Parity - One Step Closer

We'll pay for liver transplants for alcoholics, expensive inhalers for ex-smokers with emphysema, but we don't pay for the treatment of addiction and mental health. THANK YOU House of Representatives for getting us one step closer to providing equal treatment and reimbursement for these conditions. And THANK YOU Paul Wellstone - today, you are my hero... Peace, Linda

Translated: If the Senate and House can compromise, then insurers will HAVE to pay for mental health and addictions treatment. Just like they do the 'real' stuff like diabetes, heart disease, hip fractures, and all that jazz...

The Ten Commandments of Services Research

Taking a cue from my friend Sarah Moffett, a lawyer who follows a similar credo...

I. I am the Lord thy God. My name is Validity — Internal and External. Worship both. Thou shall not have any gods before Me. Much of science tends to be preoccupied with internal validity, the strength of the claim that the experimental manipulation causes the outcome. This leads to the desire to control all potentially confounding variables but may reduce external validity. External validity, or the extent to which the study findings generalize to the world beyond the research project, is very important in services research.

II. Do not worship idols. Although you must have comparison conditions, they need not be exact images. Remember that you worship Internal Validity not Perfection. In medication trials we are used to seeing "placebo," which resembles the experimental condition to the fullest extent possible. In services research, although it is important to have control conditions, it is often not possible or desirable for the comparison condition to be a twin of the experimental condition.

III. Do not take the name of "effectiveness" in vain. Remember that you worship External Validity. Many researchers think that they are doing an effectiveness study if they measure outcomes beyond symptoms. That is not what effectiveness means. Effectiveness refers to the impact of a program in the real world, beyond the tightly controlled world of clinical trials.

IV. Remember the Sabbath day and keep it holy. Research assessments should not be scheduled on important religious holidays and on anyone's Sabbath. Services researchers should pay close attention to issues of culture.

V. Honor thy fathers and mothers — and grandparents, foster parents, and families of choice. Services researchers should pay close attention to issues of culture.

VI. Do not murder your data analysis section - or your biostatistician. The quasi-experimental and group cluster designs of services research require complex statistics. The statistician should be a part of the study from the very beginning.

VII. Be faithful to intervention design, and use measures of program fidelity at all times. Given the complexity of many services research studies, which often test psychosocial and organizational interventions, it is essential that strategies are used to ensure that the interventions being tested are true to their descriptions.

VIII. Although thou shalt not steal, thou shalt borrow frequently. To the extent that services research often involves working in unique cultural and system contexts and adapting standard approaches, it is tempting for investigators to assume that they have to reinvent the wheel. It is important for services researchers to borrow heavily from the work of others.

IX. Sins of omission can get you into as much trouble as lying. Don't stick with the psychiatry literature. Remember sociology, anthropology, psychology, economics, marketing, education, political science... Services research draws heavily from a broad range of disciplines for conceptual models and approaches.

X. Do not covet the grants of your psychopharmacology clinical trials friends.

Lisa B. Dixon, M.D., M.P.H.
Dr. Dixon is affiliated with the Veterans Affairs Capitol Health Care Network and with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore.

Originally appeared in Psychiatric Services (December 2007)

Who Are You? Who, who? (And why being conservative might keep you sane(r))

The theme song for CSI is blaring in my darkened living room as I pull this post together. Yes, of course I multi-task. Left brain/right brain – right? The refrain keeps pounding in my head, over and over, such a catchy little mantra. In fact, the tune’s been kicking around my grey matter for the past few days, ever since meeting with my newly-reconvened ‘real’ writing group (as opposed to my ‘virtual’ ones). So last Thursday, I found myself in the middle of a small room, quaking in me wee boots as I read aloud one of my newly-crafted poems. As I finished the third stanza of my first-ever metered, rhyming poem (a rondeau redouble, no less!), the song flashes through my head: Who the heck am I?


It occurs to me I am a forty-something years young woman, mother to two young ‘uns, happily-married wife, and professor with crows feet marching proudly across my upper cheeks. But I didn’t write these verses I'm tripping over. Rather, Ben, the brilliant but bipolar 20 year-old protagonist of my completed (!!!!!) novel BRIGHTER THAN BRIGHT, penned these words. And of course these poems preface sections of the book and, because Ben is a genius (and I am not), they best be damn good poems if they’re ever going to be published. So as I bare my and Ben's souls to my fellow writers, some of who actually deserve the title ‘poet’, half-way through my rather serious poem about child abuse and false paternity, I burst out laughing at the absurdity of it all.

