Wednesday, December 26, 2012

Psychiatric opinion on same-sex marriage is more acceptable than an opinion on violence and aggression

I was surprised to see an insert in my psychiatric newsletter this month describing the efforts of four major mental health professional associations in opposing an amendment to the state constitution that would exclude same-sex couples from legal marriage.  The Minnesota Psychiatric Society, the Minnesota Psychological Association, the Minnesota chapter of the National Association of Social Workers, and the Minnesota Association of Marriage and Family Therapists produced this document that in essence says that there are no research findings to suggest that children from same-sex parents differ from heterosexual parents in outcomes.  The newsletter editor's column explains that there is apparently no policy on the MPS taking a stance on political and societal issues.  She put that question out to the general membership.  MPS President Bill Clapp, M.D. stated the issue succinctly:

"The MPS Executive Committee was painfully aware that the development of a consensus statement regarding marriage amendment could not possibly represent the diverse opinions of all Minnesota psychiatrists.  On the other hand we felt a responsibility to act faithfully in representing our many patients who believed the marriage amendment violated their civil rights and was overtly discriminatory". 

I think there are a number of issues relevant to this opinion that are interesting to contemplate.  First and foremost is bias in the media.  Over 2 years ago the MPS partnered with two other mental health organizations The Barbara Schneider Foundation, and SAVE - Suicide Awareness Voices of Education in producing a statement on violence prevention.  That statement highlights the lack of mental health resources, lack of training in dealing with these incidents, and the lack of quality standards in assessing and treating patients having problems with violent and aggressive behavior.  That statement was rejected by the newspaper editor. The only reason given was a potential conflict of interest because we were advocating for research and that nonspecific advocacy was viewed as a problem.  In the two years since the statement was produced, it is clear that the issues we raised are as important as ever.  My first question is why that statement pertaining to issues that mental health clinicians and the organizations involved deal with on a day by day basis was not acceptable and a statement on a purely political issue was.

I personally voted against the constitutional amendment and think that any reasonable person would.  None of my criticisms of this initiative outweighs the value of getting the research literature out there for public consumption.  It may have been useful to provide a link to all of the available research in an easily accessed format like Medline.  

On the other hand after treating violent and aggressive people and people with severe mental illnesses and addictions for 23 years, it seems like using a professional organization to take a political position on same sex marriage is a stretch.  One could argue that anything that affects the nurture of individuals is relevant to psychiatry, but there are probably few psychiatric societies that take positions on those topics.  I do think this illustrates that the media is much more willing to accept psychiatric opinion on a purely social and political issue, rather than an issue that is immediately relevant to the practice of psychiatry.

I have two minor objections about this initiative. First, it is too easy. The majority of psychiatrists are Democrats and psychiatry is the only medical specialty where that is true. It is fairly predictable that the majority of psychiatrists would support this initiative.  It is good to know that the position is supported by scientific data but I don't think that fact or the fact that psychiatrists support a political measure would carry any weight with voters.  Given the negative press associated with psychiatry and the tendency of the press to to cast psychiatry in the worst possible light, there is also the question of possible backlash against any measure supported by organized psychiatry.  The negative press about the DSM5 and antidepressants are two good evidence based examples.

My second objection is that there are numerous problems that affect psychiatric practice on a day-to-day basis where there should be immediate and very aggressive political action. Some of these topics have been ignored for decades at both the state and national levels. If I had to come up with a top 10 list (no particular order) it might look something like this:

1.  The intrusion of managed care into the practice environment.
2. The intrusion of pharmacy benefit managers into the practice environment.
3. The intrusion of managed care practices into government-funded programs.
4. Mismanagement of public facilities.
5. Mismanagement of quality measures at the population level in the state of Minnesota.
6.  The lack of timely care of acute psychiatric problems (considerable overlap with number one above).
7. Poorly thought out guidelines for reimbursement of psychiatric care emphasizing low quality high volume medication focused practices as opposed to psychosocial treatments that are often as effective.
8. Lack of uniform application of civil commitment statutes on a county by county basis.
9. Lack of crisis intervention services in more than half of Minnesota counties.
10. Inadequate residential services for people with chronic mental illnesses, addictions, and children with psychiatric problems.

