There is a SAMHSA [Substance Abuse and Mental Health Services Administration] Report now available for free download on-line [National Expenditures for Mental Health Services and Substance Abuse Treatment, 1986-2009] that is, in my opinion, a must-read for interested parties. That said, I hasten to add that it’s hard, because it’s written for policy wonks, and the graphs and tables are all corrected in unfamiliar ways – so one has to read what the scales are to see things accurately. The upper part of the figure below [my recoloring for clarity] is the relative overall US spending for each of the categories in per cent, regardless of the amount for each year – which has itself been a variable [from page 43]. Those big picture amount numbers are in the report in some mega-tables in the Appendices [page 67+ of the 108 page report] for the hearty. The middle piece of my figure was traced from rescaled graphs I had made of the patent life of the big named psychiatric drugs from various FDA sites [so accuracy is more like the right year but nothing more]. The bottom graph is straight from the report [page 38]. Again, the ordinate scale can be deceptive. It’s the percentage growth. So the fall from 1999 to 2004 doesn’t mean less was spent, rather that spending was plateauing, no longer growing like a weed.
hat tip to Jamzo… 
A commenter recently mentioned she noticed a change in psychiatry [for the worse] around 1994. I said maybe a little earlier, but agreed that it was in the right ball park. Looking at these graphs, it looks as if the guesses were on the money [pun intended]. The bottom graph shows a five fold increase in the rate of spending from 1993 to 2001 and the upper graph shows the resulting three and a half fold increase in the drug share of overall spending. Looking at the last five years on the graph, it looks as if we’ve settled into a new equalibrium – a stability in a new system. From a cost perspective, these numbers will probably even fall as the drugs go generic and cost much less. But that doesn’t fix a thing because from the perspective of our system of delivering care, the damage has been done and is likely to be self perpetuating.
A friend of a friend called yesterday with a very sticky child custody problem. In trying to get the family the help they needed, I called a child advocacy lawyer I know in Atlanta who mercifully agreed to try to help this woman through the thorniest mess I’ve heard in a long time. In talking to the lawyer, I said that if the child needed psychiatric care or evaluation and I could help her find someone suitable, to let me know. I was actually thinking of a psychologist who has spent her career amid the impossible situations that custody cases can be. But my lawyer friend understood my phrase "psychiatric care" as meaning "psychiatrist" and said, "Oh I doubt we’ll need a psychiatrist. They’re for medicines and …" adding "and they’re more expensive." I guess that’s the sad-but-true reputation of psychiatry these days, something that’s hard to add to the graph, but implied.
This is all retrospective data, ending five years ago – now part of history. Like all of history, there were no road signs broadcasting these numbers, their meanings, or their ultimate outcome along the way. But even in my cloistered office, you could just feel it, like you can feel a front passing through before the rainstorm that will soon follow. And there’s one other important thing that’s not on those graphs, something once called transinstitutionalization, moving people from one institution to another – in this case from the mental institutions of the pre-1960s to the prisons of today. In my mind, this is the biggest tragedy in the story, because we have the where·with·all to do a lot better than that. And in this case, I don’t think the blame falls on psychiatry, or pharma, or any of the usual suspects. I blame whatever drives the attitudes in society as a whole, or at least American society, that avoids looking at and caring about the people we can’t "cure," but can damn sure do a better job of taking care of, mostly outside of any institutions, if the funds [and the will] were to be available…
I was in Texas when I was first put on psyche drugs with a diagnosis of bipolar II in 1994. Being indigent due to being disabled at the time, I had no choice but to go through the state MHMR. As a single person with no income, I could be put on any number of psychiatric drugs on or off label, far more easily than I could get a state provided physical from a GP. I don’t think that was possible. The MHMR psychiatrists did not perform physical exams, either.
Thanks for the reference. What you posted so far is the expected blip in pharmaceutical spending due to patents. It is unfortunate that the chart ends at 2009 because several additional patents have expired. I would imagine we are witnessing the same blip in medicine spending at this time due to the new and more expensive replacements for non-warfarin oral anticoagulants and that will get even steeper with the new Hep C treatments. It is always more than a little ironic how you can find “cost effectiveness” studies to justify the cost of any new medication. It really gets cost effective when the patent expires.
The only change I noticed in psychiatry were not driven by the pharmaceutical industry but the managed care industry. The reduction in inpatient care for example is not just a reduction in utilization, but we now have a service line that is essentially worthless because it only assesses and treats “dangerousness” rather than the problems that resulted in the hospitalization.
I think another bias to keep in mind is that SAMHSA is an unabashed supporter of managed care and will probably interpret the data with that bias. But I suppose I will slog through the report at some point.
Federal agencies need to collect raw data and post it in a usable format instead of interpreting it for people.
you’ve got some serious skills for an old man dr mickey.
nice job consolidating the data and using a standardized scale for the plots.
unquestionably this is not only simple, but _correct_.
thanks for going through the report, collecting the relevant data, and then taking the time to illustrate your findings.
I wouldn’t dismiss the possibility that Mickey is as seriously skilled as he is precisely because he’s “an old man” with an active and open mind, many years of experience in the field of psychiatry, and some background in statistical analysis, gagan.
By the same token, I can see why you might think the qualifier is necessary, precisely because you are a young man.
hey man,
the ol adage of “time is the independent variable” kind of went out the window when people started abusing the computer in both medicine and finance (ponzi schemes in the latter needed participants in the former)
I have no idea what you’re talking about, gagan.
gagan sidhu,
I liked your observation.
Time is being conquered by computers, and maybe even the brain someday: http://brainblogger.com/2014/02/05/supercomputer-simulates-1-of-the-brain-whats-next/
But, I will weigh in on the side of humanity when I say, never the mind. A few hundred minds could shut down the blights you mentioned. That is of course, until a handful of minds think of a way around it.
wiley,
when i was a kid we were always taught that “time is the independent (x) axis”. this adage seemed to have gone to the wayside when computers were being relied on for heavy analysis, as much of the visualization presented inconsistent findings that looked nice.
that’s all.
pharma is attracted to revenue/profit opportunities
other health arenas offer revenue/profit opportunities and CNS does not
pharma interests and monies are being spent elsewhere
how does this affect the revenues of academic psychiatry?
Preliminary scan of the report – the largest prescribers of prescription drugs namely primary care physicians are not characterized in the report. Even though most people think about 80% of antidepressants being prescribed by primary care, I can guarantee that there were no Internal Medicine or FP specialists following 30-50 patients with adult ADHD. Outpatient is a fairly useless designation unless it is broken down. I also don’t believe for a second that the “insurance administration costs” were flat as the managed care hierarchy was developed.
Biggest problem with the report was right on the cover “Behavioral Health is Essential To Health” = “Managed Care is Essential To Health.”
Interesting and vital concept, gagan.
http://mathbench.umd.edu/modules/visualization_graph/page02.htm
Elementary examples, but I aced it. Ha!