Tuesday, November 12, 2019

Rosenhan Uncovered






I have been on record for many years regarding the Rosenhan experiment. To briefly recap, that was a paper published in Science in 1973 (1). In the paper the author described how eight pseudopatients were admitted to psychiatric hospitals and the treatment they received. He describes their varied backgrounds. He says that they were admitted to 12 hospitals in five states on the East and West Coast. The hospitals also varied from research institutions to institutions with much fewer resources. Most importantly he describes the script that each pseudo-patient is supposed to adhere to in order to get admitted and how they are supposed to behave post admission. 

Specifically:

“After calling the hospital for an appointment, the pseudopatient arrived at the admissions office complaining that he had been hearing voices. Asked what the voices said, he replied that they were often unclear, but as far as he could tell they said "empty," "hollow," and "thud." The voices were unfamiliar and were of the same sex as the pseudopatient. The choice of these symptoms was occasioned by their apparent similarity to existential symptoms.” (p. 251)

Apart from the false symptoms, false name, false vocation, and false employment the social history provided by the pseudopatients was supposed to be identical to their real social history. After gaining admission so patient was supposed to “cease simulating any symptoms of abnormality.”

From the purported data, Rosenhan pointed out that none of the pseudo-patients were discovered, they were hospitalized for varying lengths of time, they were given medications that they may have been trained to not take and spit out, and they made a number of observations inside the hospital. Rosenhan concluded that “It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals”.  He also uses at least half of the article for highly speculative observations on powerlessness, depersonalization, and labeling none of which really pertain to the study.

I just finished reading Susannah Cahalan’s new book The Great Pretender. It is about Rosenhan’s study and Rosenhan himself.  She has quite a lot to say about him including how this paper changed the face of psychiatric care and was a major factor in closing down psychiatric institutions.

Let me start by describing what I experienced at that time. In 1973, I was just finishing an undergraduate degree and although I was a science major - heard nothing about this paper. I was reading Science and Nature at the time. I did medical school and residency training between the years 1978 and 1986 and again heard nothing about Rosenhan - even during psychiatry rotations and seminars. That was a controversial time in psychiatry because of the tension between biological psychiatry and psychotherapy. The controversy seemed to be largely from the psychotherapy side of the equation. Psychiatry residents were pulled to one side or the other. It was always clear to me that both modalities were critical. I got what I consider to be good psychotherapy training at two different Midwest residency programs.

A unique aspect of my training happened at the University Wisconsin training program. Community Psychiatry was a mandatory six-month rotation that consisted of an outpatient clinic, crisis intervention training, and an active seminar every week. One of the leaders of that seminar was Len Stein MD. Dr. Stein was a major force and originator of Assertive Community Treatment (ACT) and other forms of community treatment that were focused on maintaining people with severe mental illness in the community. To this day I can recall a slide from one of his presentations that showed a gymnasium sized room at the local state mental hospital. In that room were cots arranged edge to edge across the entire floor. Rows and rows of these cots covering the entire floor. The men who slept on those cots were standing in the foreground. They were all wearing the same pajamas. After showing that slide, Dr. Stein would point out that this was one of the motivators that led him to help people get out of hospitals into their own apartments.  His goal at the time of Rosenhan’s paper, was to develop a way to help people with severe mental illnesses live independently in the community.  He was not only successful at it – he trained psychiatry residents how to do it. After completing my training, I went to a community mental health center and helped run an ACT team for three years.  We were highly successful at maintaining people outside of the hospital and helping them function independently.

My introduction here is to illustrate that one of the main theses of The Great Pretender, namely that Rosenhan’s experiment was one of the main forces in deinstitutionalization and closing down psychiatric hospitals is something that I disagree with. It seems to be a good theory if you want to suggest that psychiatry only changes from the outside and the change happens by people who are not psychiatrists. You can probably make that argument if you don’t know psychiatrists like Len Stein and all of the other community psychiatrists out there who were highly motivated to maintain people outside of state hospitals because it was the right thing to do. It was the right thing to do because states ration resources to the mentally ill. They always have and they always will.  Politicians don't really care about anyone with severe mental illness. Community psychiatrists know that. They know the only way to provide good treatment to those patients is to make sure that public funds follow the individual patient.

In her book Susannah Cahalan, spends a lot of time describing how seminal the Rosenhan study was. She has numerous testimonials from important psychiatrists at the time. There is even a suggestion that Robert Spitzer, MD used the study politically to advance his own agenda in writing more precise diagnostic criteria for the DSM-III. I can state unequivocally that I had not heard of this experiment until I started encountering anti-psychiatrists. That didn’t happen much until I started this blog in 2012.

What did I like about the book? I was impressed with the investigative aspects of the book. She carefully details how Rosenhan’s original description in Science does not accurately reflect what actually happened. There is not enough information available to verify whether or not the entire pseudoexperiment was completed as written. In addition to that research, she has detailed impressions of Rosenhan from fellow faculty members, coworkers, friends, and family members who knew him well. Many of these people had reservations about him and his work. Many believed that there were problems with the original paper. Many had concerns about his character that are clearly described in this book. In brief, there is plenty of circumstantial evidence in addition to the direct evidence that something was wrong with this paper.  I take this circumstantial and character evidence with a grain of salt. In any clinical or academic settings, there are always plenty of personality conflicts and politics. There is one scene in the book where Rosenhan is throwing a party and tells a colleague that he had a wig made for the pseudopatient role (Rosenhan was bald). Cahallan confirms by photo and the attending psychiatrist’s notes that he was bald and not wearing a wig during the hospitalization. I also do not consider that to be a big deal. He was described as a raconteur who liked to hear himself talk. Making up stories at parties to keep people engaged is what raconteurs and extroverts do.  

