The Cost of Success

If a program is successful, you should end it. Correct?

That's why the CDC may be gutting Massachusetts' HIV prevention programs. Infection rates are lower in the Northeast than they are in many other parts of the country, and the CDC wants to improve prevention services in places with higher infection rates. Sounds reasonable, but it could have an effect exactly the reverse of the intention.

So what does the CDC do when they find that they've caused the rate of infection in the Northeast to go up to match the rest of the country? That's what could happen, since each program has a measurable impact on the HIV infection rate.

Many prevention programs begin as a research program or a local pilot. Success means that the people who were part of the program had a lower HIV infection rate than a comparable population. Let's use a HIV prevention hotline as a possible pilot. Start by opening it to one region, then look at the infection rate both before and after the hotline opened in that region, and also compared to other regions. If the infection rate went down relative to other regions, that hotline is a success. It then gets rolled out to everyone.

Each program is based on being able to reduce the rate of HIV infection by some percentage. Commonly, the goal is 5%. It doesn't sound like a huge amount, but absolutely worth it when you consider how many people that 5% represents.

The important thing is that the rate of HIV infection is lower while the program is active. What happens when it's no longer active? What happens when five programs, each of which has shown to be able to reduce infections by 5%, are cancelled?

Addressing the higher rate of HIV infection in some areas of the country is an absolute priority. That's another topic to go into later. But here's a hint: once a successful program is gone, so are the people who can help new programs be modeled on it.

A Good Psychiatrist is Hard to Find

Today, the Globe is reporting on the lack of access to psychiatrists in the Boston area, based on a study conducted by two local hospital groups. Researchers called a number of psychiatric facilities and asked when the first available appointment is with a psychiatrist. In most cases, it was not for a while.

The hospital-based researchers used that as evidence that psychiatrists should be paid more. That prompted Blue Cross Blue Shield to say that the study was done just to be able to say that psychiatrists should be paid more. Well, of course. Who doesn't want to be paid more?

My issue with the study is that the researchers asked for appointments with psychiatrists. There are many more behavioral health clinicians qualified to treat depression. A psychologist, for example, would be fully qualified to treat depression and may have much more availability.

The main thing that a psychiatrist can do that other clinicians cannot is prescribe medication. Other clinicians ask for a psychiatrist to consult in a case where they might think medication is a good idea. It isn't always.

If I were to try this study again, I would call up those facilities and ask for someone who can treat depression. First available. I don't know what the results will be, but I would guess that a psychologist or nurse might be available in a shorter time than a psychiatrist.

Note:
In case you don't know the difference, a psychiatrist is a medical doctor (MD or DO), who completed medical school and specializes in psychiatry. A psychologist completed a doctorate (PhD) in psychology, but is not a medical doctor. Nurses may also specialize in psychiatry, and there are a few other certifications such as Licensed Mental Health Clinician (LMHC) that allow certify a person to provide behavioral health treatment.