Reading of the Week: Psychiatric Care in 21 Countries – The JAMA Psych Study; Also, Industry Payments to Psychiatrists and Batterman on Relating

From the Editor

Our patients often struggle to access care. But what is the global experience? What percentage of patients in other countries receive care that meets basic standards?

In the first selection, Dr. Daniel V. Vigo (of the University of British Columbia) and his co-authors attempt to answer these questions in a new paper for JAMA Psychiatry. They analyzed effective treatment and its key components for nine mental disorders drawing on the World Mental Health surveys which included structured interviews. Vigo et al. cover familiar ground, but the study stands out due to its unusually robust dataset which includes almost 57 000 people in 21 countries. “The proportion of 12-month person-disorders receiving effective treatment was 6.9%.” We consider the paper and its implications.

In the second selection, Dr. John L. Havlik (of Stanford University) and his co-authors weigh in on industry payment to US psychiatrists. In this Psychiatric Services paper, they analyzed six years of data covering nearly 60 000 physicians, drawing on government databases, finding: “a small number of psychiatrists (<600 psychiatrists per year) received approximately 75% of industry’s compensation to psychiatrists each year.”

And, in the third selection, medical student Alexander I. Batterman (of Rowan University) writes about a patient encounter for Academic Psychiatry. He notes the challenges of connecting with a patient who has psychosis and is dismissive. Batterman persists – and understands. “As a former epilepsy patient who is intimately aware of what it is like to be questioned and observed by clinicians and students in the emergency department, as if I were an animal at the zoo on display, I could relate to the human experience of being judged.”

DG

Selection 1: “Effective Treatment for Mental and Substance Use Disorders in 21 Countries”

Daniel V. Vigo, Dan J. Stein, Meredith G. Harris, et al.

JAMA Psychiatry, 5 February 2025  Online

Mental and substance use disorders are among the most disabling and costly noncommunicable disorders, but cost-effective interventions are underused. Increased awareness of mental disorders post–COVID-19 presents an opportunity for increasing investment in treatments, but policymakers need reassurance that population-level impacts of treatment scale-up can be measured. Previous efforts have estimated contact coverage and disorder-specific effective treatment coverage for some disorders. In the health systems literature, coverage cascade refers to the proportion of people in need that receive different levels of service, such as contact coverage (ie, any contact with services); minimally adequate treatment coverage (ie, meeting a minimum threshold); and effective treatment coverage (ie, meeting quality standards of proven effectiveness). To our knowledge, no prior study has attempted to comprehensively investigate these key components of the coverage cascade for mental disorders.

So begins a paper by Vigo et al.

• They conducted a cross-sectional study drawing on World Mental Health (WMH) surveys which were “administered to representative adult (aged 18 years and older) household samples in 21 countries.” 
• Data was collected between 2001 and 2019 and included high-, middle-, and low-income countries (e.g., Brazil, Bulgaria, Colombia, Lebanon, Mexico, Nigeria, Peru, and Romania).
• They assessed the twelve-month prevalence and treatment of nine DSM-IV anxiety, mood, and substance use disorders. To do this, respondents participated in the Composite International Diagnostic Interview. (!)
• They assessed perceived need, treatment contact, and effective treatment.
• Statistical analyses were done, including multilevel regression models to examine predictors.
• The main outcome: the proportion of effective treatment received.

Here’s what they found:

• There were 56 927 respondents (an average response rate of 69.3%).
• Demographics. 57.7% were female and the median age was 43 years.
• Prevalence. The pooled 12-month prevalence of any disorder across surveys was 13.8%. The most common: anxiety disorders (9.3%), mood (5.4%), and substance use disorders (2.3%).
• Effective treatment. “The proportion of 12-month person-disorders receiving effective treatment was 6.9%.” There was substantial variation across disorders: from 1.4% for alcohol use disorder to 12.0% for generalized anxiety disorder.
• Individual level predictors of effective treatment. Effective treatment was significantly more common among women, individuals aged 30 to 59 years, and respondents with higher education.
• Country level predictors of effective treatment. Effective treatment was more associated with general medical treatment resources than mental health treatment resources.