She also builds a careful case of additional red flags along the way. Rosenhan apparently achieved celebrity status for brief period of time. When that occurs he got a book deal and was advanced substantial sum of money. He also wrote several chapters that were read by Cahalan. He never finished the book even when he was sued by the publisher.  He never did any further research on the subject of pseudopatients getting into psychiatric hospitals or psychiatric hospitals at all. He had an active correspondence with Spitzer and one point recruited psychiatrists to convince Spitzer not to publish criticisms of his paper. Spitzer was very content with his criticism, but Cahalan points out that he may have had direct information at the time to refute the paper entirely. Rosenhan clearly broke the protocol that he described as evidenced by the medical record. The treating psychiatrist apparently sent Spitzer a copy of those records showing that as the original pseudo-patient, Rosenhan broke protocol. In addition to describing vague auditory hallucinations he added historical data that would have resulted in him being hospitalized anywhere.  Excerpts from the exact medical record are included in the book on pages 184 and 190. The author concludes (and any reader can do the same) that the facts were intentionally distorted by Rosenhan primarily with more elaborate delusional material and suicidal thoughts including the statement “everyone would be better off if he were not around.” What is recorded in the actual medical record is a person feigning a much more serious mental illness than “existential symptoms.”

Cahalan was able to locate two more pseudopatients, but one of them was not included in the study. Cahalan was unable to locate any of the other six pseudo-patients described in the Science paper despite an intensive effort.  Rosenhan also removed the data from the ninth pseudo-patient. The data from the ninth pseudo-patient was inconsistent with the others in that this patient liked his experience in the psychiatric hospital and in fact found to be very positive. He liked it so much that he published that positive experience in Professional Psychology in February 1976 (2) including the following conclusion “He recommends stressing the positive aspects of existing institutions in future research.” (p 213).

Cahalan approached Science directly. She asked them directly why they published this article in the first place given the concerns she outlined in her book. They refused to discuss their editorial process. A psychologist speculated that the submission to Science would be less rigorously reviewed because they probably did not have the top peer reviewers in the field. Although Cahalan uses a fair amount of anti-psychiatry rhetoric in her book, and seems to talk authoritatively about that field, there is no speculation that bias against psychiatry may have been involved in publishing this article.  Given what we know about general bias against psychiatry, that would seem to be a real possibility to me.

I am already on record saying that there is enough information in this book to retract the original article. I admit I don’t know the criteria for retractions or whether there is any time limit. Having been a Science subscriber for decades I know that it certainly does not meet their typical standards. I will happily go back and read articles from medicine and psychiatry in their 1973 editions to illustrate that fact if there is a shot at retraction.

Retraction would certainly create a furor in the anti-psychiatry community. Their arguments rest almost entirely on false premises and pseudoscience. As I noted in my post from seven years ago, anyone can walk into a medical facility and lie about a condition for any number of motives. In my current field, I have talked with hundreds of people who tell me they asked for a second or third opioid prescription when they did not need it for pain. They were taking it to get high. Before that I did consults in a general hospital, we were often asked to see people with factitious disorders who are feigning some medical illness. We also saw significant numbers of people who had medical symptoms but were not consciously feigning illness. The author mentions some of this but is usually quick to make it seem like psychiatry is the wildcard relative to the rest of medicine. 

I have had several people ask me if they should buy this book. I have also been asked to write a book review for newsletter.  My response is consistently, buy the book if you want to see the clear evidence that the Rosenhan experiment was more than seriously flawed – the protocol was violated by the author himself and the evidence is there black on white. A second protocol violation occurred when the Rosenhan decided to eliminate the experience of the pseudopatient who enjoyed being in the hospital and found it to be useful. I will say again that I am not an expert in retractions but believe that papers are retracted today for violations of data integrity.

Don’t buy this book if you are expecting to read a valentine to psychiatry. The author's previous book was about her episode of inflammatory encephalitis that was misdiagnosed as a psychiatric disorder. She mentions it several times to point out her credibility as a person who has experienced severe psychiatric symptomatology. At one point in the book she undergoes a SCID (Structured Clinical Interview for DSM-IV) evaluation by a psychiatrist who had a lot of input into DSM-5. After a tedious exchange he tells her that his going charge for the exam is $550. When I read that, I asked myself why would this psychiatrist go along with a SCID when he knew it was irrelevant to Cahalan’s diagnosis? Several other prominent psychiatrists are quoted in the book in a way that fits Cahalan’s thesis that psychiatry is in fact a weak link in medicine and even though Rosenhan’s pseudoexperiment was grossly flawed there is a still some valuable lesson there.

I would suggest that is really not the case. I don’t know why anyone would want to try to resuscitate this work and I sure don’t know why Science wants to keep it in a reputable journal.  The original responses over 40 years ago pointed that out. I would highly recommend reading the  original responses by Spitzer.


George Dawson, MD, DFAPA



References:

1: Rosenhan DL. On being sane in insane places. Science. 1973 Jan                     19;179(4070):250-8. PubMed PMID: 4683124.

2: Lando H. On being sane in insane places: a supplemental report. Professional Psychology, February 1976: 47-52.

Saturday, November 2, 2019

There Is No Identity Crisis in Psychiatry





The New England Journal of Medicine published an opinion in their October 31, 2019 edition titled “Medicine and the Mind-The Consequences of Psychiatry’s Identity Crisis” (1).  Claiming that psychiatry (meaning organized psychiatry and all psychiatrists) has some sort of an identity crisis is a favorite editorial topic these days. It lacks face validity considering over 40,000 psychiatrists go to work every day, have working alliances with their patients, treat problems that no other doctors want to treat, and get results. Furthermore, most psychiatrists are working in toxic practice environments that were designed by business administrators and politicians. As a result, psychiatrists are expected to see large numbers of patients for limited periods of time and spend additional hours performing tasks that are basically designed by business administrators and politicians and have no clinical value.

The authors in this case fail to see that problem. In their first paragraph they critique “checklist amalgamations of symptoms” as if that is psychiatric practice or what psychiatrists are trained to do in their residency programs. I happen to be an expert in these checklists because I have been critiquing them from the outset. The state of Minnesota mandates that all patients being treated for depression in primary care settings have to be rated on these checklists over time, and that data is supposedly analyzed as a quality marker. Anyone familiar with the analysis of longitudinal data will realize that cross-sectional data points on different patients at different points in time are meaningless. But that doesn’t prevent politicians in Minnesota from dictating psychiatric practice and it doesn’t prevent these authors from blaming psychiatry for it.

