Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Thursday, October 1, 2015

Does Talk Therapy Work?

Take a look at the article in today's NY Times, Effectiveness of Talk Therapy Is Overstated, a Study Says.  

It's about a study published in PLOS one,

Does Publication Bias Inflate the Apparent Efficacy of Psychological Treatment for Major Depressive Disorder? A Systematic Review and Meta-Analysis of US National Institutes of Health-Funded Trials

Well, it's all very interesting. They were trying to look at publication bias in studies about talk therapy, and they found it. Of the 57 studies that met their inclusion criteria, 13 were never published-they learned about them by contacting the study authors.

And by their estimation, talk therapy is 25% less effective than previously believed.

The study looked at NIH grants between 1972 and 2008, and tried to match the grants to published studies. They were pretty thorough in their search terms:

(1) “depression” (depression, depressive, major depressive disorder, mood disorder, affective disorder, melancholic, melancholia) and (2) “psychological treatment” (cognitive therapy, behavior therapy, behavioral therapy, interpersonal therapy, psychodynamic therapy, dynamic therapy, humanistic therapy, therapy, supportive therapy, experiential therapy, [self-] control therapy, [problem-] solving therapy, [supportive-] expressive therapy, family therapy, group therapy, marital therapy, couples therapy, aversive therapy, exposure therapy, psychotherapy, psychotherapies, psychotherapeutic, counseling, disease management, psychoanalytic, behavioral activation, cognitive behavioral analysis system, desensitization, relaxation techniques, and progressive muscle relaxation). 

Of note to me is that they included "psychoanalytic", but not "psychoanalysis".

Inclusion criteria were:

(1) a randomized clinical trial examining (2) psychological treatment for (3) acute depression in (4) adults

This is a diagram of how they selected studies:

It bothers me a little that they started out with 4073 studies, and ended up with 57. But they seem to have been pretty thorough in how they went about it.

This is the table of the 57 varieties of studies they looked at:

Sorry,  I meant:

Of note again to me is that 5 of the studies are in Short Term Psychodynamic/Psychoanalytic Psychotherapy (STPP).

I'm not terribly surprised by their results. I don't put that much stock in the long-term effects of short term therapy. You may recall my post, Analytic Evidence, probably worth a shifty in this context. I've never been a big fan of CBT, except in very specific presentations, but admittedly, I think my CBT training was inadequate.

What I don't like about the study, and the Times article, is the overall message to the uninitiated. These were short-term treatments, and they were heterogeneous in type. These limitations are not addressed in the discussion section of the study. So the message is that all "Talk Therapy" doesn't work as well as we thought, with no differentiation between type or duration of therapy. And this is misleading and may keep people from seeking help.

Thursday, September 17, 2015


You've probably seen it already, but if you haven't, please read it:

Restoring Study 329: efficacy and harms of paroxetine and
imipramine in treatment of major depression in adolescence

It's been eagerly anticipated, and everyone pretty much guessed what the conclusions would be, but it's finally official. The data from Study 329 show that paxil improved depression in adolescents no more than placebo (same for imipramine).

More importantly, from my perspective, since there are always some outliers who respond to meds others don't, are the adverse events. The re-analysis showed a lot more harm than the original. Paxil had a lot more psychiatric adverse events, such as suicidal behavior, and imipramine a lot more cardiovascular events.

The efficacy of paroxetine and imipramine was not
statistically or clinically significantly different from
placebo for any prespecified primary or secondary
efficacy outcome. HAM-D scores decreased by 10.7
(least squares mean) (95% confidence interval 9.1 to
12.3), 9.0 (7.4 to 10.5), and 9.1 (7.5 to 10.7) points,
respectively, for the paroxetine, imipramine and
placebo groups (P=0.20). There were clinically
significant increases in harms, including suicidal
ideation and behaviour and other serious adverse
events in the paroxetine group and cardiovascular
problems in the imipramine group.

The reasons for the discrepancies are interesting. It seems like the difference in efficacy results was related to the fact that the original authors deviated from protocol, so that the same data give different results:

The marked difference between the efficacy outcomes as reported by us and those reported by SKB results from the fact that our analysis kept faith with the protocol’s methods and its designation of primary and secondary outcome variables.

The authors/sponsors departed from their study protocol in the CSR itself by performing pairwise comparisons of two of the three groups when the omnibus ANOVA showed no significance in either the continuous or dichotomous variables. They also reported four other variables as significant that had not been mentioned in the protocol or its amendments, without any acknowledgment that these measures were introduced post hoc. This contravened provision II of appendix B of the Study 329 protocol (“Administrative Matters”), according to which any change to the study protocol was required to be filed as an amendment/modification.