In terms of a guiding principle, a professional organization needs to advocate for what adversely impacts its members every day. When you have issues on the above list that are not only pressing but have been pressing for two decades the question becomes: "Why has nothing been done?"  It is much more uncomfortable to do something relevant to every practicing psychiatrist than something that most psychiatrists would have done anyway.

The other factor is that none of the issues on the list was ever voted on.  This is a key dimension in American politics.  Business lobbyists working behind the scenes at the state and federal levels generally get what they want flying under the radar.  They are there every day pushing a pro-business and in many cases pro-government agenda.  The last thing they want is any political reform that actually tips the balance in the direction of patients and physicians.

There were no referendums or amendments put up for a vote when the Minnesota statutes were rewritten to favor managed care companies.  That is where the heavy lifting is for professional groups in American politics and that is where MPS needs to be.

George Dawson, MD, DFAPA

Daniel Christensen, Kathleen Albrecht, Bruce Minor and Bill Clapp.  Children parented by same-sex couples do just fine.  StarTribune October 28, 2012

Tuesday, December 25, 2012

What is wrong with the APA's press release about the NRA statement?

The APA released a statement about the NRA's comments, probably Mr. LaPierre's statements on Meet the Press on Sunday and a separate NRA release. There are several problems with the APA statement:

1.   The American Psychiatric Association expressed disappointment today in the comments from Wayne LaPierre…

Why would the APA be "disappointed" in a predictable statement from a gun lobbyist?  I really found nothing surprising in Mr. LaPierre's presentation or the specific content. As I previously posted, the NRA predictably sees guns as the solution to gun violence.  The concept "more guns less crime" has been a driving force behind their nationwide campaign for concealed carry laws. The concealed weapons that are being carried are handguns and handguns are responsible for the largest percentage of gun homicides in the United States. It is probably a good idea to come up with a solution rather than reacting to a predictable statement.

2.  The person involved in the shooting is named…

Although it is controversial, there is some evidence that media coverage is one factor that can lead predispose individuals to copy a particular crime.  Although this press release is a minimal amount of information relative to other news coverage, it does represent an opportunity for modeling techniques for more appropriate media coverage and that might include anonymity of the perpetrator.  The NRA release makes the same mistake.

3.   In addition, he conflated mental illness with evil at several points in his talk and suggested that those who commit heinous gun crimes are “so possessed by voices and driven by demons that no sane person can ever possibly comprehend them,” a description that leads to the further stigmatization of people with mental illnesses.

It is always difficult to tell how rhetorical a person is being when they use terms like "evil" and "demons". If they are considered to be descriptive terms for a supernatural force that suggests an etiology of mental illness that was popular in the Dark Ages.  Evil on the other hand does have a more generic definition of "morally wrong or bad;  immoral; wicked”.  In this case it is important to know if the speaker is referring to a definition that is based on evil as a supernatural force or a more common description. This is another educational point. People who experience voices and irrational thoughts involving homicide can be understood. Psychiatrists can understand them and can help them to come up with a plan to avoid acting on those thoughts and impulses and getting rid of them.  The NRA release is basically an indication of a high degree of naïveté in thinking about the unique conscious state of individuals.  The APA release should correct that.

4.  The APA notes that people with mental illnesses are rarely violent and that they are far more likely to be the victims of crimes than the perpetrators

The actual numbers here are irrelevant.  Psychiatric epidemiology cannot be casually understood and the media generally has the population whipped up about the notion of psychiatric overdiagnosis of everything anyway. The idea that some mentally ill persons are dangerous is common sense and forms the basis of civil commitment and emergency detention laws in every state of the union. Advocates need to step away from the notion that recognizing this fact is "stigmatizing". The APA needs to recognize that their members in acute care settings are dealing with this problem every day and need support. It is an undeniable fact that some persons with mental illness are dangerous and it is an undeniable fact that most of the dangerous people do not have mental illness. Trying to parse that sentence usually results in inertia that prevents any progress toward solutions.

