him assurance that his nightmares weren’t real.

For good or ill, this is the way most working psychiatrists function. They are guided, for the most part, not by the studies and statistics of so-called “evidence-based medicine,” but by their own individual combinations of instinct and experience.

This is true even in the realm of psychopharmacology, which is perfectly amenable to randomized controlled trials; but it is especially and unavoidably true for the doctor-patient interaction. This interaction is important in all fields, but in psychiatry it is an explicit and essential part of the therapy. And it is incredibly difficult to quantify.

Two therapists may use the same method but achieve radically different results. The most important factor in the success of the therapy is the individual therapist – not his degree, not his school of thought, but just his individual character. It’s a bit sobering to think that one’s ability to do this job well is so dependent on innate talent. Why all this education if the job isn’t one that can be learned or taught?

I hope my intervention with the patient in this story was helpful for him. In the long run, one short interaction with an on-call resident isn’t likely to have much of an effect either way. But it’s more than a little unsettling to realize I’ve undertaken such a journey with no compass or road map.

disciplinary medication

Disclaimer: I am not a child psychiatrist and do not speak with professional authority on this subject. These are my own ideas based on various readings and personal experiences.


Everyone loves to hear about someone overcoming obstacles to become a star. This NYT article about Michael Phelps, ADHD-child-turned-Olympian-superstar, caught my eye.

I found most intriguing the bit where Phelps’ mother says that, although he was incapable of sitting still for five minutes in school, he was able to sit patiently at poolside for hours awaiting his chance to swim.

I've heard many stories like this about ADD/ADHD/CD/ODD children: unmanageable under the stringent circumstances of formal schooling (sit still, don't move, don't talk, pay attention), they blossom under circumstances that channel and challenge their natural energy.

In fact, one research team has come up with interesting results suggesting that children with ADHD benefit from exposure to natural settings (Kuo and Taylor).

All this leads me to suspect that this entity which we treat as a disease may actually be a personality trait that lies on the normal spectrum, but that happens to be incompatible with the demands of our technological society.

Human beings evolved to forage, track game, and avoid becoming prey. Those are the tasks for which we were optimally designed. Sitting quietly in school for six to ten hours a day is not in that job description. Humans are amazingly flexible, so most of us can handle it to a greater or lesser degree; but it's not surprising that those out on the high-energy end of the personality spectrum are having some trouble.


So does that mean that we should not diagnose or treat ADHD?  If in another place and time it would have been simply a character trait, does that mean we shouldn't medicate it?  Well, I wouldn’t say that either. Some of the behaviors described for these kids are absolutely beyond the pale of what parents and teachers could be expected to manage by themselves.

Whether these behaviors would be different in a different environment – out on a farm, say, or in a forest – is perhaps irrelevant. We can’t move the kids out of the society they’re in. This is it, for better or worse.

And as always, I’m all for behavioral interventions ahead of pharmacological ones. If the behavior of kids on the milder end of the spectrum can be improved by fixing their diets or letting them tear around outside for a few hours, then that’s an easy decision to make.

But what about kids on the extreme end of the spectrum? The kids who scream, bite, kick, punch, and cannot be coaxed, bribed, threatened, or punished into any semblance of normal behavior?  This is the difficult question faced by parents of ADD/ADHD children: to medicate or not to medicate?

I’m generally extremely wary of giving psychoactive medication to children. The brain is not completely developed until the mid-twenties, and the brains of young children adapt gleefully and abundantly to changing stimuli. If those stimuli include, say, an extended period of dopamine blockade, the brain will adapt by upregulating its sensitivity to dopamine, attempting to restore a more typical balance of dopamine activity.  How long do these effects last? Nobody knows.

Even for the best-studied drugs, there's more information available about gross parameters like height and weight than there is for long-term psychiatric effects.  E.g., Ritalin has been around for a while and is relatively well-studied in children.  At this point it's pretty clear that Ritalin does not have gross effects on children's overall growth and development. I'd be more concerned about subtle long-term changes to their mood and behavior. These things are of course significantly harder to study.  I did find some studies looking at behavior in adult animals who had received psychoactive meds as juveniles.

Here’s a study that shows rats that get Ritalin as adolescents are more sensitive to amphetamines as adults. (Valvassori et al.).  Here's another one that demonstrates the same thing, and also suggests some baseline behavioral changes (Carlezon et al.).  Similar results in this third study (Brandon et al.).

This was later studied in humans and it doesn't look like kids treated with Ritalin are any more likely to become speed addicts as adults than anyone else (less actually), but I'm not aware of any follow-up on, e.g.,  long-term susceptibility to depression or other mental health concerns.

Meanwhile, children are starting to receive medications with much less pediatric data behind them than Ritalin.  For example, the FDA approved the antipsychotic Risperdal for use in children based on three clinical trials that lasted 3, 6, and 8 weeks respectively.

(Risperdal is not approved for use in ADHD specifically but is sometimes prescribed off-label for that indication.)

Huh? Where’s the study that looks at the kids five, ten, or twenty years later? That’s the one I want to see. And barring that (given the difficulties of conducting such extended trials), I’d love to see some more animal studies.

So about those animal studies.  I didn't find many, and what I did find wasn't encouraging. Here’s a study that shows alterations of development, outgrowth, and axonal migration in developing worms receiving antipsychotics (Donohoe et al.).

Unfortunately, the need for behavior control is urgent, and the information just isn’t out there. I think the vast majority of parents are pretty cautious, as they should be, about medicating their kids, and will do so only as a last resort. I also think that’s the right approach; and in the final analysis, if you need it, you need it. Sometimes you have to trade the threat of an unknown outcome in the future for a drop of sanity in the here and now.