The difference in adverse events had to do with how the events were coded. The original article used a now obsolete and unavailable coding system, and the language in the Case Study Reports (CSR's) was often translated to something innocuous. I particularly liked one table which showed the ways that adverse events could be inaccurately reported:

As for GSK's reaction, the NY Times included this quote from the original authors:

Dr. Keller and his co-authors strongly disputed the reassessment of their work. In a joint statement, he and his team said they incorporated secondary measures before knowing which patients were taking Paxil and which were not — not afterward, as the new analysis claims, for some of the measures. “In summary, to describe our trial as ‘misreported’ is pejorative and wrong,” they conclude.

The authors of the new study, Joanna Le Noury, John M Nardo, David Healy, Jon Jureidini, Melissa Raven, Catalin Tufanaru, and Elia Abi-Jaoude, had their work cut out for them:

This RIAT exercise proved to be extremely demanding of resources. We have logged over 250 000 words of email correspondence among the team over two years. The single screen remote desktop interface (that we called the “periscope”) proved to be an enormous challenge. The efficacy analysis required that multiple spreadsheet tables were open simultane- ously, with much copying, pasting, and cross check- ing, and the space was highly restrictive. Gaining access to the case report forms required extensive correspondence with GSK.12 Although GSK ultimately provided case report forms, they were even harder to manage, given that we could see only one page at a time. It required about a thousand hours to examine only a third of the case report forms. Being unable to print them was a considerable handicap. There were no means to prepare packets for multiple independent coders, to decrease bias; to make annotations or use margin comments; or to sort and collate the adverse event reports. Our experience highlights that hard copies as well as electronic copies are crucial for an enterprise like this. 

I think they deserve huge thanks.

So check out the study. And also check out Study329.org for the whole history, as well as multiple posts by authors Mickey Nardo at 1boringoldman.com and David Healy at Davidhealy.org and Rxisk.org.

Tuesday, September 15, 2015

My ICD-10 Bad

I recently posted about ICD-10, with a link and a widget and whatnot. Most of what I posted is still valid, as far as I know. But I got a message today from the same friend and colleague who sent me the original link, about an email she received from the state:

Claims should not contain both ICD-9 codes and ICD-10 codes. Claims that are billed with both ICD-9 and ICD-10 diagnosis codes on the same claim may also be considered unprocessable. Therefore, services rendered prior to October 1, 2015 should be billed separately than services rendered from October 1, 2015 forward.

So I'm going to take the ICD-10 diagnoses off my September bills, and the ICD-9 diagnoses off the October bills. I'm guessing the insurance companies will be confused, but at least they won't be able to say I didn't do what they asked.

Remember: 9 through 9 (September), and 10 starts in 10 (October).

And big thanks to Susan.

Wednesday, September 9, 2015

ICD-10, Comin' At Ya

A friend and colleague sent me a little present-a link to an online ICD-9 to ICD-10 converter.

The site is AAPC.com, and I couldn't figure out what, exactly, AAPC stands for, but as far as I can tell, it's something like, American Association of Professional Coders, and it offers training and certification in medical coding and billing, among other things.

The above link also has a countdown timer to October 1st, when ICD-10 coding will be required.

I've posted previously about ICD-10, (and there's still the page link up at the top of my blog with common diagnoses conversions). There seems to be a lot of fuss about the conversion, but I don't think it's going to be that big a deal in psychiatry. I think there is a much more manageable number of codes than in, say, internal medicine, so I'm not too concerned. What I've been doing about it, lately, is starting to include ICD-10 coding in my charts, and on this month's bill. But I'm also retaining the ICD-9 coding on the bill, for the time being, because I think it's going to be a while before the insurance companies get things figured out, and with both codes, they don't have an excuse not to reimburse.

So my bills say something like:

Dx: ICD-9  296.30; ICD-10  F33.9

Hopefully, that'll work out okay.

Incidentally, what I mean by including ICD-10 coding in my charts is that I handwrite the ICD-10 code on the inside of a patient's folder, i.e. physical chart, right under where I've handwritten the ICD-9 code. Sometimes low-tech is a good thing.

I asked the friend who sent me the link if I could post it, and she, in turn, asked the person who sent her the link, who wrote back that I could post it, and who wished to have her information listed in this form:

Rachel T. Greenwald, Ph.D. of RTG Billing, telephone (347) 980-2417 and email rachel@rtgbilling.com.