The APA seems to have missed a golden opportunity to suggest a plan to address the current problem. The problem will not be addressed by responding to predictable NRA rhetoric.  There several other nonstarters in terms of a productive dialogue on this issue including - the specifics of the Second Amendment and specific gun control regulations. The moderator of Meet The Press made an excellent point in the interview on Sunday when he asked about closing the loophole that 40% of gun purchases occur at gun shows where there are no background checks. It was clear that the NRA was not interested in closing that loophole. The main problem is that the APA has no standing in that argument. Second nonstarter is the whole issue of predictability. Any news outlet can find a psychiatrist somewhere who will comment that psychiatrists cannot predict anything. That usually ends the story. If your cardiologist cannot predict when you will have a heart attack, why would anyone think that a psychiatrist could predict a rare event happening in a much more complicated organ? Psychiatrists need to be focused on public health interventions to reduce the incidence of violence and aggression in the general population and where it is associated with psychiatric disorders. 

What about Mr. LaPierre’s criticism of the mental health system?

“They didn't want mentally ill in institutions. So they put them all back on the streets. And then nobody thought what happens when you put all these mentally ill people back on the streets, and what happens when they start taking their medicine.  We have a completely cracked mentally ill system that's got these monsters walking the streets. And we've got to deal with the underlying causes and connections if we're ever going to get to the truth in this country and stop this…”

Is it an accurate global description of what has happened to the mental health system in this country? He certainly is not using the language of a mental health professional or a person with any sensitivity toward people with mental illness.  There are numerous pages on this blog documenting how the mental health system has been decimated over the past 25 years and some of the factors responsible for that. Just yesterday I was advised of a school social worker who not only was unable to get a child hospitalized but could not get them an outpatient appointment to see a psychiatrist. The government and the managed care industry have spent 25 years denying people access to mental health care and psychiatrists. They have also spent 25 years denying people access to quality mental health care that psychiatrists are trained to provide. We have minimal infrastructure to help people with the most severe forms of illness and many hospital inpatient units do discharge people to the street even though they are unchanged since they were admitted.   Any serious dialogue about the mental health aspects of aggression and violence needs to address that problem.

That is where the APA’s voice should be the loudest.

George Dawson, MD, DFAPA

Supplementary Material:  Quotes from and locations of transcripts – feel free to double check my work.

"I'm telling you what I think will make people safe. And what every mom and dad will make them feel better when they drop their kid off at school in January, is if we have a police officer in that school, a good guy, that if some horrible monster tries to do something, they'll be there to protect them." (p2)

"Look at the facts at Columbine. They've changed every police procedure since Columbine. I mean I don't understand why you can't, just for a minute, imagine that when that horrible monster tried to shoot his way into Sandy Hook School, that if a good guy with a gun had been there, he might have been able to stop..."—(p3)

"There are so many different ways he could have done it. And there's an endless amount of ways a monster.."—(p6)

"I don't think it will. I keep saying it, and you just won't accept it. It's not going to work. It hasn't worked. Dianne Feinstein had her ban, and Columbine occurred. It's not going to work. I'll tell you what would work. We have a mental health system in this country that has completely and totally collapsed. We have no national database of these lunatics." (p6)

"23 states, my (UNINTEL) however long ago was Virginia Tech? 23 states are still putting only a small number of records into the system. And a lot of states are putting none. So, when they go through the national instant check system, and they go to try to screen out one of those lunatics, the (p6)

"I talked to a police officer the other day. He said, "Wayne," he said, "let me tell you this. Every police officer walking the street knows s lunatic that's out there, some mentally disturbed person that ought to be in an institution, is out walking the street because they dealt with the institutional side. They didn't want mentally ill in institutions. So they put them all back on the streets. And then nobody thought what happens when you put all these mentally ill people back on the streets, and what happens when they start taking their medicine."We have a completely cracked mentally ill system that's got these monsters walking the streets. And we've got to deal with the underlying causes and connections if we're ever going to get to the truth in this country and stop this"—(p7)

"The truth is that our society is populated by an unknown number of genuine monsters — people so deranged, so evil, so possessed by voices and driven by demons that no sane person can possibly ever
comprehend them." (p2)

"Yet when it comes to the most beloved, innocent and vulnerable members of the American family — our children — we as a society leave them utterly defenseless, and the monsters and predators of this world know it and exploit it. That must change now!" (p2)

"As parents, we do everything we can to keep our children safe. It is now time for us to assume responsibility for their safety at school.  The only way to stop a monster from killing our kids is to be personally involved and invested in a plan of absolute protection. The only thing that stops a bad guy with a gun is a good guy with a gun. Would you rather have your 911 call bring a good guy with a gun from a mile away ... or a minute away?" (p5)