A few thoughts:

1. This is a good study with a robust dataset published in a solid journal.

2. The main finding in a sentence: mental disorders were common but effective treatment was not.

3. This summary doesn’t quite capture the nuance and detail of the study.

4. Just 6.9% received effective care. Wow.

5. Why was that? The authors looked at demographic factors. There was a clear gender gap: “Women were 50% more likely to receive effective treatment despite men having more than twice the substance use disorders prevalence and suicide death rate than women.” (!)

6. They also analyzed barriers to access. “The largest barriers to effective treatment were (1) low perceived need, a key driver of receiving treatment that characterized fewer than half (46.5%) of person-disorders… (2) low treatment contact given perceived need, which characterized roughly one-third of person-disorders (34.1%)… and (3) effective treatment given minimally adequate treatment, which characterized fewer than half (47.0%)…” Of these three, low perceived need was the biggest barrier – suggesting that stigma and self-stigma may be more problematic in many countries than care availability.

7. What are the policy implications? The authors see several, including a need to build up capacity among primary care providers (which would help the low treatment contact).

8. Like all studies, there are limitations, including that the survey data drew from only 21 countries.

The full JAMA Psych paper can be found here:

https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2829593

Selection 2: “National Trends in and Concentration of Industry Payments to U.S. Psychiatrists, 2015–2021”

John L. Havlik, Lydia Ososanya, Deanna Tang, et al.

Psychiatric Services, January 2025

Pharmaceutical companies and medical device manufacturers make billions of dollars of payments to physicians annually in the United States. Some of these payments are made to promote research collaboration and provide opportunities for continuing medical education; many are made to promote industry products. Because of the potential conflicts of interest inherent in industry payments to physicians, in 2010, the U.S. Congress passed the Physician Payments Sunshine Act as part of the Affordable Care Act to make information on these payments available to the public. This act created the Open Payments Database (OPD), requiring for the first time that payments to physicians from medical device or pharmaceutical companies be publicly reported. Associations between industry payments and the prescribing behaviors of physicians are now well established. Although previous studies have characterized long-term trends in industry payments in other specialties, only a 2-year analysis exists for psychiatry. Moreover, it remains unclear whether the pharmaceutical and medical device industries distribute a relatively small amount of money evenly across psychiatrists or whether large payments are highly concentrated in the hands of a select few.

So begins a paper by Havlik et al.

• They conducted a cross-sectional study to understand the extent and concentration of non-research industry payments to US psychiatrists.
• They cross-referenced records in a US government database (CMS National Plan and Provider Enumeration System) with the Open Payments Database of general (non-research) industry payments to clinicians, “comprising travel fees, consulting fees, meals, gifts, and other payments unrelated to research.” 
• The data was from 2015 to 2021.
• They did different analyses, including assessing the number and proportion of psychiatrists receiving industry payments and calculating the median and interquartile range (IQR) of payments per psychiatrist each year.

Here’s what they found:

• There were 56 955 psychiatrists in the sample.
• Any payment. 75.0% received at least one payment between 2015 and 2021, though payments declined with time. The median psychiatrist received $0 from industry each year.
• Total payment. Industry payments to psychiatrists in 2015–2021 totaled $357 971 774.
• Types of payment. “Food and beverages accounted for the largest number of payments made to psychiatrists (86.9%), followed by gifts (6.0%) and consulting compensation (5.4%)…”
• Concentration. 1% of psychiatrists received 74.7% of industry payments. (!!)
• Geography. “Psychiatrists among the top 1% in the amount of industry payments received were significantly more likely to be licensed in Florida (1.98 times as likely), Ohio (2.02 times), Oklahoma (2.36 times), or Texas (1.50 times) than to be licensed anywhere else in the nation…”

A few thoughts:

1. This is a good study with interesting data, shedding light on an important issue.

2. The main findings: many psychiatrists received some payment but only a small number received the vast majority of industry compensation.

