LETTERS Letters from readers are welcome. They will be published at the editor’s discretion as space permits and will be subject to editing. They should not exceed 500 words with no more than three authors and five references and should include the writer’s e-mail address. Letters commenting on material published in Psychiatric Services, which will be sent to the authors for possible reply, should be sent to Howard H. Goldman, M.D., Ph.D., Editor, at [email protected]. Letters reporting the results of research should be submitted online for peer review (mc.manuscriptcentral.com/ appi-ps).
Antidepressant Prescribing in Elderly Populations To the Editor: We read with great interest the report by Simon and colleagues (1) in the July issue about the prescribing of antidepressant medications in the absence of an evidence-based indication. The study involved a large cohort of patients from geographically diverse health systems. We agree that examination of all inpatient and outpatient diagnoses over a full year likely provides a more accurate estimate of the true rate of prescribing in the absence of a diagnosis than do studies that evaluate single-encounter data, such as the National Ambulatory Medical Care Survey. The data presented by Simon and colleagues echo some of our work, which has found high rates of antidepressant prescribing to patients with no significant symptoms or a recorded psychiatric diagnosis in older adult populations, even when medical indications for use of such drugs are considered (2,3). We have some minor concerns about the methods used by Simon and colleagues, such as the inclusion of adjustment disorder with depressed mood as a diagnosis and use of psychiatric diagnoses from the inpatient setting. Patients who are diagnosed as having major depressive disorder as medical inpatients may be more appropriately PSYCHIATRIC SERVICES
considered to have an adjustment disorder or demoralization, conditions for which there is minimal evidence to suggest benefit from pharmacotherapy. It would have been informative to know the setting from which the diagnoses were derived and how this varied by age group. Moreover, although it is true that medications such as trazodone, bupropion, and tricyclic antidepressants are often used to treat non–mental health indications, we feel that wholesale exclusion of these medications in the age analyses was unfortunate because of the potential for harm regardless of indication. Nevertheless, applying Simon and colleagues’ most conservative 27% rate to the 10% rate of antidepressant prescription in the U.S. population of nearly 250 million adults indicates that close to seven million adults are prescribed an antidepressant in the absence of an evidence-based indication. The continued growth in antidepressant use coupled with the growth in the geriatric population means that older adults will likely account for an ever larger share of this group and be prescribed a medication with no clear indication but with the potential for negative sequelae. We believe that this is a population health matter of great importance that remains high on our list of concerns regarding treatment quality. Ilse R. Wiechers, M.D., M.P.P. Donovan T. Maust, M.D., M.S. Dr. Wiechers is with the Northeast Program Evaluation Center, Office of Mental Health Operations, U.S. Department of Veterans Affairs, West Haven, Connecticut, and with the Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut. Dr. Maust is with the Department of Psychiatry, University of Michigan, Ann Arbor, and the Center for Clinical Management, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor.
References 1. Simon GE, Stewart C, Beck A, et al: National prevalence of receipt of antidepressant prescriptions by persons without a psychiatric diagnosis. Psychiatric Services 65:944–946, 2014 2. Wiechers IR, Kirwin PD, Rosenheck RA: Increased risk among older veterans of prescribing psychotropic medication in the
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absence of psychiatric diagnoses. American Journal of Geriatric Psychiatry 22:531–539, 2014 3. Maust DT, Mavandadi S, Eakin A, et al: Telephone-based behavioral health assessment for older adults starting a new psychiatric medication. American Journal of Geriatric Psychiatry 19:851–858, 2011
In Reply: We thank Dr. Wiechers and Dr. Maust for their comments. In response, we would emphasize three points. As we discuss in our report, our data reflect providers’ recording of mental health diagnoses during a single year, excluding any diagnoses recorded in a prior year and cases in which a provider recognized a mental health diagnosis without recording it (1). Consequently, our estimate that only 27% of patients who were using newer antidepressants had no mental health diagnosis is an upper bound, and the true proportion is certainly lower. Second, providers’ diagnoses of adjustment disorder versus major depression do not reliably distinguish different levels of depression severity. We agree that antidepressant treatment may be unnecessary or even inappropriate for less severe depression. But our previous research (2,3) indicates that providers’ use of different diagnostic codes is more related to