"Now, I can imagine the shocking headlines you'll print tomorrow morning: "More guns," you'll claim, "are the NRA's answer to everything!" Your implication will be that guns are evil and have no  place in society, much less in our schools. But since when did the word "gun" automatically become a bad word?" (p5)

"Is the press and political class here in Washington so consumed by fear and hatred of the NRA and America’s gun owners that you're willing to accept a world where real resistance to evil monsters is a lone, unarmed school principal left to surrender her life to shield the children in her care?" (p6)

Additional Reference:

Copycat Phenomenon in medical literature (references 5, 13, 20, 26 are most relevant).

Saturday, December 22, 2012

90862 Redux?

My original post on the problems with the 90862 CPT code has turned out to be one of the most popular posts on this blog.  I decided to revisit that post in the context of the impending code changes the first of the year.  The headline in this weeks Clinical Psychiatry News says it all: "New E&M Coding Set to Go Into Effect Jan. 1".  The article encourages psychiatrists to learn the new system in the hope that they will be able to get more fair reimbursement in the future.  The explicit downside is that more documentation will be required.  In my own practice more complex E&M codes can require anywhere from two to four times as much time and effort to document with additional time to managed the case apart from additional telephone calls, lab review, and consultation.  The implicit downside is that despite the promise of more reasonable reimbursement that will actually take political action as stated: "Values might rise in 2014, after the professional societies have a chance to survey psychiatrists on the new codes and the RUC (Relative Value Update Committee) looks at revaluing those codes..."

For anyone reading this who does not have a knowledge of this coding system this template from the American Academy of Family Practice provides a good summary.  To give a general idea of the subjectivity of this entire system, I have been documenting and billing 15 and 30 minute 90862s at my current employer for over two years.  Our coding expert told me that all of these notes would meet criteria for 99214.  Actual time with the patient is roughly 20-30 minutes with 10-20 minutes added onto that for associated tasks (lab ordering, call to other doctor, associated paperwork, etc).  I have been billing like this for most of my career, except in a previous specialty clinic where I used E & M codes.

The interesting aspect of this coding system that I always come back to (and can't emphasize enough) is the near total subjectivity of it.  I have described my 90862 procedure and that usually results in a note of about 300 to 500 words.  When I review the notes of other psychiatrists, I often see the note condensed to 4 brief sentences.  The entire note can be less than 75 words.  It is often difficult to tell if an actual conversation occurred between a doctor and a patient.  I describe this to point out the huge variation in the documentation of clinical practice and there is good reason for it.   Compulsive documentation takes an incredible amount of time.  It is usually not possible for me to complete the documentation that I think is necessary during the regular work day and I know I am not alone.  I have called primary care physicians at 7 or 8 PM to find many of them still there trying to catch up on all of the paperwork and documentation from that day.  That is a lot of time investment because of a vague guideline.

The most interesting aspect of coding is how it has been used to intimidate physicians by both the government and the insurance industry.  Apart from satisfying billing requirements most physicians engaged in compulsive documentation are doing it because of the threat of a coding audit.  In that situation the actual notes are reviewed and somebody makes a decision about whether the documentation meets certain coding requirements for a particular bill.  If the decision is no - the physician involved could face massive financial repercussions.  Some insurance companies will look at 10 notes and on that basis calculate a rate of overcoding and multiply that rate by the total patient they cover in that practice and demand repayment.   Although this physician has apparently not been told why the FBI decided to close down her practice, the tactics described on her blog are the similar to those described in cases of alleged billing "fraud".  Keep in mind the only scientific study of this process showed that professional coders could agree that a document reflected a particular billing code at a rate no greater than chance.

Anyone who has read along to this point have probably picked up on the fact that I am not very hopeful that this is a major reform in psychiatric reimbursement.  This whole system was invented to control physician reimbursement and not improve it.  It is a system that looks like it may have some objectivity on the surface but beyond the surface it is pure politics.  The best example I can think of is that any insurance company can decide to reimburse physicians at any rate they want.  They may decide for example that "Dr. Dawson has been billing 90862s for decades, why would we want to suddenly reimburse him for 99214s?  We will just pay him the same regardless of what his coding expert or billing document says."  Just another inefficiency that physicians need to tolerate that detracts from the provision of medical care.