Their additional opening critique on “medication management” ignores the fact that this procedure was invented by the federal government. This procedure and all the associated billing codes did not exist in psychiatry until HCFA thought it was a good idea to assign these codes to psychiatrists and call them “medication management”. It was only recently that psychiatry could use the same E & M codes that the rest of medicine uses for the provision of complicated care including psychotherapy. Instead of just stating that the authors say “We are facing the stark limitations of biological treatments, while finding less and less time to work with patients on difficult problems”.  Apart from the rhetoric I don’t know what that means. If I have a patient with a difficult problem - I make the time to work on it.  If there were any stark limitations in psychiatry – they occurred before the invention of biological treatments. In those days, people died from severe psychiatric disorders and the associated effects of severe hyperactivity, starvation, and dehydration.  Many people also had their lives disrupted when they were sent to state mental hospitals for years or in some cases decades.  Those were the historic limitations in psychiatry.

They move onto a critique about diagnosis and their opinion that “the solution to psychological problems involves matching the “right” diagnosis with the “right” medication". I don’t know where the authors went to psychiatry school but that is a new one on me.  At a different point in their opinion piece they critique the current diagnostic manual. If they read that manual they would notice there are conditions with strictly psychological and social etiologies that do not require medical treatment. They also minimize the role of tertiary consultants like myself. I see thousands of people who were started on psychiatric medications by non-psychiatrists. There is clearly a lack of expertise prescribing those medications and I make the necessary adjustments including stopping medications that were inappropriately prescribed. I also prescribe the indicated treatment when it was never provided in the first place. That all happens in the context of a therapeutic relationship and providing necessary psychotherapy.

Somehow the authors conclude that a lack of “scientific and intellectual integrity” does a disservice to patients, practicing psychiatrists, and medical colleagues. They suggest that medical colleagues are striving to provide the best possible and “most humane care to people with medically and psychologically complicated conditions”. I don’t know who the authors think is holding up the psychiatric and psychological end of that treatment. I worked in a multidisciplinary clinic with every imaginable consultant for 22 years. Nobody hesitated to refer patients to me for psychiatric care. They knew it would be comprehensive, that the assessment would be exhaustive, and that the treatment plan would be beneficial. We also had an active consultation-liaison team that provided active ongoing consultation to a large medical-surgical hospital. Without those psychiatric services there is no “humane care” to the medically complex psychiatric patient. This psychiatric function is widely known and these treatment plans can be read directly from the pages of the NEJM.

The authors provide a one sentence sketch of brain function and how the external world affects our “brain-minds”. They grudgingly acknowledge that basic science may be a necessity. They bemoan the fact that advances in neuroscience “are still far from offering real help to real people in hospital, clinic, and consulting room”.  That is not what I observed in 35 years of practice. There has been a steady improvement in psychopharmacology both in terms of safety and selectivity. There have been major advances in neuromodulation -both electroconvulsive therapy and transcranial magnetic stimulation. There have been pharmacological advances in addiction psychiatry with more medication assisted treatments. There have been advances in specific conditions like severe psychiatric disorders associated with pregnancy and various forms of catatonia. The diagnostic advances related to basic science research have been stunning. When I first started consulting in nursing homes 35 years ago - every diagnosis was either “senility”, “senile dementia”, or “atherosclerosis”. There were no science-based diagnoses of dementia in those days. We currently have a comprehensive approach to detailed dementia diagnoses as well as a comprehensive approach to diagnosing 127 different conditions associated with substance use disorders all neatly detailed in the diagnostic manual that they seem to have a problem with. Hopefully there is no more “senility” in nursing homes.


The authors attack neuroscience in the usual ways. They state they agree that discoveries in neuroscience are exciting but on the other hand “are still far from offering real help to real people in the hospital, clinic, and consulting room.” They restate that twice in the space of this brief essay. Is that true?  Some reading in the area of translational psychiatry might be in order. Every week I assess many patients for anxiety disorders. A significant number of them have been anxious their entire life. There are currently no good conceptualizations and indicated treatments that separate this group from people who develop anxiety later in life. From the work of Kalin and others (3,4), the biological basis of anxious temperament and potential solutions to lifelong anxiety is now becoming a possibility. Progress in neuroscience has gone from receptors and neuroendocrinology in the 1980s to genetics and multiomics in the 21st century. Now there is more than speculation and empirical trials. Entire mechanisms that include genetics, transcription, anatomic substrate and the impact of the environment on brain systems are determined.

There is in fact a group dedicated to bringing neuroscience into the clinical realm – The National Neuroscience Curriculum Initiative. It is possible to think of a neuroscience-based formulation as easily as one might think of a psychodynamic formulation.  The point of neuroscience research in psychiatry is the same as it is in any other specialty with one exception - the organ being studied is more complex and generates a conscious state. The basic science of practically every other field has been studied more intensely and with more resources than brain science has been studied. Many other fields have not produced miracle cures when it comes to chronic illnesses and the basic treatments of these illnesses have been static for decades. The cures or disease altering interventions often occur after much more time has been spent studying them then we have spent studying the brain. In that context, basic science brain research is as on track as any other field

The most erroneous opinion advanced by these authors is that psychiatry has somehow abandoned the social and psychological elements of care. They cite an author who is a historian and who suggests that psychiatrists should limit their scope to “severe, mostly psychotic disorders”. There are many authors with similar irrelevant opinions about psychiatry but they generally aren’t quoted in an opinion piece for the NEJM. Nothing that author says is realistic or accurate in this article, but that is typical of the so-called critics of psychiatry. The authors own proposals for change in psychiatry are similarly irrelevant because it is apparent that they have a limited understanding of what is going on in the field or what psychiatrists do on a day-to-day basis.

The next section of their opinion piece is about funding and how biological funding has “replaced all other forms of psychiatric research”. They provide no evidence in terms of actual numbers. I expended some effort to try to do that.  I asked NIH, NIMH, SAMHSA, one of my US Senators and I tweeted the director of the NIMH to get an answer to the question about the proportion of funding for basic science versus psychosocial mental health research. I also searched the AAAS research reports to see if anything was listed there. What I got back was largely devoid of any useful data.  The above links were sent to me by a public affairs specialist at the NIH.   