providers’ practice styles than to severity of depressive symptoms. Third, we do not agree that depression diagnoses made in the context of serious general medical illness represent demoralization or some other condition not deserving of treatment. Depression in the context of serious medical illness is not distinct in terms of phenomenology (4) or response to treatment (5). Gregory E. Simon, M.D., M.P.H. References 1. Rost K, Smith R, Matthews DB, et al: The deliberate misdiagnosis of depression in primary care. Archives of Family Medicine 3: 333–337, 1994 2. Simon GE, Ludman EJ, Tutty S, et al: Telephone psychotherapy and telephone care management for primary care patients starting antidepressant treatment: a randomized controlled trial. JAMA 292:935–942, 2004 3. Simon GE, Von Korff M, Rutter CM, et al: Treatment process and outcomes for managed
1285
LETTERS care patients receiving new antidepressant prescriptions from psychiatrists and primary care physicians. Archives of General Psychiatry 58:395–401, 2001 4. Simon G, VonKorff M: Medical comorbidity and validity of DSM-IV depression criteria. Psychological Medicine 36:27–36, 2006 5. Simon G, Von Korff M, Lin E: Clinical and functional outcomes of depression treatment in patients with and without chronic medical illness. Psychological Medicine 35: 271–279, 2005
Assessing Online Dietary Information for People With Schizophrenia To the Editor: Diets high in calories and saturated fat and poor in fiber and fruit contribute to the development of obesity and chronic health conditions among people with schizophrenia (1). Providing information on healthy diets may help these individuals develop more healthful behaviors that may lead to weight maintenance or loss (2). Such information would outline the benefits of and barriers to behavior change and boost an individual’s confidence to eat healthfully. Research shows that individuals with schizophrenia turn to the Internet for health information and that use of online psychoeducational resources has clinical benefits (3). Although online health information for this population is easily accessible, it is of poor quality and written at a high reading level (4). Web sites that offer dietary information for individuals with schizophrenia have not been evaluated. This review examined the theoretical and technical quality and reading level of online dietary information for the purposes of helping people with schizophrenia lose weight. Methods used in a previous study (4) were used to find and evaluate Web sites. The following search terms were used: schizophrenia, diet, weight, obesity, eat, food, and nutrition. Combinations were entered in Google, and the first four pages of links were examined. Web sites were included if they provided information in English on eating behaviors for the purposes of losing weight for people with schizophrenia. Included sites were evaluated by two reviewers (PG and HP) for Web site characteristics (information 1286
source, clicks to reach content, and presence of discussion or comment boards), accuracy (dietary recommendations, such as lowering food and beverage intake and following dietary guidelines), technical quality (JAMA quality standards), and theoretical quality (knowledge dissemination and cognitive and behavioral strategies). Nutritional information was evaluated by using a method devised by Ostry and colleagues (5). Overall, 13 Web sites met inclusion criteria. [A list with links to the main domains of each site is available in an online data supplement.] Most sites were designed by independent sources (N58), such as bloggers. It took an average of four clicks to find the desired content, and nine sites provided discussion or comment boards. No sites recommended that individuals eat a variety of foods from different food groups, and fewer than half (N56) mentioned limiting foods and beverages high in calories. Few recommended choosing lower-fat dairy products (N51) and leaner meats (N52). Seven had high technical quality scores for authorship information, reference use, information currency, notification of disclosures and endorsements, and contact information. Most sites (N512) scored poorly on theoretical quality, indicating a lack of any behavioral theory and knowledge dissemination strategies. The average reading grade as assessed by the FleschKincaid Readability test was 11.9, well above a recommended grade of 6–8. Online dietary information for individuals with schizophrenia needs to be improved because current content is based on poor dietary recommendations, not supported by behavioral theory, and written at a high reading level. There is a need for well-designed Web sites with information based on current evidence of how persons with schizophrenia can limit weight gain, lose weight successfully, and reduce the risk of life-shortening chronic illnesses. Paul Gorczynski, M.A., Ph.D. Hiren Patel, B.Sc., M.Sc. Rohan Ganguli, M.D., F.R.C.P.(C.) The authors are with the Centre for Addiction and Mental Health, Toronto, Ontario, Canada. Mr. Patel is also with the Institute of Medical Science and Dr. Ganguli is also with
PSYCHIATRIC SERVICES
the Department of Psychiatry, both at the University of Toronto, Ontario.
