April 1, 2022
By Tom Insel, MD, and Matthew Hirschtritt, MD, MPH
Good morning, Research Roundup readers.
We are tempted to begin with an April Fool’s joke, but if we told you there was full parity in mental health or an increase in recovery, you’d see through the ruse. But it’s no joke to say it’s been an extraordinarily busy week for mental health policy: a Senate Committee on Finance hearing and report on parity, a SAMHSA convening on 988, a GAO report on behavioral health and COVID-19, and a lot of press attention to mental health.
And it’s been a busy week for mental health research as well. We’ve chosen just a few stories, highlighting some of the progress on how we treat psychosis. New evidence supports the treatment of cognitive symptoms with psychological interventions, the economic case for early intervention, and the safety of antipsychotics in pregnancy. All good news. We also wanted you to see the challenge of measuring outcomes in mental health care, with one result being that psychiatrists are less likely than other physicians treating Medicare patients to receive bonuses for performance. As always, let us know what we missed.
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Cognition and Schizophrenia: New Thinking about Thinking
The standard view of schizophrenia includes a person beset by hallucinations, delusions, and maybe bizarre behavior. But people with schizophrenia battle much more than these dramatic symptoms. Over the past two decades, a body of research has focused on the more subtle problems with the way people with schizophrenia think – the so-called cognitive deficits of the disorder. Most scientists today consider these cognitive deficits the greatest source of disability from schizophrenia.
In one paper out this week in Schizophrenia Research, a group of experts led by Philip D. Harvey of the University of Miami discuss new insights into cognitive aspects of the disorder. Noting that cognitive deficits (changes in attention, memory, judgment, and processing speed) precede the other symptoms of the disorder, they suggest that cognition may be an important target for early intervention. They call out the value of cognitive remediation, a behavior-training-based approach that teaches specific cognitive skills and strategies along with psychosocial rehabilitation. While the effects of cognitive remediation are variable and the impact is often small, the American Psychiatric Association Practice Guidelines now recommend this intervention for the treatment of schizophrenia, recognizing that improving cognition is vital for academic success, employment, and other positive outcomes
A second paper from JAMA Psychiatry reviews the results of metacognitive training for people with psychotic illnesses. Metacognitive training is a structured approach that indirectly addresses the delusions of psychosis by questioning cognitive biases, such as jumping to conclusions, belief inflexibility, and overconfidence in judgments. The idea is to raise doubts in delusional beliefs by increasing the patient’s awareness of such biases while avoiding a direct confrontation over irrational thinking. This is truly more like a training program than therapy, with specific modules and homework that focus on discrete skills.
Since its original development 15 years ago, metacognitive training has been the focus of many studies. In a new meta-analysis of 40 studies with 1816 participants, Martin LePage of McGill University and colleagues examine the impact of the training on both symptoms such as delusions and hallucinations and long-term outcomes such as self-esteem and overall functioning.
Overall, the effects were significant but small to moderate in size. The reduction in delusions and hallucinations were especially notable, while the improvements in self-esteem and functioning were weaker. While these effects were not large, the overall improvements were sustained one year after training.
Psychological treatment for people with psychosis, whether it’s framed as cognitive remediation, meta-cognitive training or more traditional cognitive-behavioral therapy, is becoming an important part of recommended care. The effectiveness of these psychological treatments will likely depend on their careful combination with medical interventions and rehabilitative services that ensure appropriate housing, job and academic support, social support, and case management. Taken together in the context of a strong therapeutic alliance, these treatments can make the difference between recovery and disability.
Cognitive dysfunction in schizophrenia: An expert group paper on the current state of the art. Schizophrenia Research: Cognition. March 22, 2022
– Tom Insel
Antipsychotics in Pregnancy
Are antipsychotic medications safe for pregnant women? There are reasons for concern: Antipsychotic drugs cross the placenta, they have lasting neurologic and behavioral effects in the offspring of pregnant rodents, and children of mothers treated with these drugs have been reported to show transient delays in motor development. Yet recent cohort studies from Hong Kong and five Nordic countries found no association between antipsychotic exposure at any time point during pregnancy and the risk of autism spectrum disorder (ASD) or attention deficit hyperactivity disorder (ADHD).
New data from large national databases with 14 years of follow-up provide another source of reassurance. Loreen Straub from Brigham and Women’s Hospital and colleagues reviewed birth cohorts of 3.4 million children, including 10,000 born to women exposed to at least one antipsychotic during the second half of pregnancy. In the subsequent 14 years, neurodevelopmental disorders were indeed more common in the offspring of women who had received antipsychotics during pregnancy. But this increase was no longer significant after adjustment for confounding variables such as maternal diagnosis, lifestyle factors, and maternal conditions which independently increase the likelihood of neurodevelopmental disorders.
Remarkably, the lack of association between drug exposure and offspring outcome held across drugs, across exposure windows, and across both public and privately insured populations. The one possible exception was exposure to aripiprazole, which appeared to slightly increase risk to children even after correction for these other variables.
As the authors note, “The benefits of antipsychotic treatment for pregnant women with severe mental illness are undisputed.” Their use during pregnancy has doubled over the past two decades, but safety has continued to be a question for parents and providers. From the available data, we can now say that with the possible exception of aripiprazole, this class of medications does not appear to increase the risk of the neurodevelopmental disorders, including autism or ADHD, in the offspring.
Association of Antipsychotic Drug Exposure in Pregnancy With Risk of Neurodevelopmental Disorders: A National Birth Cohort Study. JAMA Intern Med. March 28, 2022
– Tom Insel
Using the Right Metrics to Measure Psychiatrist Performance
Would you judge a psychiatrist based on how consistently she screened her patients for breast cancer?