I remembered reading about an analysis in American Psychologist suggesting that 30% of the $1.6B NIMH budget goes to psychosocial research. I was able to find the article (2) and it was not straightforward as most advocates of increased psychosocial research think. That 30% figure comes from a graphic generated by a review of research abstracts of 15% (2,028) of all funded studies from 1997-2015. They were coded on a 1 - 5 scale by doctoral level students where 1 = entirely focused on biomedical topics to 5 = entirely focused on psychosocial topics.  There was a positive trend in favor of biomedical research but the authors point out several limitations in the data and areas for further study. And they make this important comment:

“A test of the differences in regression slopes indicated that there was, however, no difference in the increase in award size for R01 grants, F(1,475) = 3.97, p = ns, suggesting that the proportion of biomedical grants awarded increased, but they did not receive disproportionately larger awards than psychosocial grants. This is notable given that biomedical research is often more costly because of expensive procedures and larger research teams.” (p. 417-418)

This reference provides a very balanced look at the issue including a discussion of the significant limitations of psychosocial treatments - something that you do not see in the NEJM piece or from the people claiming that basic science research is clinically worthless. 

Although the authors are critical of neuroscience results, they don’t seem to mention the lack of innovation in psychotherapy and other psychosocial therapies. More significantly they ignore the fact that these therapies are routinely not funded by managed-care companies, government insurers, and responsible counties. They blame psychiatry for the “abandonment and incarceration of people with chronic, severe mental illness” when in fact the necessary psychiatric beds and inpatient facilities as well as community housing for these patients has been actively shut down by businesses and governments over the past 30 years.  It seems that counties have adapted managed-care practices that includes rationing services for the chronically mentally ill to the point that they end up in jail. The authors seem to conveniently blame psychiatry for that. Once again they could read about what psychiatry really does in the pages of the NEJM and how these very patients are served by ACT teams. The treatment approach was invented to improve the quality of life of people with chronic mental illness and support them in independent living. It does not work in a vacuum and there has to be a funding source.

The authors suggest that psychiatry needs to be “rebuilt”. From their suggestions about training programs I wonder if they participate in training programs, teach residents, and work on resident curricula.  And if they do - I wonder what that training program looks like. I say that because all the suggestions they have seem to have been in place for decades. In fact, their entire argument is reminiscent of the old "biological psychiatry versus the therapists" argument from about 1984. That argument should stay firmly planted in the "old history" folder.

Their concluding paragraph is a extension of earlier rhetoric.  They talk about psychiatry having an exclusive focus on “biological structure” rather than meeting the needs of real people. I go to work every day and talk to real people all day long. I know quite a lot about the biological structure the brain and its function. I must because I don’t want to be treating a stroke, brain tumor, a traumatic brain injury, or multiple sclerosis like a purely psychiatric problem. I also realize that if I conceptualize the psychiatric disorder as a specific brain area or network - that is still occurring in a unique conscious state. That conscious state is generated by the most complex organ in the body. It is an organ with tremendous computational power. All psychiatrists are treating people with unique conscious states and there is no specialty more aware of that. And in that complex setting psychiatrists are focused on helping the people they are seeing. They are the only ones accountable.

There is no “identity crisis” in psychiatry. Making that claim requires a suspension of the reality about how psychiatrists are trained and the grim practice environments that many of us face. Those grim practice environments are the direct result of governments and businesses actively discriminating against psychiatrists and their patients. That has resulted in discrimination that is so gross that county jails are now regarded as the largest psychiatric hospitals in the USA.  Pretending that these problems are the result some flaw in psychiatrists one of the greatest medical myths of the 21st century.  These authors and the New England Journal of Medicine are promoting it.  This opinion piece is so poorly done it makes me wonder what the editorial staff at NEJM are doing. It is as bad as another opinion piece that should never have been published in the psychiatric literature.   

The real message from the profession that should be out there is:

“Give us a practice environment where we can do what we are trained to do! Get out of the way and let us do our work! Give us the resources that every other medical specialist has!”

Very few of those environments exist.  They have been rationed out of existence by politicians, bureaucrats and administrators.  People who know nothing about the field seem to be totally unaware of that problem and like these authors they never comment on it. Only people lacking that awareness would believe an article like this - or write it.


George Dawson, MD, DFAPA


References:

1: Gardner C, Kleinman A. Medicine and the Mind - The Consequences of Psychiatry's Identity Crisis. N Engl J Med. 2019 Oct 31;381(18):1697-1699. doi:10.1056/NEJMp1910603. PubMed PMID: 31665576.

2: Teachman BA, McKay D, Barch DM, Prinstein MJ, Hollon SD, Chambless DL. How psychosocial research can help the National Institute of Mental Health achieve its grand challenge to reduce the burden of mental illnesses and psychological disorders. Am Psychol. 2019 May-Jun;74(4):415-431. doi: 10.1037/amp0000361. Epub 2018 Sep 27. PubMed PMID: 30265019.  

I thank these authors for making this paper available on ResearchGate.


3: Kalin NH. Mechanisms underlying the early risk to develop anxiety and depression: A translational approach. Eur Neuropsychopharmacol. 2017 Jun;27(6):543-553. Doi: 10.1016/j.euroneuro.2017.03.004. Epub 2017 May 11. Review. PubMed PMID: 28502529; PubMed Central PMCID: PMC5482756.


4: Fox AS, Kalin NH. A translational neuroscience approach to understanding the development of social anxiety disorder and its pathophysiology. Am J Psychiatry. 2014 Nov 1;171(11):1162-73. doi: 10.1176/appi.ajp.2014.14040449. Review. PubMed PMID: 25157566; PubMed Central PMCID: PMC4342310.



Supplementary:

The Psychiatry Milestone Project: an indication of what psychiatry residents are evaluated on in their training programs. Link.



Graphic Credit: 

The graphic was downloaded from Shutterstock per their standard user agreement.



Sunday, October 27, 2019

ProPublica Vital Signs





It has been a while since ProPublica came out with a list of physicians who receive money from the pharmaceutical or medical device industry.  They began posting their new list of physicians who get the greatest reimbursement to the outrage of some who saw their Twitter post.  They also posted their updated Vital Signs search engine that allows anyone to search for how much money a physician receives as payments from the pharmaceutical or medical device industry.  I was able to locate my profile (it is not always easy) and it is readable. I do it when they post an update just to make sure there are no errors.  I don't accept money from anybody and also don't attended sponsored free CME courses because that is also listed as a benefit from whoever is sponsoring the course.