But I wouldn’t be soothed into thinking that just because we don’t know about long-term ill effects of childhood medication doesn’t mean they don’t exist. You can only know something is there if you look for it, and that’s something the biomedical research community doesn’t yet appear to have done.

color-by-number

A new patient walked into my psychopharmacology clinic last week. She seemed reasonably typical at first. A line in the chart noted that she was somewhat wary of psychotropic medications, but then many patients are, and I don't tend to mind that attitude myself since I also subscribe to the less-is-more theory of psychiatric meds.

She was on a fraction of the normal dose of a common antidepressant, which, she reported, was her only medication. It seemed unlikely that this small dose was having any effect, positive or negative, on her mental health; but her mood was stable and she was sleeping and eating well. Things looked good. The main points covered, I asked if she had any other concerns.

"Well, I had my brain imaged," she offered. Brain imaging? Did she have a neurological disorder I hadn't known of? I asked which physician had ordered the tests.

"Oh, I did it myself. I saw it on TV and thought it would be a good idea."

Brain imaging advertised on TV, direct-to-consumer?

She handed me a sheaf of papers, of which the first few pages read like Baby's First Book of Neuroanatomy crossed with the New Age Guide to Herbal Remedies. "Prefrontal cortex: Planning ! Attention!... L-tyrosine!... Anterior cingulate: Cooperation! Flexibility!... St John's Wort!" There was then a list of "hyperactive" and "hypoactive" regions in this patient’s brain.

She'd paid out of pocket to have her brain SPECTed at a clinic that advertises on late-night TV.

Where to begin.

Let me just state up front that there is no established role for brain imaging in psychiatry at this time. None. You can't look at a picture of blood flow (or any other parameter) in the brain and make a diagnosis. (SPECT has some utility in distinguishing Alzheimer's from vascular dementia, but that's more neurology than psychiatry.)

To start out with, despite the existence of a number of studies looking at blood flow in depression, there is not a clear consensus on which areas of the brain are most involved.

Then, let me point out that we have no standard against which to judge baseline levels of regional activity. Blood demand fluctuates on a moment-to-moment basis depending on what the brain is doing at any particular time. The variation in demand between individuals and times is not very well described. So my patient's brain regions were over- or underactive compared to what? Somebody else's brain thinking sad thoughts? Her own brain thinking happy thoughts? The average of ten other people's brains doing a crossword puzzle? Any way you slice it, it doesn't sound informative.

Even when looking at more stable and reliable imaging correlates of clinical depression, in which a clear average population difference exists between depressed individuals and normal controls, there is so much overlap between the two groups that you can't usually infer a person's mood from his brain scan alone. Check out this graph from a review by J.H. Meyer, showing MAO-A density in different brain regions.






While there are clear differences between the populations on the whole, it's also just as clear that an isolated brain scan likely won't tell you much about whether that individual is depressed or not. There are just too many people in the overlap region.

As you can tell from these links, science is still in the phase where we use clinical data as the gold standard against which to judge the validity of imaging results. Going the other way round - starting with the scan and inferring the diagnosis - is something that's far away from our current level of understanding.

Consonant with this, the 'interpretation' of this woman's SPECT scan was nothing you couldn't have figured out from talking to her for a few minutes. After citing a number of areas in which 'dysfunction' was discovered by the SPECT scan, it described some related problems she might have, such as "negativity, guilt, blame, irritability." The kinds of things you could diagnose more easily from a cheap interview than from an expensive brain scan.

The recommendations included a number of OTC supplements (without indication of dosage, of course, since these supplements are largely unregulated, little is known about optimal dosing and in any case actual content may vary wildly from what's written on the label). Some of them were items that have some evidence for their utility (e.g., omega-3 fatty acids); others seemed relatively benign (e.g. Coenzyme Q10) but with little available evidence regarding their use in depression; and others (e.g., St John's Wort - see this FDA advisory) can be positively harmful under the wrong circumstances.

My patient was on all of the recommended supplements - some six or seven different pills - despite having declared the Lexapro as her only medication. This is an incredibly frequent error made by patients, who are soothed by the 'supplement' label into thinking the items are somehow safer or less likely to produce side effects than chemically prepared medications. In fact, there are a number of supplements that have produced significant health problems in their users (e.g., ma huang, which was ultimately banned by the FDA), and since their preparation is poorly regulated, both the dose of the medication and the number and identity of the compounds present are pretty much up for grabs. These facts make supplements a rather riskier bet than prescription preparations.

There were some other very general recommendations of the type that any mainstream psychiatric practitioner would typically make: cognitive behavioral psychotherapy, good social and emotional support, exercise, self-relaxation, and a balanced diet without excess use of nicotine and caffeine. All useful advice, none of it requiring the service of gamma ray scans.

I fully expect that brain imaging will one day have a place in psychiatric practice. However, that day is not today, and I find it upsetting when my patients are conned into paying good money for a useless procedure, a dose of radiation, and some occasionally inappropriate advice.

I do find it curious that so many people place deeper trust in the uncharted waters of alternative medicine than they do in the well-documented, frequently evidence-based recommendations of the standard medical establishment. Things aren't always peachy in the world of traditional medicine; doctors have done a lot of harm as well as a lot of good. But I like to think that as a profession we ultimately learn from our mistakes, and I'd submit as evidence the enormous strides modern medicine has made in extending the productive lifespan, reducing infant mortality, etc etc etc. And in a plug for my own specialty of psychiatry, although there are many patients who are beyond our present capacity to help, I know many others who have unquestionably been saved from suicide or from personal and social destruction.

When someone shows me a randomized controlled trial that demonstrates the utility of a supplement, I'll be happy to use it and recommend it. (I already do recommend both fish oil and melatonin under the appropriate circumstances.) Until then, it's just a black box; and that's not something I'm comfortable giving to a patient.