Acknowledgments and disclosures Funding for this study was made available through a postdoctoral fellowship at the Centre for Addiction and Mental Health. The authors report no competing interests.
References 1. Dipasquale S, Pariante CM, Dazzan P, et al: The dietary pattern of patients with schizophrenia: a systematic review. Journal of Psychiatric Research 47:197–207, 2013 2. Strassnig M, Brar JS, Ganguli R: Dietary intake of patients with schizophrenia. Psychiatry 2:31–35, 2005 3. Rotondi AJ, Anderson CM, Haas GL, et al: Web-based psychoeducational intervention for persons with schizophrenia and their supporters: one-year outcomes. Psychiatric Services 61:1099–1105, 2010 4. Gorczynski P, Patel H, Ganguli R: Evaluating the accuracy, quality, and readability of online physical activity, exercise, and sport information for people with schizophrenia. Mental Health and Physical Activity 6:95–99, 2013 5. Ostry A, Young ML, Hughes M: The quality of nutritional information available on popular websites: a content analysis. Health Education Research 23:648–655, 2008
Do Organizations Forming ACOs Have Mental Health Providers? To the Editor: Since passage of the Affordable Care Act, accountable care organizations (ACOs) have received significant attention in the quest to achieve the “triple aim”: better care and better health at reduced cost. As described by Berwick (1), ACOs are “groups of physicians, hospitals, and other health care providers . . . willing to assume responsibility for the care of a clearly defined population.” The Centers for Medicare and Medicaid Services (CMS) assigns a patient to an ACO when its physician members are the primary providers of the patient’s health care and then calculates an annual cost target for the ACO’s population. In the ACO “pioneer model,” for systems with the most experience offering integrated care, organizations are eligible for a larger share of the savings in return for also sharing financial risk (2).
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Antidepressant Prescribing in Elderly Populations To the Editor: We read with great interest the report by Simon and colleagues (1) in the July issue about the prescribing of antidepressant medications in the absence of an evidence-based indication. The study involved a large cohort of patients from geographically diverse health systems. We agree that examination of all inpatient and outpatient diagnoses over a full year likely provides a more accurate estimate of the true rate of prescribing in the absence of a diagnosis than do studies that evaluate single-encounter data, such as the National Ambulatory Medical Care Survey. The data presented by Simon and colleagues echo some of our work, which has found high rates of antidepressant prescribing to patients with no significant symptoms or a recorded psychiatric diagnosis in older adult populations, even when medical indications for use of such drugs are considered (2,3). We have some minor concerns about the methods used by Simon and colleagues, such as the inclusion of adjustment disorder with depressed mood as a diagnosis and use of psychiatric diagnoses from the inpatient setting. Patients who are diagnosed as having major depressive disorder as medical inpatients may be more appropriately PSYCHIATRIC SERVICES
considered to have an adjustment disorder or demoralization, conditions for which there is minimal evidence to suggest benefit from pharmacotherapy. It would have been informative to know the setting from which the diagnoses were derived and how this varied by age group. Moreover, although it is true that medications such as trazodone, bupropion, and tricyclic antidepressants are often used to treat non–mental health indications, we feel that wholesale exclusion of these medications in the age analyses was unfortunate because of the potential for harm regardless of indication. Nevertheless, applying Simon and colleagues’ most conservative 27% rate to the 10% rate of antidepressant prescription in the U.S. population of nearly 250 million adults indicates that close to seven million adults are prescribed an antidepressant in the absence of an evidence-based indication. The continued growth in antidepressant use coupled with the growth in the geriatric population means that older adults will likely account for an ever larger share of this group and be prescribed a medication with no clear indication but with the potential for negative sequelae. We believe that this is a population health matter of great importance that remains high on our list of concerns regarding treatment quality. Ilse R. Wiechers, M.D., M.P.P. Donovan T. Maust, M.D., M.S. Dr. Wiechers is with the Northeast Program Evaluation Center, Office of Mental Health Operations, U.S. Department of Veterans Affairs, West Haven, Connecticut, and with the Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut. Dr. Maust is with the Department of Psychiatry, University of Michigan, Ann Arbor, and the Center for Clinical Management, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor.
