Friday, August 17, 2007

My Three Shrinks Podcast 30: Parity Feels Like a Bird

[29] . . . [30] . . . [31] . . . [All]

So we are back from vacations and stuff. We had two podcasts we recorded before we took our relative hiatus, and this is the first of them. I plan to get the next one out over the weekend.

August 17, 2007: #30 Parity Feels Like a Bird

Topics include:
  • Mental Health Insurance Parity Legislation. 20-minute discussion about some of the current legislation (mind you this was recorded before the revisions made in early August to SB 558). Go to this link to see recent parity-related posts. This leads into a brief discussion of...
  • Mind-Body Dualism. Why are there different rules for brain stuff than for body stuff? Isn't the brain part of the body? Will we still be having this debate in yet another 2400 years?
  • Pink Floyd's Syd Barrett. Brief mention of my post last month, Shine On, You Crazy Diamond, which, in turn, points to the "Images in Psychiatry" section of the July, 2007, issue of AJP, a tribute written by Paolo Fusar-Poli. "Nobody knows where you are, How near or how far."
  • Three articles on suicide in the July 2007 AJP. The first, by Simon & Savarino, is a well-done study looking at the relationship between the initiation of depression treatment (medication or psychotherapy) and suicide attempts by looking at outpatient insurance claims of a half-million members. They found that suicide attempt rates were highest in the month before treatment initiation, and that the patterns were similar for medications and psychotherapy. See below image. Most of the people (some 90% or so) were being treated by their primary care physicians. Those with the highest risk appeared to have been referred on to therapists or psychiatrists. Regardless (and not surprisingly), the patterns were the same. As stated by David Brent in his editorial, "it is much more likely that suicidal behavior leads to treatment than that treatment leads to suicidal behavior."

  • 2nd Suicide Article by Posner et al about Classifying Suicidal Events. The Columbia Classification Algorithm of Suicide Assessment (C-CASA) is explained, in an attempt to standardize the disparate definitions currently in use across treatment trials. Click here to see examples of difficulties in defining injurious behaviors as adverse events. Click here to see the Table of C-CASA definitions and training examples.

  • 3rd Suicide Article by Gibbons et al about the Relationship Between Antidepressant Initiation and Suicide Attempts in a Large Veteran Population. This group found that SSRI antidepressants had a protective effect. "Suicide attempt rates were lower among patients who were treated with antidepressants than among those who were not..."
The last few seconds is from Astronomy Domine, from Pink Floyd's album, Pipers at the Gate of Dawn, can be purchased at iTunes.

The next podcast, or podette, will be a brief one (for us) which I will post this weekend (yes, two podcasts in as many days... we have to make up for lost time somehow) prior to our next regular podcast, which we will record on Aug 19, probably between 3-5 pm ET. If any other psychiatrist listeners can join in at that time via Skype or Talkshoe, let us know and we might include you as a guest on the show.

Find show notes with links at: The address to send us your Q&A's is there, as well.

This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from
Thank you for listening.


Roy said...

n=1 asked (in the SB558 post):
"Thanks for posting the suicide and treatment statistics. By any chance do you know if those included military deployed in Iraq/Afghanistan? AMEDD is struggling with mental health issues, and the acting Army surgeon general seems to be tackling them in open air, transparent settings, as evidenced by the prominence of mental health issues on the AMEDD website."

Here's what I found out:

The study was done on all veterans receiving a depression diagnosis (ICD9 296.2, 296.3, 300.4, 311) in 2003 or 2004, AND had at least 6 mos f/u, AND had no hx of these dx or of antidepressant rx from 2000 to 2002.

I did a word search, and nowhere in the document aret the terms "Iraq" or "Afghanistan" used. However, the mean age was 57.6 yrs old, so that tells you that the majority did not see any Persian Gulf activity (in 2000's or in the early 1990's).

Extrapolating from their numbers (in Table 4), less than 2% of the 226,000 veterans were age 18-25:
18-25y = 2%
26-45y = 16%
46-65y = 48%
>65yr = 35%

They did note that the suicide attempt rate in the 18-25yo group of UNTREATED veterans was FIVE TIMES HIGHER that the rate in similarly aged placebo-treated depressed subjects in FDA studies, which certainly speaks this part of your question.

FYI, They list three limitations of their study.
1-"despite our attempt to eliminate bias due to the nonrandom assignment of patients to medications, confounding by selection remains a possibility. Nevertheless, much of the bias would very likely be in the opposite direction. For example, as previously noted, we would expect patients receiving SSRIs, either alone or in addition to other antidepressants, to have more severe or more treatment-resistant illness than those receiving no antidepressant. Thus, we would expect the suicide attempt rate among patients receiving SSRIs, either alone or in combination with other antidepressants, to be higher than the rate among patients not treated with an antidepressant, rather than lower, as we observed."

2-"our results apply to suicide attempts only; our data did not include lethal and other attempts that did not result in contact with the VA medical record system. Whether our results also hold for completed suicide remains an open question. We
are attempting to obtain cause-of-death information for this cohort and hope to be able to address this question."

3-"this is largely a male population, and our results may not directly apply to women."

N=1 said...

Thanks very much, Roy, for investigating this. FYI - Ilona Meagher has written a book titled, Moving A Nation To care, which is devoted to Iraq and Afghanistan veterans and active military who are delaing with PTSD. She also maintains a blog called PTSD Combat which provides rich resource listings and contacts, and it also chronicles military and veteran related PTSD stories.

I blog about military health and military healthcare systems with a fairly heavy focus on professional nursing and behavioral health issues, as well.

Midwife with a Knife said...

I have to agree with the fact that the tragedy is not that (according to my insurance plan) I pay $15 per visit for a "medical" problem vs $25 per visit for a "mental health" problem, but that so many people have no insurance at all.

According to, at the current dose of Asacol I'm on for UC, if I were to pay out of pocket, the total cost would be something like $400/month. The Relpax I take, occaisionally, for migraines would be about $100-$200/month depending on how many migraines I have. (It's $111 for 6 doses). Let's see... I also take Yasmin (because I don't like having periods, so sue me. I'm an obstetrician/gynecologist, I opt out of menstruation) with a retail cost of $35/month.

So, I consume in the neighborhood of $500-$600 of drugs a month. And I'm really pretty healthy. If this is what it costs to be pretty healthy, I can't imagine what it costs to be really sick. My max copay is $15 for a month's supply of a non-formulary, non-generic drug, so my copays run me around $45/month, which is really completely affordable. I think I would have a really hard time affording the $500-$600. Admittedly, I could drop the Yasmin and suck it up, but I can't drop the Relpax, because I get visual disturbances with the migraines, and I've had them at work before. Nobody wants someone doing a c-section when they can't see.

So, I can't imagine what I would have done if I had developed the UC during the time of my life when I was underinsured or uninsured. I don't think I could have been able to afford the workup ($5000 colonoscopy (very little of which goes to the doc doing the test) plus a bunch of blood tests) or the treatment.

Which leaves me to wonder, what do people without insurance do? As a doc, I'd be happy to waive my fee for poor people, but it's generally not the doctor's fee that is the killer. It's all of the other stuff.

Just some thoughts, sorry for rambling.

Rach said...

were you asking, mi casa est su casa?

Roy said...

Yes, that's what I was trying to say. Thank you.

Gerbil said...

So, um, how exactly is parity like a bird? (Because it's hard to catch and then it poops on your car?)

Roy said...

FYI: Two of the links to the Posner C-CASA article had errors in them. The links are working now.