That may seem an oddball question, but Medicare is applying metrics like that to all doctors—including psychiatrists—who are participating in the new Merit-Based Incentive Payment System (MIPS), part of the Quality Payment Program. This new program seeks to improve the quality of care by paying a bonus to physicians who complete certain procedures. Almost all outpatient clinicians who treat Medicare patients are currently mandated to enroll in the value-based MIPS, and a portion of their compensation (9% in 2022) is tied to their MIPS scores.
Among the 210 individual MIPS measures, doctors must report on at least six items. But there are few measures that are specifically relevant to psychiatric practice. For instance, psychiatrists aren’t expected to control their patients’ high blood pressure or diabetes, though those are commonly chosen MIPS measures. Perhaps even more importantly, there is no clear consensus on what metrics should even be used to assess mental health practice in the first place. So how does this new bonus system work for psychiatrists?
Andrew Qi of Washington University and colleagues dug into Center for Medicare and Medicaid (CMS) data to figure out how well MIPS measured psychiatrists’ performance. Using data from nearly 600,000 outpatient doctors (over 9,000 of them psychiatrists) in the 2020 MIPS, the researchers compared performance scores and value-based reimbursement for psychiatrists versus all other doctors.
On average, psychiatrists “had significantly lower performance scores,” the researchers noted. Their adjusted performance scores were about 7%, lower than all other doctors (84.0 vs 89.7), and psychiatrists were more than twice as likely to receive a penalty based on their MIPS performance (6.1% vs 2.9%). Psychiatrists were about 4% less likely to get a positive payment adjustment (92.6% vs 96.3%) and about 7% less likely to get a bonus payment adjustment (82.0% vs 88.7%). In fact, psychiatrists performed worse than all other doctors combined on all the MIPS domains.
A close look at the most commonly reported Merit-Based Incentive Payment System measures in 2020 helps explain these disparities. For instance, checking whether older patients had received a pneumonia vaccination, screening for colorectal cancer, and counseling for weight management were all popular metrics. But these are not likely to happen in the course of a psychiatric visit.
So why are psychiatrists being scored on measures that are not relevant for their scope of practice? It comes down to having few relevant options from which to choose. Psychiatry as a field has not defined the measures that matter. The solution to this problem won’t be simple, but it needs to draw from research and expert consensus on what’s worth measuring in psychiatric practice—and how to quantify it.
Comparison of Performance of Psychiatrists vs Other Outpatient Physicians in the 2020 US Medicare Merit-Based Incentive Payment System. JAMA Health Forum, March 25, 2022.
– Matthew Hirschtritt
The Dollars and Sense of Treating Psychosis Early
The first symptoms of schizophrenia and other psychiatric disorders usually show up in adolescence or early adulthood. But those symptoms – such as paranoia or disorganized behavior – may never develop into a psychiatric disorder. Identifying early symptoms of psychosis and providing treatment can substantially improve the course of the illness. And while the strongest predictor of good outcomes for so-called first-episode (or early) psychosis is a shorter duration of untreated psychosis, the median time between a patient in the US experiencing psychotic symptoms and getting appropriate treatment is an eye-popping 74 weeks.
Early intervention programs are designed specifically to reduce this duration of untreated psychosis. Ultimately, the goal is to prevent development of a full-blown psychotic disorder when possible or improve outcomes among those who already have a disorder. But there’s a catch: Early psychosis intervention programs carry a hefty price tag. In 2018 dollars, the typical cost of this type of program hovers somewhere around $13,000 to $17,000.
Jean-Eric Tarride of McMaster University and colleagues crunched Canadian data to figure out whether there’s a business case for widespread use of early psychosis intervention programs. The researchers simulated the five-year costs of intervention – including the price tag of the program itself and hospitalizations. They also looked at the benefits of the program, including increased productivity and reduced hospitalization of the patient after the intervention.
Compared with usual treatment for psychosis, early intervention programs carried a per-patient, annual additional cost of about CAN$11,000 (about $8,000 US dollars in 2019). But the benefits – including increased productivity, reduced hospitalizations, and reduced mortality – amounted to about CAN$96,000 (about $71,000 US dollars). The researchers therefore estimated that the “net benefit” (benefits minus costs) of early psychosis interventions was about CAN$85,000 (about $62,900 US dollars).
In this Canadian sample, the potential benefits of early intervention programs win out over the associated costs. Similar research on early interventions in the US has come to a similar conclusion, estimating 3.2 fewer hospitalizations and 2.7 more years of employment over the course of a lifetime, compared with usual treatment. Moreover, the US likely has even more than Canada on the cost side of the equation because of the higher risk of incarceration and lengthy emergency department stays for people with psychosis. If anything, the study by Terride and colleagues might underestimate the true benefits of this type of program in the US.
Economic Evaluation of Early Psychosis Interventions From A Canadian Perspective. Canadian Journal of Psychiatry, March 21, 2022.
– Matthew Hirschtritt
If you or anyone you know is considering suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255. And if you’re a veteran, press 1.
Tom Insel, MD, is a psychiatrist, neuroscientist, and former director of the National Institute of Mental Health (NIMH). He is a donor to MindSite News and chair of its Editorial Advisory Board. Dr. Insel’s financial conflict of interest statement, which includes equity and advisory roles in several early-stage mental health technology companies, can be found here.
Matthew Hirschtritt, MD, MPH, is a clinical psychiatrist with the Permanente Medical Group, Inc., a mental health services researcher with the Division of Research, Kaiser Permanente Northern California, and assistant program director of the Kaiser Permanente Oakland Adult Psychiatry Training Program. His current research focuses on identification and treatment of patients with first-episode psychosis, as well as implementation of a telehealth-based mental health evaluation and referral program.