Observation: About a month prior to this publication, I chaired a meeting of the Arkansas state employee formulary committee and we reviewed the use of agents for the treatment of type 2 diabetes. Our discussions essentially mirrored the content of this JAMA commentary. It was the unanimous opinion of the committee that metformin represented the best first-line agent for managing diabetes and that, other than for medical contraindications, all other agents should be added to metformin rather than substitute for the medication. Our committee more or less implemented the message of the commentary in our formulary management program. From a cost-effectiveness perspective, the data are compelling.
“I am not your therapist” – A fairly remarkable, yet not surprising article appeared in the New York Times on March 5, “Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy” documenting the economic incentives that have driven psychiatrists away from counseling and focusing almost exclusively on medication management. An older psychiatrist commented, “I had to train myself not to get too interested in their problems.”
Observation: Of course, this raises the question of psychiatry’s value to an internal medicine physician. Recently, I had a long-standing patient with a stable, complex mood disorder ask if I could handle her medication refills. She saw little value in paying for a psychiatric visit when the physician saw her for 10 minutes and had his nurse write a prescription. It was hard to argue with her logic. On a related matter, many observers are concerned that too many children and adolescents are receiving psychotropic medications rather than counseling for their behavioral and mood issues. This New York Times report underscores the deficit in counseling resources in most communities as psychiatry reaches for the prescription pad to sustain practice volume and avoids engagement in patient and family psychodynamics. And it offers more evidence of a health system with distorted incentives and questionable resultant care patterns.