References 1. Simon GE, Stewart C, Beck A, et al: National prevalence of receipt of antidepressant prescriptions by persons without a psychiatric diagnosis. Psychiatric Services 65:944–946, 2014 2. Wiechers IR, Kirwin PD, Rosenheck RA: Increased risk among older veterans of prescribing psychotropic medication in the
' ps.psychiatryonline.org ' October 2014 Vol. 65 No. 10
absence of psychiatric diagnoses. American Journal of Geriatric Psychiatry 22:531–539, 2014 3. Maust DT, Mavandadi S, Eakin A, et al: Telephone-based behavioral health assessment for older adults starting a new psychiatric medication. American Journal of Geriatric Psychiatry 19:851–858, 2011
In Reply: We thank Dr. Wiechers and Dr. Maust for their comments. In response, we would emphasize three points. As we discuss in our report, our data reflect providers’ recording of mental health diagnoses during a single year, excluding any diagnoses recorded in a prior year and cases in which a provider recognized a mental health diagnosis without recording it (1). Consequently, our estimate that only 27% of patients who were using newer antidepressants had no mental health diagnosis is an upper bound, and the true proportion is certainly lower. Second, providers’ diagnoses of adjustment disorder versus major depression do not reliably distinguish different levels of depression severity. We agree that antidepressant treatment may be unnecessary or even inappropriate for less severe depression. But our previous research (2,3) indicates that providers’ use of different diagnostic codes is more related to providers’ practice styles than to severity of depressive symptoms. Third, we do not agree that depression diagnoses made in the context of serious general medical illness represent demoralization or some other condition not deserving of treatment. Depression in the context of serious medical illness is not distinct in terms of phenomenology (4) or response to treatment (5). Gregory E. Simon, M.D., M.P.H. References 1. Rost K, Smith R, Matthews DB, et al: The deliberate misdiagnosis of depression in primary care. Archives of Family Medicine 3: 333–337, 1994 2. Simon GE, Ludman EJ, Tutty S, et al: Telephone psychotherapy and telephone care management for primary care patients starting antidepressant treatment: a randomized controlled trial. JAMA 292:935–942, 2004 3. Simon GE, Von Korff M, Rutter CM, et al: Treatment process and outcomes for managed
1285
LETTERS care patients receiving new antidepressant prescriptions from psychiatrists and primary care physicians. Archives of General Psychiatry 58:395–401, 2001 4. Simon G, VonKorff M: Medical comorbidity and validity of DSM-IV depression criteria. Psychological Medicine 36:27–36, 2006 5. Simon G, Von Korff M, Lin E: Clinical and functional outcomes of depression treatment in patients with and without chronic medical illness. Psychological Medicine 35: 271–279, 2005
Assessing Online Dietary Information for People With Schizophrenia To the Editor: Diets high in calories and saturated fat and poor in fiber and fruit contribute to the development of obesity and chronic health conditions among people with schizophrenia (1). Providing information on healthy diets may help these individuals develop more healthful behaviors that may lead to weight maintenance or loss (2). Such information would outline the benefits of and barriers to behavior change and boost an individual’s confidence to eat healthfully. Research shows that individuals with schizophrenia turn to the Internet for health information and that use of online psychoeducational resources has clinical benefits (3). Although online health information for this population is easily accessible, it is of poor quality and written at a high reading level (4). Web sites that offer dietary information for individuals with schizophrenia have not been evaluated. This review examined the theoretical and technical quality and reading level of online dietary information for the purposes of helping people with schizophrenia lose weight. Methods used in a previous study (4) were used to find and evaluate Web sites. The following search terms were used: schizophrenia, diet, weight, obesity, eat, food, and nutrition. Combinations were entered in Google, and the first four pages of links were examined. Web sites were included if they provided information in English on eating behaviors for the purposes of losing weight for people with schizophrenia. Included sites were evaluated by two reviewers (PG and HP) for Web site characteristics (information 1286