It’s enough to make me crazy. Or at least qualify me for a diagnosis of disordered personalities…

To write about people who only exist in your head means you need to get down into their souls. You live them, breathe them, become them. There were times last year when I would jolt awake in the dark, convinced I was in a psychiatric hospital. Because that's where Ben was at that particular juncture of the story. And when he was shot in the left shoulder, well…. I couldn’t sleep on that side for weeks. It hurt too much.

So now, I am taking a poetry class in character as Ben. My instructor’s great, very tolerant of my eccentricities, and my classmates ask appropriate and probing questions about my life as a young, mentally-ill Harvard undergrad who runs marathons (ha!) and comes from a family of considerable means (double ha!). I’ve learned a lot about writing poems - and being a writer in drag.

Here’s the first stanza of my rondeau redouble…

Newton’s Principia
(Or a Young Boy’s Lesson on Gravity)

He runs free beneath God’s sky-blue brilliance.
On cider-tinged air, quills quiver and twist.
Crimson stains white, the world roars its silence;
bodies of mass fall, clenched into tight fists.

------

Want better mental health? Go conservative! According to a recent Gallup Poll, Republicans are significantly more likely than Democrats or Independents to rate their mental health as excellent. Fifty-eight percent of Republicans report excellent mental health, compared to 43% of Independents and 38% of Democrats. These distinctions held up after controlling for age, sex, race/ethnicity, education, income, church attendance, marital status, having children, and presidential job approval. What we don’t know is what comes first – the healthy head or the conservative bent.

Thus, in addition to talk therapy and chemistry, there are at least two other ways to attain a healthier and happier mental life: eating dirt and voting Republican. Hmmmm…. Which of the two is most palatable? Peace, Linda

The Mind - Au Naturale

For decades, psychiatrists, surgeons, family physicians, and quacks have resorted to a myriad of methods to still the sadness and quell the voices echoing in our heads. Lobotomies, insulin treatment, electroconvulsive (shock) therapy were once standards of care for mental illness, along with all sorts of medicaments and solutions. Now, we're more humane – we manage most of our mental ailments by ingesting pills. And what a variety: olanzapine, lamotrigine, sertraline, paroxetine, quetiapine, aripiprazole, ziprasidone, duloxetine, venlafaxine. The syllables drip off my tongue, almost a lilting poem.

But folks who have the blues or other mental and emotional maladies are starting to tell their prescribing psychiatrists and family docs: no thanks. Why? The growing evidence that some medications are as effective as placebo, their prohibitive expense and increasing hassles imposed by insurers, and side effects that sometimes seem worse than the disease: weight gain, diabetes, lack of libido, and changes in cognitive and emotional capacities. And, of course, some people just don’t want anything screwing with their head.

Which I find fascinating. Why wouldn’t someone in the throes of severe emotional distress not gobble a small, white sphere to feel better? to become functional? To return to ‘normal’?

This dilemma underlies both my research and my fiction. During the day, I ponder how to improve patient ‘adherence’ to antidepressants and antipsychotics. My hypothesis: take your meds, and you'll experience improved clinical outcomes and save money. Crass, perhaps, but these are endpoints I can measure by crunching very large datasets comprised of millions of medical and pharmacy claims using fancy statistics and large hard-drives.

But the numbers only go so far: Why don’t people take their meds? Why do they resist medically-accepted treatments? Why aren’t people adherent to experts' proscriptions?

A pivotal section of BRIGHTER THAN BRIGHT finds Ben, my protagonist, wallowing in a mixed manic-depressive state and grappling with the decision of whether to take an antipsychotic. After days of fear and indecision, he succumbs and experiences a miracle - the reinstatement of his mind…

I waken and hear the whir of highway traffic and, more distant, the lonesome wail of a train. The night workers rustle, talk softly, prepare for the next group of caretakers. Someone moans from another room. These are the only sounds; my mind is quiet; there is no noise, no morbid, florid thoughts, no whooshing or thrumming or humming, no lingering nightmares or images or memories. Normal? Is this what normal feels like? I don’t remember.

There are many ways to attain and maintain mental health. Whatever it takes - pills, gamma rays, sun, running, talk therapy, magnets applied to your temples, Emotional Freedom Techniques, or hey, dirt - stay healthy and happy. Peace, Linda

*****
For an excellent article on the pitfalls and pros of medications – and their 'natural' alternatives - turn to The Unmedicated Mind http://online.wsj.com/article/SB118428285736265304.html?mod=googlenews_wsj