Although they are using a practice address I have not had for over 9 years (it is blurred but available on the ProPublica site) - when I was at that site I saw many Medicare and Medicaid patients.  At one point those were the only patients I was treating.  The disclaimers written on this page need clarification.  I am currently working 4 days a week and for me that is at least a 45-50 hour week and seeing full schedules of patients. The reason ProPublica has no information on my medical practice is that I receive no payments from the medical device or pharmaceutical industry, but you don't know that for sure by reading this information and the disclaimers. The introduction to the new database update gives an example of the reporter searching on the names of his primary care MD and the consultants he has seen.  He looks at the report of payments in terms of royalty or licensing fees, promotional speaking, consulting, travel  and lodging reimbursement, and food and beverage reimbursement.  What he does not say is what these figures mean to him.

I have written about this database in the past in terms of what it does and does not mean.  Over the past decade these payments were used as an easy way to discredit physicians, in some cases entire specialties.  Psychiatry and psychiatrists were at the top of the list, despite the fact that according to ProPublica they were ranked well below most other specialties in terms of medical industry payments.  The furor seems to have diminished as physicians are now subject to more rigorous payment reporting than politicians. In modern society - it seems that the illusion of transparency is all that is required to satisfy the moral outrage of the public.  After all - we have politicians who are actively engaged is legislating issues that affect their top campaign contributors.  There could probably not be a more significant conflict of interest and nobody bats an eye.

Despite the unrealistic idea that physicians are easily influenced and are in lock step to treating their patients according to orders from the pharmaceutical and medical device industry - this database serves a symbolic purpose.  That is - personal treatment from your physician will somehow be better now that all of these payments are known. You might make value judgments about physicians on that basis, but it would probably be a mistake. Physicians should be paid for their work and their intellectual property.  As a group they end up giving far too much of it away. And the largest conflict of interest affecting personal medical care is not mentioned in this database.  That is how your insurance company, managed care organization, or pharmaceutical benefit manager rations your care and tells your physician what they must prescribe, what tests to order, and how they can treat you if they want to remain an employee or get reimbursed.  Don't expect to see those numbers anytime soon. And by the way - that rationed care adds at least a trillion dollars to the health care budget - just as a jobs program for administrators and it skims an unknown (but probably large) percentage off the treatment your physician really wants to provide.

In the meantime - remember that this blogger is beholden to no one.


George Dawson, MD, DFAPA



Supplementary 1:

I discussed some critical issues when a Presidential appointee stood to make massive profits while in the Executive Branch.  Although that deal fell through, the President himself has made an estimated $2.3 billion in profits while sitting in the Oval Office.  This is the same President that provided massive tax cuts to businesses and massive rollbacks in environmental regulations on businesses. In the meantime, physicians accepting $10 worth of pharmaceutical or medical device company pizza are reported to the payments database.

Should $10 worth of pizza be a red flag for anything?



Sunday, October 6, 2019

Inappropriate Sinus Tachycardia (IST) In The Psychiatric Clinic





I don’t recall what I was researching the other day but I happened across a brief review paper on a subject I have been following for a while (2). That subject is inappropriate sinus tachycardia (IST). I posted recently about closely following the cardiac status of patients being seen by psychiatry both on the inpatient side and in the outpatient clinic. When that is done a significant portion of those patients will have tachycardia defined as heart rate of greater than 100 bpm. In some cases the heart rate ranges as high as 120 to 130 bpm.  Many of these patients are surprised to learn how high their heart rate is and what constitutes a normal heart rate. Others are very focused on the cardiac status and experience palpitations in periods of rapid accentuated heart rate. I commonly hear “it feels like my heart is coming out of my chest”.

That type of cardiac symptom can certainly occur during panic attacks. The majority of people I see with sinus tachycardia do not have panic attacks or panic disorder. They are generally anxious but the phenomenon I have not seen addressed is how much anxiety is due to the cardiac symptoms? Many have what I describe as cardiac awareness. By that I mean they can sense their heart beating by various mechanisms. Many can feel the pulsation of blood through the body especially in the head and neck area. Others can hear their heartbeat. Many can sense their heart beating against their chest wall. The person has that kind of focus any irregularity like occasional pauses or extra beats leads to heightened anxiety. As that anxiety builds some people will feel chest pain, chest pressure, and shortness of breath or near panic symptoms.

 A significant number of those patients will have anxiety associated with symptomatic IST. There are also groups of patients with frequent panic attacks, nocturnal panic attacks, night terrors, and medical problems associated with tachycardia and other cardiac symptoms.  It has been surprising to me to find that significant sustained sinus tachycardia is often ignored in primary care settings. The reason for that may be the latest review in UpToDate (1). In that review the authors define the syndrome and the evaluation and conclude that the condition generally has a benign course in that tachycardia induced cardiomyopathy is rare. They suggest that diurnal variation of the tachycardia may protect against that.

Since IST is by definition tachycardia with no known medical cause intrinsic heart disease and associated causes of tachycardia need to be ruled out. In psychiatric patients panic attacks and anxiety are typically considered psychiatric causes of tachycardia but they are rare causes of sustained tachycardia. The hyperadrenergic state of panic attacks generally resolves when the panic attack resolves and that is frequently in 20 minutes or less.  It is common to see very anxious people in clinics and when their vital signs are checked they are typically normal. Sustained tachycardia is more common with other comorbidities such as medication side effects, excessive caffeine use, stimulant use, alcohol or sedative hypnotic withdrawal, and in some cases insomnia. Deconditioning can also be a factor one person has been isolated and sedentary for any reason and they suddenly need to walk a distance to get to the clinic. There is a gray zone of overlapping conditions that need to be considered. For example, an acute pulmonary embolism, congestive heart failure, and emphysema or COPD can lead to cardiopulmonary symptoms including tachycardia. They can generally be ruled out by a medical history, review of systems, and brief examination.

Tachycardia secondary to medication side effects often requires tracking several variables.  In the ideal case, an indicated medication can be selected that does not have the side effect - in this case tachycardia. But there re some medications that are unique enough that they may be used in situations where the tachycardia persists because there are no other good alternatives. With clozapine (3) the tachycardia can be secondary to anticholinergic side effects, alpha blockade and hypotension, or intrinsic cardiac side effects like myocarditis. Patient often get tachyphylaxis to the anticholinergic effects but all of these variables need close monitoring. It takes a lot of ruling out to conclude that a patient on clozapine has IST and this is a good example of the importance of the baseline evaluation and reviewing avaiable records and vital signs in the electronic medical record.

