From the Editor
Is clozapine prescribing effected by demographics?
In the first selection, from Psychiatric Services, Natalie Bareis (of Columbia University) and her co-authors consider medication prescriptions for those with psychotic disorders, drawing on US Medicaid data. “Our results indicate significant variation across states and among racial-ethnic groups in prescription patterns of six types of psychotropic medications, even after we had adjusted for multiple patient factors.” Indeed, they find that clozapine is much more commonly prescribed for those who are White. We consider the paper and its implications.
Clozapine: a simple molecule but complicated availability in the US?
In the second selection, Dr. Jonathan Rogg (of the University of Texas) and his co-authors consider equity and telemedicine. In a paper for the Harvard Business Review, they describe the services offered in a low-income area of Texas, and the lessons learned. “The Covid-19 pandemic has forced a rapid evolution in technology with the potential to help the most disadvantaged patients. Our experience during the pandemic has demonstrated that telemedicine can overcome access-related challenges faced by indigent populations. By allowing them to access care in their homes or even their jobs, it can help them address health issues expeditiously with minimal disruption to their lives.”
Finally, in the third selection from The Globe and Mail, writer Leah Eichler writes about her uncle, who probably had an undiagnosed mental illness. She writes about his disappearances and erratic behaviour. “We like to believe our relationships are solid, that love is somehow inextricably linked to permanence. Missing our loved ones, if anything, highlights how impermanent even our closest relationships can be.”
Please note that there will be no Reading next week.
Selection 1: “Variation in Psychotropic Medication Prescription for Adults With Schizophrenia in the United States”
Natalie Bareis, Mark Olfson, Melanie Wall, T. Scott Stroup
Psychiatric Services, 30 September 2021 Online First
Several classes of psychotropic medications are commonly prescribed to people with schizophrenia spectrum disorders, but only antipsychotic medications have strong evidence for effectiveness in treating such patients. Among these medications, clozapine and long-acting injectable (LAI) formulations have distinctive roles. Clozapine is the established medication of choice for treatment-resistant schizophrenia and is the only drug approved for this indication. LAI antipsychotic medications are important options to help ensure medication adherence, but their benefits and how they are used are controversial. Evidence for an important role for antidepressants in schizophrenia treatment has been increasing, whereas mood stabilizers and benzodiazepines have limited evidence for effectiveness in this disorder.
Treatment variation refers to differences in treatment that are not attributable to differences in clinical presentation for persons with the same condition. Variation in treatment patterns is thought to reflect professional uncertainty—a lack of consensus or evidence regarding the best treatment choice for a condition. Other factors contributing to such variation are uncertainty of sequential timing of treatments, differences in availability of providers and services, and provider preferences. Regulations, variations in health insurance benefits, pharmacy benefit management, and consumer preferences are other possible contributors. In some cases, treatment variations may reflect inequities due to socioeconomic status, race, or ethnicity.
So begins a paper by Bareis et al.
Here’s what they did:
- They drew data from US Medicaid, which covers low-income Americans.
- They considered prescriptions for those with schizophrenia spectrum disorders.
- “Percentages of patients in each state who filled prescriptions of at least 15 days of any antipsychotic, clozapine, antidepressant, benzodiazepine, mood stabilizer, or long-acting injectable (LAI) antipsychotic medication were determined after adjustment for demographic and clinical covariates.”
- Statistical analyses were done, including “multivariate regressions of clinical and demographic factors predicting prescription patterns were conducted.”
Here’s what they found:
- The total dataset: 357 914 people.
- Demographics: 49% women, 35% non-Hispanic Black, 40% non-Hispanic White, and 12% Hispanic.
- Patients with schizoaffective disorder made up a third of the sample. Comorbid physical health problems were common: cardiovascular disease (35%), hyperlipidemia (24%), and diabetes mellitus (21%) were the most common.
- “Across states, adjusted proportions of prescriptions ranged from 4% to 22% for LAIs and from 1% to 11% for clozapine.” (!)