I'm trying not to do anything shady in this, but it seems to be a free site, open to the public, and it was a nice gesture. So I hope that turns out okay, too.

And in case you haven't noticed, I put an ICD-9 to ICD-10 converter widget, which I got from the AAPC site, at the top of the column to the right. I tried it out, and it takes you to the site, rather than just giving you the code right in the widget, so I may take it down at some point. But right now, with the conversion imminent, I consider it a public service.

Tuesday, September 1, 2015

Bipolar Image

A reader kindly sent me a link to a research graphic on bipolar disorder that she helped to create, from a site called, "TopCounselingSchools.Org", which provides information about degrees available in counseling. I know nothing about the site, but I liked the image, so I'm sharing it with you.

The Highs and Lows of Bipolar Disorders

It's a really nice graphic. Visually appealing, not glaring, not too much information in one place, nothing blinking at you, information organized into clearly defined sections, just enough information to get you started, provides its sources. I can't vouch for the stats, but they seem about right.

The whole image is too large for this post, so here's a piece of it:

The one thing I found confusing is that in the first section, there's this:

It's one of several general statistics in that section.

Then, in the next section, there's this:

The American statistic above is one of the first you come across. By the time I got to the second section, I'd forgotten that I'd already read the stat for America, and I started looking for it, and was confused when I couldn't find it. I eventually (like 10 seconds) figured it out.  The only thing I'd change would be to repeat the American figure with the others in this section, since the type of display is different from the original one. This is really just me being fussy and weird. It's a great graphic.

So check it out.

And thanks to the reader who sent it. I don't know if she wanted her name listed or not, so if she does, I'll update this post.

Monday, August 24, 2015


City Bakery Melted Chocolate Cookie-Part Cookie, Part Chocolate Bar

I've gone back and forth on whether to write about the termination of my analysis, after the fact. I did write about it in Termination, before it happened. Somehow, this is harder.

So, my analysis ended. The last session was difficult and confusing, and probably will remain confusing for a long time.

First, there was the cookie saga. I decided to get my analyst a parting gift, and since it's impossible to encompass the entirety of an analysis in one object, I decided on cookies. I wanted a specific kind of cookie from a specific bakery (the melted chocolate cookie from City Bakery), but then I wasn't sure I'd be able to get that kind of cookie, so I baked my world-famous-awesome brownies (see This Post for the recipe), but then I felt uncomfortable giving her something I baked myself so I went back to the original cookie idea. And all of this got experienced, acted out, and narrated in the last few days of my analysis.

Another thing I did in the last few sessions was talk about all the things that made me uncomfortable about the process of terminating. Like which words my analyst would choose to end the last session, and how I felt about the intimacy of shaking her hand when I left.

Yet another thing I did, as a larger gesture, was make a blessing. Having been raised as an Orthodox Jew, many, if not all of my fundamental references are Judaic. And one thing observant Jews do is make blessings, which follow the specific formula of, "Blessed are you, lord our God, king of the universe, who is/does something." The italics are the part that varies.

There are blessings for all kinds of things, from rainbows to acknowledging scholarship to thunder to hearing bad news. There is a blessing for every type of food, categorized in very specific ways, of course, but pretty much everything is covered: bread, wine, potato chips, strawberries, and yes, cookies. And even though I'm not as observant as I was growing up, I still make blessings over food. It's a way of reminding myself that I am privileged enough to have food.

In the last few weeks of my analysis, I tried to think of a suitable blessing to make over termination. It was tough. One idea I had was the blessing parents make when a child becomes a Bar or Bat Mitzvah, which goes something like, "Blessed are you....who has removed this one's punishment from me." It sounds awful in translation, but simply means that the child has attained an age at which one begins to take responsibility for ones own actions. That has something of the right idea for a termination, but I told my analyst it seemed more suitable for her to say about me, than for me to say about her.

A friend suggested a blessing about healing a broken heart, which was pretty good, but not quite right.

In the end, I invented my own blessing. It's based on the prayer that's said at funerals and other types of memorial events, such as a Yahrzeit (anniversary of a death), which seemed suitable, since termination has an element of death to it. The end of the prayer translates to something like, "...May he rest in his resting place in peace..."

The Hebrew word that's translated as "resting place" is Mishkav, which literally means, lying-down place. Like a couch. So I used the same word but tweaked it a little to, "Blessed are you, lord our God, king of the universe, who raises (me) up from the couch in peace."
For me, it captures the idea that I leave not "cured", but in more peace than I was in when I started.