A more common scenario is the anxious patient with no clear cardiac or pulmonary disease who has persistent tachycardia and in many cases palpitations. They are often treated with beta-blockers with some success. I have seen people have been unable to tolerate beta-blockers, people who did not respond beta-blockers, and some people with beta-blocker withdrawal who had severe anxiety panic and tachycardia because the beta-blocker was stopped too quickly. In both the review and the up-to-date summary, IST patients are commonly resistant to beta-blockers and need another intervention. The suggested intervention is ivabradine a novel medication described as a blocker of the hyperpolarization-activated cyclic nucleotide-gated (HCN) channel responsible for the cardiac pacemaker If current. That directly affects heart rate at the SA node. It also affects retinal currents leading to phosphenes or transient bright spots in the visual fields. 

The main indication for ivabradine is congestive heart failure. There are cardiac complications including atrial fibrillation. That suggests to me that most psychiatrists should probably not consider prescribing this medication unless there is ample clinical experience and the required monitoring is not intensive - similar to beta-blockers today.

The main message in this post is that close attention does need to be paid to vital signs on every inpatient unit and outpatient psychiatric clinic. It is not enough to say that tachycardia can be dismissed as anxiety. It is also not enough to use a quasi-medical intervention like telling the patient to drink more fluids if they have not been assessed for hypovolemia. A close look for intrinsic cardiac conditions and the list of conditions and the differential diagnosis from the review article below and the UpToDate review should be a minimal requirement for medical psychiatrists. If that cannot be done, the patient should definitely see their primary care physician preferably prior to initiating any treatment with a medication that would obscure the clinical picture. The evaluation and recommendations of the primary care physician should be available in the patients psychiatric chart. For completion, I also get copies of other cardiac testing that has been done including echocardiograms and exercise stress tests.

The advantage of a diagnosis of IST is that it recognizes there is a specific diagnosis to account for inappropriate tachycardia rather than a default psychiatric diagnosis. That is important because it protects the patient and potentially offers more effective care. The treating psychiatrist should still be in the loop for the necessary lifestyle modifications, education about the condition and monitoring and treating any associated anxiety.



George Dawson, MD, DFAPA


References:

1.  Munther K Homoud. Sinus tachycardia: Evaluation and management.  Section Editor: Jonathan Piccini, MD, Deputy Editor:Brian C Downey, MD in UpToDate.  Accessed on October 6, 2019.

2.  Ruzieh M, Moustafa A, Sabbagh E, Karim MM, Karim S. Challenges in Treatment of Inappropriate Sinus Tachycardia. Curr Cardiol Rev. 2018 Mar 14;14(1):42-44. doi: 10.2174/1573403X13666171129183826. Review. PubMed PMID: 29189171; PubMed Central PMCID: PMC5872261

3. Miller DD. Review and management of clozapine side effects. J Clin Psychiatry.2000;61 Suppl 8:14-7; discussion 18-9. Review. PubMed PMID: 10811238.

Saturday, October 5, 2019

Physicians Preservation Act?






I got this idea today while reading the usual Twitter complaints about the electronic health record. A post by physician I knew was particularly poignant. She pointed out that she was getting burnout from the excessive time it takes to do EHR documentation compounded by the fact that nobody ever reads it. This is a complaint I have had for a long time.  I was lucky enough to be on the ground as the EHRs rolled out. There was quite a prelude to the rollout with about a solid 10-year buildup of documentation and billing requirements. Those requirements originated with the federal government specifically HCFA – the precursor to CMS. All of the initial EHRs were designed around these documentation and coding templates. It was strictly a business focus sold as something necessary for medical practice.

I can recall the first people on the medical staff who were designated to sell the system. They came to see me and I pointed out that I have never been a touch typist and the fastest I can type is 12 words a minute with two mistakes. When they realized I wasn’t kidding they tried to soften the blow by saying that we would be slowly transitioned to creating the entire document. During that transition time we would still be able to dictate admission notes and discharge summaries. When I complained that this would still be quite a burden on physicians producing all these documents I was told by an internist (who I had a very high opinion of) “You need to thank our CEO for getting us this state-of-the-art system.” That was one of the more depressing remarks that I’ve heard in my career.

I did try to make the most of it. I got an early version of Dragon and started dictating all my notes and into Word and pasting them into the EHR.  It was not pretty. There were many mistakes and if I missed some of those mistakes it could prove to be an embarrassing document. The nursing staff I worked with helped to edit those documents and point out the mistakes but some mistakes invariably went through. I learned that the nursing staff in my immediate proximity were the only people who ever read those notes. I was generating multiple 500 to 1000 word documents a day and suddenly realized that I had to complete that work between 10 PM and midnight every day. Within a few years the new car smell was off the EHR and things were getting ugly.  I started to see 18 to 20 page progress notes based on import and cut-and-paste features. My speculation is at one point the vendor was desperate to prove they could introduce some physician friendly features. The ability to start a new daily progress note based on yesterday’s note soon became history. Administrators decided that the new note looked too much like the old note even though they were based on same template.

EHR politics is always interesting to observe. There are a cadre of administrators and “super users” who are tasked with selling the product to the frontline physicians. There are also various helpdesks that are run by the vendor. Staff at those helpdesks are supposed to be available for troubleshooting and problem solving. The troubleshooting and problem solving eventually fades away. EHRs are typically implemented in modules. I walked into work one morning and realized that the module that allowed electronic prescribing was completely changed. The change was not announced and since it was an enterprise wide implementation there were hundreds of physicians trying to figure it out for themselves. It added hours to everyone’s day.

With the shift of billing, coding, and documentation to physicians many other jobs were lost due to the EHR. For 15 years I would go to the basement of the hospital every Sunday and make sure all of my records were dictated and signed. I ran into the same staff there every weekend who greeted me and assisted me with completing those records. Suddenly they were gone because now I was doing all of their work in the EHR. When I first started working at my job, I would dictate daily progress notes and they would be pasted into the chart by the secretarial staff the next day. Billing and coding specialists would come to the unit, read those notes, and attach a billing fee. I had no idea about the billing system and didn’t really care. With the EHR all of those staff were replaced. I was not only doing their jobs but now I was legally responsible for any billing errors and the suggested penalties were high. All of this additional work and responsibility was directly transferred to physicians through the EHR.