- “Non-Hispanic Blacks and people of other race-ethnicities were more likely than non-Hispanic Whites to fill prescriptions for LAIs, and non-Hispanic Whites were more likely than individuals from other racial-ethnic groups to fill prescriptions for clozapine and all other medications.”
A few thoughts:
- This is a good paper, drawing on a large database.
- There is incredible variability in prescribing habits. As the authors note: “Significant variation was found among states in prescription of each psychotropic medication class, with 10-fold and fivefold variations in clozapine and long-acting injectable (LAI) antipsychotic medications, respectively.” The results aren’t surprising, but they underscore (yet again) how much people’s mental health care is influenced by various factors, including geography.
- Is there inequity here? Whites were more likely to get clozapine than other groups. For example, non-Hispanic Blacks were 60% less likely to receive clozapine than White patients; Asians, 17% less. (!!) Many consider clozapine to be the gold standard in care – ouch. The paper does have a couple of limitations. First, the data is dated, drawn before the recent health reforms (the Affordable Care Act) were implemented, which expanded coverage to working poor families, who are disproportionately racialized. As well, individual states have different reimbursement formulas for different medications, skewing prescribing. That’s not to suggest that inequity doesn’t exist but that further study would be needed.
- This is an American study drawing on a program that is partially federally funded and implemented at the state level. What would prescribing look like here?
The full Psychiatric Services paper can be found here:
Selection 2: “How to Make Telemedicine More Equitable”
Jonathan Rogg, Zheng Ben Ma, Michael Pandya, et al.
Harvard Business Review, 7 October 2021
Telemedicine, which provides a way to safely coordinate and deliver care to patients from a distance, has gained popularity in recent years among doctors, patients, and health systems. But its widespread acceptance was dramatically accelerated by the Covid-19 pandemic, which has given patients timely access to care without exposing them to the risk of contracting the coronavirus. However, it also poses a risk of widening inequities in health care in the United States by improving care for those who already have access while leaving behind those who are in need. As the pandemic has highlighted, the disparity is already huge: More than 31 million Americans were uninsured in 2020, limiting health care access during the worst public health crisis in decades. Therefore, it is vital that telemedicine be implemented in a way that closes, rather than increases, the gap.
The approach taken by Harris Health System, the safety-net health care system for Harris County, Texas, can serve as a model for using telemedicine to improve access for disadvantaged populations. Harris County, which encompasses metropolitan Houston, is the third-most-populous county in the United States and has a large indigent, multilingual, and multicultural population – many of whom lack health care insurance.
So begins a paper by Rogg et al.
The article focuses on their work in Harris County. Launching in the first weeks of the pandemic, they review the stats:
- “In the first year, we conducted more than 500,000 video or telephone visits.”
- “[W]e have conducted more than 40,000 new patient visits (i.e., those with people who had not seen a provider in our system for at least three years) using telemedicine.”
- “Of those, nearly 60% were economically disadvantaged patients who qualified for either charity care or Medicaid… people of color accounted for a higher proportion of telemedicine visits than for in-person appointments (86% vs 80%).”
The paper discusses several core approaches; we highlight here three.
Invest in training
“Telemedicine is a fundamentally different way for patients and physicians to experience health care. For example, most physicians do not routinely ask patients at the beginning of an encounter, ‘Can you see and hear me clearly?’ Yet, this is an important first step when conducting a video visit.”
They note that many providers weren’t familiar with televideo-based care. This deficiency required action; “upfront investment in training is critical.” They describe how physician staff were trained up and telepsychiatry was added to the residency-training curriculum. They also note several small steps that the health system took: “We developed training videos, tip sheets, clinical practice guidelines, and workflows to assist each department in integrating telemedicine into care.”
Anticipate patients’ needs
“Before a health system establishes a telemedicine program, it is imperative to understand how and why patients will use telemedicine.”
The authors note the importance of understanding patient needs. “Crucially, health systems must carefully consider their patients’ access to essential technology required for telemedicine encounters, including broadband internet, computers with webcams and microphones, and smartphones with reliable data services.” They worked to provide telemedicine services – but also maintained in-person care for some.