So the last session went something like this:

I came in and handed my analyst a bag with the gift. She laughed and asked if these were the brownies or the cookies. I told her they were the cookies, but then I felt bad. Maybe she really wanted to try my world-famous-awesome brownies, and I could have brought both those and the cookies. Oh well. There went that opportunity.

I felt like I should say something momentous that encapsulated the entirety of my analytic experience, but all I could think to say was that my analyst had been very kind. I felt like she should say something broad to summarize our work together, but she just said she'd enjoyed working with me. She also said the door is always open, should I wish to return. I felt like that was decent of her, but it made me wonder if she thought I might not be able to manage on my own.

In the middle of the session, I silently made my blessing, then told her I had made it.

All the old doubts were right there. Have I done enough? Can I manage on my own? Does she like me? Can I share the things I'm inclined to keep to myself? Is she disappointed that I didn't bring her brownies? Can I tolerate the pain of this separation?

It was like a miniature version of my whole analysis, reliving all these feelings that I had grappled with over the years, and made some kind of peace with, only to re-experience them right at the end.

There was a lot more laughing than I had expected, on both our parts. I felt like my preemptively bringing up my discomfort with her final wording, or with shaking her hand, had lessened the pain of those experiences, but also lessened their power. They became more awkward than sad, and I wondered if she was feeling sad too, but was uncomfortable showing it, or felt it was inappropriate to let me see her feeling that way, and maybe the laughter was more nervous than fun. I was disappointed that she wasn't obviously sad. I might have been more disappointed if she had been.

In the end, she said, "We do have to stop." And she laughed. I smiled. I got up, walked to the door, and we shook hands with a quiet, nervous laughter. And then I left.

It wasn't our best session. It wasn't our worst session, either. It was just one of many sessions. I'm grateful for my whole analysis, and I'm also glad, and sad it ended.

So, cookies for closure, discussion for honesty, and a blessing for peace.


Saturday, August 22, 2015

Addyi REMS-A Shanda

I seem to be on an Addyi kick lately. I got an email today about the Risk Evaluation and Mitigation Strategy (REMS) for Addyi, the newly approved medication for Hypoactive Sexual Desire Disorder.

There was a lot of fuss about this REMS, because Addyi is known to cause hypotension and syncope particularly alcohol is consumed. So the FDA created a REMS that involved special training and official certification for prescribers of Addyi (as well as pharmacies dispensing Addyi).

I mentioned in a previous post that I didn't want to do the training. I assumed it would be something along the lines of the 8 hour training required to prescribe Buprenorphine, and I didn't want to put that kind of effort into it. More importantly, I don't think the drug works, and I thought it would be easier to tell a patient I'm not certified to prescribe Addyi, than to have a long discussion about why it's not a good idea for her to take Addyi. Yeah, okay, that's a copout. I also didn't want to support this Shanda* of the FDA and Sprout (the company that makes Addyi).

*Shanda is Yiddish for something shameful or scandalous. I think Yiddish has much better words than English for expressing exasperation and outrage. Also sounds. An appropriate one here would be, Feh.

Buuuut...I got curious after I got the email. So I checked it out. What's involved is:

1. Read the Addyi Prescribing Information

2. Complete the Addyi REMS Program Prescriber and Pharmacy Training

3. Complete the Addyi REMS Program Knowledge Assessment

4. Enroll by completing the Addyi REMS Program Prescriber Enrollment Form

I want to go out of sequence for this next bit. I'll start with the Knowledge Assessment. Here it is:

Please note, this is not a section of the Knowledge Assessment. This is it. The whole shebang. I didn't need special training to answer this one.

And the training? It took me less time than reading through this post. The main point of it seems to be the Patient-Provider Agreement Form. This needs to be signed by both prescriber and patient, and states that the prescriber has counseled the patient, and the patient understands the counseling.

It's kind of brilliant. The FDA is covered for approving Addyi by the existence of  this special "training". Sprout is covered for producing and selling a dangerous drug that doesn't work by putting the burden of counseling the patient on the prescriber. And by covered, I mean legally.

This is what's required of the prescriber:

There might have been something useful in the "training" if it included recommendations for assessing a patient's ability to abstain from alcohol, or suggestions about how to encourage a patient not to drink while taking Addyi. But that would place some liability on Sprout or the FDA. So they didn't do it.

I am definitely not gong to enroll as a prescriber.