The only real bright spot from the EHR was the ability to see imaging studies, electrocardiograms, and laboratory results as soon as they were available. It took years to get that implemented to the point it worked effectively.

Are there workarounds to successfully use the EHR without burnout, depression, and excessive work? I think that there are. The last few years I have been seen by ophthalmologists who were retinal specialists and an otolaryngologist or ENT physician. In both cases these positions were using a scribe or a third person in the room who documented the history, exam, findings, and treatment plan as indicated by the physician. In the case of the retinal specialist he was working with an ophthalmology fellow and made corrections to that examination by directions to the scribe. The same thing happened with the ENT physician but in that case the scribe was also an RN who could provide more details about the suggested treatment plan. In both cases the physician walked out of the room at the end of the encounter with no further documentation burden. That led one of my colleagues to point out that the only reasonable workaround for the EHR problem is to use two people - the physician and a scribe or staff person who could also function as a scribe.

That led to my idea about the Physicians Preservation Act at the top of this post. It addresses all the flaws in the system that were brought about by heavy lobbying and Congressional advocacy for a burdensome inefficient electronic documentation system. As I pointed out in a 2015 post, the system has never lived up to claims of efficiency or savings even when physicians started to do the work of four or five people. This entire administrative structure is there to produce excessive documentation that nobody reads. There is also a massive environmental cost since the system must operate through thousands of networked personal computers that in many cases are operating 24/7 along with the associated data storage facilities. 

My suggested solution is a compromise between the likely inertia of the current EHR system and the politics that keep it in place and the massive burden it places on physicians and their families. There are just too many special interests in Congress keeping this system afloat. The question is how long can the country afford to lose doctors because of it.

My guess is not too much longer.


George Dawson, MD, DFAPA


Saturday, September 21, 2019

Cardiac Screening In Psychiatric Patients





There is a paper that just came out (1) that I consider a must-read for all psychiatrists.  Some experts might qualify that and say that it is only necessary to know the subjects if you are treating the medically ill, the elderly, pediatric patients, patients with cardiovascular disease, or patients with cardiac risk factors. The problem with those qualifications is that you have to know everything in this paper (and others) in order to make that determination. Beyond that you have to been trained in how to determine if your patient is seriously ill or not. In the case of all medical specialists, serious illness generally means treatment by another specialist or in a more intensive setting. For that reason, the cardiac aspects of care in this paper are required knowledge.

Three of the authors of this paper are cardiologists, two are psychiatrists, and one is a clinical pharmacist. They have produced a very practical document on identifying problems with tachycardia, QTc prolongation, sudden cardiac death, myocarditis, and dilated cardiomyopathy.  They provide very specific endpoints and suggest some basic intervention that can be done before the patient is referred to cardiology. Examples would be assessment of tachycardia, suggested treatment thresholds, common treatment interventions like beta-blockers and calcium channel blockers, and referral to cardiology if there is a progression to other cardiac symptoms, nonresponse to the initial therapy, or an arrhythmia beyond sinus tachycardia. They provide similar guidance on the other common conditions and relate them to second-generation antipsychotics (SGAs). 

All of the authors are from the United Kingdom.  I am not familiar with the standard settings for practicing psychiatry in the UK, but in the US there is a high degree of variability. For example, in practicing on inpatient settings it is not a problem to order ECGs or even stat ECGs. Echocardiograms and other imaging studies of the heart are easily obtained as well as cardiology consultation. In a previous inpatient setting where I practiced, I requested a cardiology consultation for a young woman with a QTc of 520 ms who required treatment with antipsychotic medications. She was seen immediately and an electrophysiology study was done. After that study I was advised by cardiology that I could safely treat the patient with olanzapine. At the other end of the spectrum, I know there are psychiatrists reading this who have no access ECGs, medical testing, or cardiology consultants. They are often practicing in an office that lacks a sphygmomanometer or staff routinely checking patient vital signs. Many of those office settings are essentially nonmedical and any psychiatrist practicing there - would need to bring in their own equipment and probably take their own vital signs.  A basic standards would be that every practice setting for psychiatry in the country should have the tools to make the measurements recommended in this paper, but I am not aware that any standard like that exists.

The second obstacle to realizing these guidelines is the way electronic health records (EHR) are set up. Major organizations and the EHR companies themselves produce templates that are typically designed for business purposes rather than medical quality. A visit to a psychiatrist in that organization results in that template being filled out with a business rather than a clinical focus. In other words, sections of bullet points are completed based on what coders believe will capture the necessary billing from insurance companies. One of the key sections is often the review of systems (ROS). Because these documents are not designed by physicians and there are no uniform standards, a functional review systems is often not there. In the case of cardiac symptoms, there needs to be a clear section that encompasses all the symptoms described by the authors in this paper. As an example, take a look at the cardiac symptomatology that I recorded in this post and the modified extended review of systems that I typically ask patients about.

Any inpatient or outpatient assessment done by a psychiatrist should include a thorough medical history, a review of systems that is focused on medical rather than psychiatric systems, a set of vital signs including noting whether or not the cardiac rhythm or pulse is regular or irregular and a further description of the irregularity.  A focal exam for additional heart and lung findings and determination of pulses and peripheral edema may be indicated.  The take home point is that this history taking combined with a few additional findings should be all that is necessary to order further tests like an ECG, refer for an acute assessment, or refer to a primary care physician or cardiologist for further assessment.  If the patient is being followed for the metabolic complications of SGAs, there may already be a fasting blood glucose, and lipid profile in the chart to assess additional risk factors.  Over the years I have also found that recording a theory about why I think the patient is symptomatic is also very useful.  In my practice that has ranged from medication side effects to an acute myocardial infarction.

With those issues we can proceed to consider the assessments and treatments recommended by this group. I am not going to repeat the content of the paper here.  I recommend that any interested psychiatrist or psychiatric resident get a copy of this paper and study it in detail if you are not already familiar with the concepts. I will list a few of the points that I found to be interesting after doing these assessments for a long time.