3. They comment on the profound concentration of payments on the few: “A common excuse for taking payments from industry may be that ‘everyone is doing it,’ yet, in reality, just a few hundred psychiatrists per year receive substantial (>$10,000) industry payments.”

4. The authors compared psychiatrist compensation to other specialties. In 2019, the median cardiologist received $725; the median dermatologist, $414; the median psychiatrist, $166. 

5. It’s excellent that the United States has regulations allowing such transparency; as a Canadian, I’m envious.

6. Like all studies, there are limitations. The authors note several, including that the pandemic years may have affected the results, since physicians traveled to fewer conferences and thus received fewer payments for food and speaking.

7. For the record, the Reading of the Week receives no support from industry.

The full Psych Services paper can be found here:

https://psychiatryonline.org/doi/10.1176/appi.ps.20240218

Selection 3: “When the Tide Recedes”

Alexander I. Batterman

Academic Psychiatry, 7 January 2025  Online First

It was getting late. I noticed the winter sun sink towards the trees and felt the caffeinated tide keeping me afloat drain out of my body. Little did I know how this final encounter would leave a lasting impact that would be remembered deep into my career. I was told she had a history of schizophrenia and HIV and presented with ‘psychosis.’ My heart pounded as my hands nervously pulled out the sterile curtain dividing the patient from the hallway. The patient lay in a recliner, her body twisted uncomfortably and locked in place as if stuck in quicksand. Her icy eyes bore into mine. I knew the first words uttered would likely dictate the success of the conversation. I have found that the best dialogue is free flowing and evolving – driven by human ears, eyes, and hands. Perfectly rehearsed, overly rigid, and intentional words do not hit the same way. I took a deep breath and remembered to speak to her as though she were one of my parents. I introduced myself and acknowledged that she had been waiting for a while.

So begins a paper by Batterman.

The interview is challenging. The patient explains: “I do not need you people… You people will never understand me.” Though Betterman tries to reassure her, she is dismissive, arguing that “good medical care is only for privileged people.” He pushes on. “I let her molten waves of anger greet me. I rode with them, knowing it was not personal. We locked eyes.”

But slowly, they connect. “The levy holding back her bottled-up thoughts had firmly cracked. She expressed disgust at being unsheltered and possibly perceived as lazy. She immigrated to this country from Africa and has always worked hard, including at a college she attended. She then discussed being a research patient for a doctor who diagnosed her with ‘AIDS mania,’ but questioned her diagnoses and alluded to the doctors having had devious motives. She opened up about her spirituality and how it is misinterpreted as hallucinations.”

He decides to discuss his own healthcare experiences. “I went on to recount my own experiences as a patient, as a human like her. This included feeling as though I was waiting forever to be seen in the emergency department. I reassured her that she was a priority to us and that the emergency department was simply busy that day.”

It works. “I could sense her gaze soften when her eyes opened, and the icy tides receding. I went to a cabinet, pulled out a bagged lunch that included chips and apple juice. I returned and handed her the items. This physical exchange was strangely therapeutic, direct evidence that I was listening – from my hands to hers.”

His preceptor is unable to connect with her. “After discussing the patient with my preceptor, it was time to visit her again. The physician tried to start a dialogue; however, it quickly became apparent that the icy tides had somehow returned, burying the beauty previously uncovered.”

He comments on the process:

“The patient interview is much like a painting. Both the patient and clinician continually add to the patient’s canvas, with the clinician using eyes and ears to sense how the patient is painting their picture, adjusting strokes and colors as needed. More importantly, who the artist is matters – our soul responds better knowing there is an understanding soul on the other side as opposed to a ‘perfectly calibrated’ algorithm.”

A few thoughts:

1. This is a well-written essay.

2. Connecting with patients can be challenging. Remember: if clinical care were easy, they would have replaced us with an app by now.

3. Batterman discloses his health problems to the patient. It helps. But is that the right decision? Is it overly revealing and open to misinterpretation?

The full Acad Psychiatry paper can be found here: 

https://link.springer.com/article/10.1007/s40596-024-02102-6

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.