And they built up translation services. “Another important consideration is patients’ preferred language for communicating with their physicians. Integration of professional medical interpretation should be easy for the physician and seamless for the patients. This is especially important for areas of the country with large immigrant communities. Given that the majority of our patients speak a language other than English, we made sure that interpreters were readily available for video visits.”
Always have a backup plan
“Numerous external factors can make video visits challenging. The target population may have financial or geographic barriers to accessing a computer, smartphone, or high-speed internet. Elderly patients may face challenges using new technologies. As part of our workflow a non-physician staff member reaches out and ensures the patient has the proper technology and resolves issues prior to the telemedicine appointment. Additionally, our physicians are trained how to troubleshoot common technological problems. While it is easy to build a one-size-fits-most approach in telemedicine, a thoughtful and flexible approach should be taken in reaching those with the greatest challenges in accessing care.”
A few thoughts:
- This is an interesting paper, describing a real-world implementation of telemedicine. It’s important to appreciate the size of the network, which covers 25 outpatient clinics, and geographic area larger than Rhode Island.
- They have been creative. As an example, to better reach the homeless, they opened telemedicine hubs in shelters. (!)
- The focus is on telemedicine – but the lessons seem relevant to our neck of the woods, telepsychiatry.
- HBR isn’t a scientific publication, and basic data is missing, including for outcomes and satisfaction.
- As we weigh our post-pandemic feature, the three core ideas forwarded seem highly relevant and practical.
- The authors emphasize the technology gap, which is a fair point. Some 28 million North Americans lack access to reliable broadband. But there is also a knowledge gap. Some patients may have the necessary equipment, but lack an understanding of how to use it.
The full paper can be found here:
Selection 3: “My uncle often went missing. I worried about the day he wouldn’t come back”
The Globe and Mail, 8 October 2021
When I was 12, my uncle spontaneously decided to whisk me and my twin brother away to Florida for our birthday. The plan was to surprise my grandparents, who wintered there, and then continue to Disney World. It’s difficult to underscore how big of a deal this was. We weren’t the kind of people who could readily afford a trip to Disney World and the promise of three days alone with my young, hip and single uncle opened something inside me: a window to freedom.
As a bookish kid in a non-bookish family, I stood out painfully. But my uncle, he got me. We could talk about books, about current events, even about religion. He was an Orthodox Jew but also the child of Holocaust survivors, and it was clear even to my young eyes that he struggled with the logic of how God permitted such evil in the world.
He was funny and magnetic, bordering on mercurial. In hindsight, he likely suffered from a major, undiagnosed mental-health issue as well as addiction issues, but my younger self didn’t understand that.
So begins an essay by Eichler.
She notes the problems of her uncle. “As long as I can remember, I worried about the day he would never come back. Did he sleep on the street; did he stay with friends; did he leave the country? No one ever knew. In my heart, I knew one day it would be my job to look for him, when no one else did. He didn’t live long enough for me to try.”
The author discusses missing persons, noting how some capture much media attention. “My mind wanders back to him whenever a missing person lands on the news agenda, as it has with Gabby Petito over the past few weeks. While the obvious similarities between a slain celebrity Instagrammer and my uncle, who likely never owned a cellphone and died of disease and neglect, remain few and far between, it’s that feeling of missing that pokes at a sore spot in my chest.”
The essay goes on to speak about her uncle and the loss. “Many people, my uncle included, often go missing of their own volition – not uncommon with those engaging in maladaptive behaviours. He’d reappear as if neither of us skipped a beat. Perhaps I was too young to ask him directly, or too worried about his response, but the lesson learned was that we cannot hang on to anyone.”
The essay concludes by circling back to her Florida trip. Eager to get to Disney World, she discovers the next morning that her uncle has, again, disappeared.
A couple of thoughts:
- This is a beautifully written essay.
- The story is haunting. “In my heart, I knew one day it would be my job to look for him, when no one else did. He didn’t live long enough for me to try.”
The full Globe and Mail essay can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.