source, clicks to reach content, and presence of discussion or comment boards), accuracy (dietary recommendations, such as lowering food and beverage intake and following dietary guidelines), technical quality (JAMA quality standards), and theoretical quality (knowledge dissemination and cognitive and behavioral strategies). Nutritional information was evaluated by using a method devised by Ostry and colleagues (5). Overall, 13 Web sites met inclusion criteria. [A list with links to the main domains of each site is available in an online data supplement.] Most sites were designed by independent sources (N58), such as bloggers. It took an average of four clicks to find the desired content, and nine sites provided discussion or comment boards. No sites recommended that individuals eat a variety of foods from different food groups, and fewer than half (N56) mentioned limiting foods and beverages high in calories. Few recommended choosing lower-fat dairy products (N51) and leaner meats (N52). Seven had high technical quality scores for authorship information, reference use, information currency, notification of disclosures and endorsements, and contact information. Most sites (N512) scored poorly on theoretical quality, indicating a lack of any behavioral theory and knowledge dissemination strategies. The average reading grade as assessed by the FleschKincaid Readability test was 11.9, well above a recommended grade of 6–8. Online dietary information for individuals with schizophrenia needs to be improved because current content is based on poor dietary recommendations, not supported by behavioral theory, and written at a high reading level. There is a need for well-designed Web sites with information based on current evidence of how persons with schizophrenia can limit weight gain, lose weight successfully, and reduce the risk of life-shortening chronic illnesses. Paul Gorczynski, M.A., Ph.D. Hiren Patel, B.Sc., M.Sc. Rohan Ganguli, M.D., F.R.C.P.(C.) The authors are with the Centre for Addiction and Mental Health, Toronto, Ontario, Canada. Mr. Patel is also with the Institute of Medical Science and Dr. Ganguli is also with
PSYCHIATRIC SERVICES
the Department of Psychiatry, both at the University of Toronto, Ontario.
Acknowledgments and disclosures Funding for this study was made available through a postdoctoral fellowship at the Centre for Addiction and Mental Health. The authors report no competing interests.
References 1. Dipasquale S, Pariante CM, Dazzan P, et al: The dietary pattern of patients with schizophrenia: a systematic review. Journal of Psychiatric Research 47:197–207, 2013 2. Strassnig M, Brar JS, Ganguli R: Dietary intake of patients with schizophrenia. Psychiatry 2:31–35, 2005 3. Rotondi AJ, Anderson CM, Haas GL, et al: Web-based psychoeducational intervention for persons with schizophrenia and their supporters: one-year outcomes. Psychiatric Services 61:1099–1105, 2010 4. Gorczynski P, Patel H, Ganguli R: Evaluating the accuracy, quality, and readability of online physical activity, exercise, and sport information for people with schizophrenia. Mental Health and Physical Activity 6:95–99, 2013 5. Ostry A, Young ML, Hughes M: The quality of nutritional information available on popular websites: a content analysis. Health Education Research 23:648–655, 2008
Do Organizations Forming ACOs Have Mental Health Providers? To the Editor: Since passage of the Affordable Care Act, accountable care organizations (ACOs) have received significant attention in the quest to achieve the “triple aim”: better care and better health at reduced cost. As described by Berwick (1), ACOs are “groups of physicians, hospitals, and other health care providers . . . willing to assume responsibility for the care of a clearly defined population.” The Centers for Medicare and Medicaid Services (CMS) assigns a patient to an ACO when its physician members are the primary providers of the patient’s health care and then calculates an annual cost target for the ACO’s population. In the ACO “pioneer model,” for systems with the most experience offering integrated care, organizations are eligible for a larger share of the savings in return for also sharing financial risk (2).
' ps.psychiatryonline.org ' October 2014 Vol. 65 No. 10
