Mental Health's Double Standard

Depression is a scourge, widely considered the second greatest cause of health disability worldwide. It has always been tough to treat. New studies show it having a worse course the older we get. Yet new governmental regulations are making the possibility of adequately treating depression in older folk so onerous that fewer doctors may attempt it.

Aging and Depression

A new study from the Netherlands, published in Lancet Psychiatry, looked at what happens to depression course and treatment as people get older. Surveying a thousand patients, male and female (66%) aged 18-88, they examined four factors relating depression with aging:

1. Were patients still diagnosed with depression after two years?

2. Was the symptom course more prolonged and difficult?

3. Did it take longer to get better?

4. Was the change in severity worse?

The answer was yes for all four. The older you were, the worse the outcome.

How come? The authors wrote that though older age was a “consistent and important risk factor” for poorer results, this “could not be explained by a range of well established risk factors.”

Why Depression Is Worse With Age

It does not take much imagination to see why depression would get worse with age. Some of the factors that make depression more difficult to treat as we grow older include:

1. More illness and disease of all stripes.

2. Greater social isolation and loneliness. As you grow older, friends and relatives move away. Some get sick. Others die. Making friends at age 80 is different than at 20.

3. Lesser financial resources. Pensioners are less likely to have employment prospects.

4. Decreasing resilience. It’s not pleasant to contemplate, but overall capacity to adapt is not the same at 80 as at 20. Wisdom may become enhanced but aging changes the body’s ability to remake and renew itself. That includes all parts, brain and bone, heart and lung.

Depressive symptoms are often physical. Depressed patients also experience more physical ailments. Medical workups and treatment are expensive. Treating depression early and effectively save bucketloads of money. Studies done by Emily Mumford and others going back to the 1980s demonstrated treating depression in the older cut medical costs significantly.

For a long time researchers have recognized that a combination of pharmacology and psychotherapy is the best bet for treating depression, to which can be added light therapy, physical activity, and social engagement.

So why is Medicare trying to make treatment of depression by American practitioners so difficult?

Targeted Probe

The psychiatrists who still see Medicare patients recently discovered they were part of a new third-party auditing program that declared that at least a quarter of their treatments were in “medical error,” three times that of non-psychiatric colleagues.

The infractions? Medical necessity? No, no cases were said to be unnecessarily treated. Was it upcoding? That was 6%, far less than other non-psychiatric services.

The reason? For 92% it was "failure of documentation." A prime example that brings on a Federal “targeted probe”—not putting the exact start and stop times of treatment.

Do you see your internist starting and stopping a stop watch every time she sees you, and immediately writing down the times?

Other required items that provoke a "targeted probe" include:

1. Required separation of psychiatric/psychotherapy and medical charts. In other words, as far as Medicare is concerned, physicians are simultaneously required to write—on the same human being—two separate charts, audited separately.

Did you know you are simultaneously two different people? For Medicare purposes, you are.

Even though it’s critical to consider all your medical problems and psychiatric conjointly. Even though that’s the standard of care worldwide. Even though that’s supposedly enshrined in the Mental Health Parity Act of 2004.

Doesn't pain affect mood and mood pain? Try to imagine a surgeon having to write two charts following an appendectomy—for the “medical” and “surgical” parts.

Other niceties of the documentation requirements include:

A. Making sure you are willing to be treated and want to be in the office. Does your internist ask you every time you come in you think it worthwhile your diabetes should be treated and that you are entirely willing to accept and personally engage in treatment, and immediately documents that?

B. Showing progress with each visit. This may be difficult with chronic illnesses. Does your internist “cure” your diabetes and COPD each time she sees you?

C. Writing up a treatment plan which defines “observable positive outcomes” that are meant to progress with time. When asked an auditor whether these treatment plans should use established parameters I was told no—make up your own. Just make them up.

D. Establish to the minute how much time was spent in session, including how much of it was psychiatric versus medical. Is talking about pain medical or psychiatric? Should you establish cutoffs by the minute or second? Half minute?

E. Define the exact timing, associations, change with other factors, of all your symptoms. Clearly it’s important to know you’ve been having eight rather than nine migraines per week, and that your migraines began eighteen months and two weeks ago rather than eighteen months ago.

Those are just a few of the requirements—there are lots, lots more. And the third parties who audit are incentivized—they apparently get a percentage of every dime “clawed back.”

What do these auditors declare is the goal of their work? To "reduce provider burden.”

Cue George Orwell.

Bottom Line

Treating depression is difficult. It takes a lot of work. You have to integrate medical and psychiatric problems, medication and psychotherapy, social issues and family difficulties, actionable lifestyle advice. Through yours and your patients' efforts, you might get somewhere.

Meanwhile Medicare wants you to describe and immediately explain everything you do in two separate charts with thoroughly different demands and mindsets - as if you're two different doctors and your patient is two separate people.

When I showed the documentation requirements to foreign practitioners they thought it was a spoof.

Actually the joke’s on us. If research is any guide, not treating psychiatric illnesses in the elderly leads to exploding medical costs.

Welcome to American health care.