Tacycardia is a common problem in psychiatric patients and the population in general. Here the authors were focused on tachycardia as a side effect of SGAs and haloperidol.  They produced a table showing the incidence of tachycardia across a number of SGAs and haloperidol and illustrate that clozapine by far has the highest prevalence of tachycardia. In the table haloperidol, asenapine, and sertindole at the lowest incidence of tachycardia at about 1%. They point out this problem is generally self-limited but it suggests a number of investigations that should be considered before monitoring for improvement over time. The recommended treatments (bisoprolol, ivabradine) are not recognizable medications for physicians in the US. In the US, beta-blockers are commonly used. They suggested treatment is predicated on whether patients are symptomatic or not with palpitations. Although UpToDate describes sinus tachycardia as a benign condition with no worse outcome than a control group, this tachycardia is drug-induced. My main concern with persistent drug-induced tachycardia is tachycardia induced cardiomyopathy. My other concern is that common causes of tachycardia in the patients I see include excessive use of caffeine (alcohol, or other substances), deconditioning, and sleep deprivation. Establishing a baseline prior to any of these prescriptions is important.  There is always a lot of debate about whether or not electrocardiogram should be done. I agree with the authors that the ECG is an inexpensive screen and should be done to make sure that it is a sinus rhythm. Another bit of information that may not be available is whether the pulse is irregular or not. Many clinics have automatic blood pressure and heart rate measuring devices and not all of them make that determination.

The section on the QTc interval was interesting because the authors provide very clear guidance on measuring QTc, the problems with that measurement, and very clear guidelines on what to do about that measurement. They cite the threshold for stopping or reducing treatment with QTc prolonging agents as an interval greater than 500 ms or relative increase of greater than 60 ms. They also use the American Heart Association definitions of prolonged as QTc > 450 ms in men and > 460 ms in women.  They point out that the most common calculation of QTc (Bazett’s formula) overcorrects heart rates greater than 100 BPM and they suggest that other formulae may be used for that situation. Like many psychiatrists I have ordered hundreds of ECGs for determining baseline cardiac conduction. The vast majority have been normal. The ones that were not - were typically unrelated to the medication I was prescribing. Many conduction abnormalities were related to increasing age and latent cardiac problems. The other common scenario where I am concerned about cardiac conduction is polypharmacy. It is possible for a person to be taking multiple medications for psychiatric indications - all of which may affect cardiac conduction. The drug interaction software for most EHRs as a very low threshold for this type of interaction.

The myocarditis section of this paper was very interesting. In Table 1 - the authors included prevalence figures for myocarditis in the same table where they documented the prevalence of tachycardia for each medication. The figures are based on isolated case reports. The review the controversy about clozapine and widely variable reports of incidence. The incidence quoted for Canada and the USA was 0.03%. Different criteria used to diagnose myocarditis was considered an important point of variance. A set of clinical criteria is provided in the paper as well as when to refer to a cardiologist. In addition to the ECG, serum troponin, C-reactive protein, echocardiogram, and cardiac MRI are considered. The referral indicators included elevated troponin, CRP, and abnormalities at echocardiogram. My interpretation is that psychiatrists in the US who have access to those measures and ready access to cardiologists could potentially use those markers. The most reasonable approache is to be able to recognize the symptoms of myocarditis clinically and be able to refer the patient to cardiology were most of the testing could occur. The clinical description of myocarditis in the paper sounded very similar to typical viral myocarditis with chest pain, dyspnea, flu-like illness, fever, and fatigue. These are nonspecific symptoms especially during influenza season. The clinician has to have a high index of suspicion based on treatment with clozapine. The paper contains an ECG tracing of saddle -shaped ST elevation considered to be a finding consistent with myocarditis. It was visible in most leads.

The approach to dilated cardiomyopathy was very similar in terms of recognizing the symptoms of congestive heart failure and the necessary investigations. There was guidance and when to request an echocardiogram based on BNP and in NT-ProBNP measures as well as when referral to cardiology was indicated. The standard of care in the US is the psychiatrist recognizing what is happening but not treating dilated cardiomyopathy. In most clinical with limited resources, this is a good reason to have a referral relationship with a primary care clinic - especially one that can do the testing on site. There are many primary care and even urgent care clinics that cannot do the testing suggested in this paper.

In the case of myocarditis and dilated cardiomyopathy, the question of whether a patient should be re-challenged if they need the offending medication and their underlying cardiac condition has improved. The authors suggest close consultation with a cardiologist at that point. Given the data my own practice has been to not re-challenge with the offending medication but to try a different treatment modality. The concern in the article is that the patient’s ability to function from a psychiatric standpoint may require use of that specific medication. I do not think that enough is known about the outcome of either condition to resume the original medication, but if favorable outcome studies or case reports exist, I might revise that opinion.

All things considered this is an outstanding article on the cardiotoxicity of SGAs. The graphics in the paper also excellent with management flow diagrams and well-designed tables.  The authors restate that cardiotoxicity is very low.  It is the job of every psychiatrist who prescribes these medications and others to make sure that patients are monitored for these complications. There is always a question of what constitutes adequate informed consent when we are talking about a potential complication rate of 0.03%. At that level it is certainly possible that many psychiatrists have never seen these complications and never will. I think it is reasonable to let people know that medications they are taking can cause rare but potentially serious side effects including death. The informed consent issue was not touched on in the paper but a day-to-day practice it is an important one.  From a practical standpoint I generally advise people that if they are taking a medication with rare but potentially life threatening side effects, they have to take all physical symptoms seriously. Physical symptoms cannot be attributed to common explanations like colds, the flu, or gastroenteritis.

This paper had a very specific focus and it did not touch on the other metabolic and neurological complications of these medications that require additional screening.  One of the reasons I posted my ROS document on this blog was to make ti easy for any clinic or psychiatrist to build their own template with the relevant questions needed for their own patient population. 

For some psychiatrists and clinics the work in cardiac screening just got a lot harder.  For others who have been doing all of this for decades - there will be very little difference.



George Dawson, MD, DFAPA



References:

1:  Sweeney M, Whisky E, Patel RK, Tracy DK, Shergill SS, Plymen CM.  understanding and managing cardiac side effects of second-generation antipsychotics in the treatment of schizophrenia. Br J Psych Advances 2019: 1-15.

2:   Patel RK, Moore AM, Piper S, Sweeney M, Whiskey E, Cole G, Shergill SS, Plymen CM. Clozapine and cardiotoxicity - A guide for psychiatrists written by cardiologists. Psychiatry Res. 2019 Jul 24:112491. doi:10.1016/j.psychres.2019.112491. [Epub ahead of print] Review. PubMed PMID: 31351758.