George Dawson, MD, DFAPA  

King MS, Lipsky MS, Sharp L. Expert agreement in Current Procedural Terminology evaluation and management coding. Arch Intern Med. 2002 Feb 11;162(3):316-20.

"The only thing that stops a bad guy with a gun is a good guy with a gun"

That is a direct quote from the NRA's chief lobbyist Wayne Lapierre.  In the same NYTimes piece he goes on to say that declaring our schools gun free zones serves only: "“tell every insane killer in America that schools are the safest place to effect maximum mayhem with minimum risk.”  There has been some mild outrage in response to this comments but I don't know what people would expect from the NRA.  They see guns as a solution to everything.  They literally believe that with guns there is less crime despite the hard data that points to the fact that the USA has the highest (by far) homicide rate by firearms, the highest rate of gun ownership, and the highest rate of assault deaths of any of the top 30 countries of the Organization for Economic Cooperation and Development.  In fact, this NY Times graphic of the data shows that over half of the homicide rate is firearm related.  The total homicides in the US at 9,960 is nearly seven times greater than the total of all the other countries on the list.  The total number of suicides by firearms greatly exceeds this number (18,735 in 2009).  It seems to me that the gun data suggests that we currently have maximum mayhem with maximum risk.

Getting back to the proposed NRA solution.  Let's look at the arithmetic first.  Just considering the number of public schools in the US, current data from the National Center for Education Statistics puts that number at 98,817.  Assuming a cost of one armed guard per school with vacation coverage and benefits I would conservatively estimate a cost of about $100,000 per year or a total of about $9.8 billion dollars per year.  That is a substantial outlay of capital for what is an unproven strategy.  According to the Wikipedia list there have been 40 school shootings since 1989.  Using a a mean number of schools during the period (or about 91,638) would mean that the odds of one of these armed guards encountering a shooter would be about 2/91,638 on an annual basis.  The Transportation Security Administration responsible for airport security has a total budget of  $7.7 billion and they cover 450 airports but confiscate 1,300 firearms and 125,000 prohibited items per year.  $929 million of the TSA budget is for the Federal Air Marshal Service that assigns agents to commercial flights.  To put an armed guard in the schools would roughly cost what it costs to secure air travel in the US.  The main difference would be that school guards might have a much lower level of vigilance than air travel security and they would need to be very vigilant to head off a sudden and potentially very lethal attack.

Arithmetic aside, there is also the question of associated costs.  In medicine we are familiar with the screening arguments for breast and prostate cancer.  There is always a false positive and false negative cost.  With false positive PSAs and mammograms there is the ordeal of unnecessary biopsies and exposure to other unnecessary tests.  There is no way to estimate the impact of armed guards at schools.  Currently there are about 500,000 violent crime and over a million thefts committed against teachers in America's middle and high schools.  In a previous Institute of Medicine report,  the authors found that a  "substantial number of boys" carry firearms in schools.  That same study reported:

"Despite all this effort to keep guns from children  the committee was somewhat astounded at the ease with which the young people in these cases acquired the weapons they used.  Only in the Jonesboro case were the powerful weapons in the home of one of the too well secured for them to access.  But it was easy to defeat the security measures of another relative and get hold of a powerful semiautomatic rifle with a scope.  In general, it is easy for young teens to circumvent both the law and informal controls designed to deny them weapons they use in their crimes." (ref 1)

There is also the risk of unintentional discharge of weapons.  The New York City Police Department keeps a public record of all weapons discharges from its 33,497 police officers.  According to this report there have been 15-27 "unintentional discharges" per year over the past ten years.  With a school workforce nearly three times as large and possibly less vigilant than an NYPD officer that is potentially a lot of accidental discharges.   How many are acceptable in and around our schools?  The false negative/false positive cost of putting  armed guards into schools based on these factors is really unknown.  

Considering this problem has also led me to think about some epidemiological concepts that we were all taught in medical school.  Primary prevention measures are designed to reduce the incidence of new cases of disease.  Secondary prevention is focused more on people who are identified as being at risk but who are unaware of the fact that they may have the problem.  Tertiary prevention occurs after the problem is declared.  In the case of suicidal or homicidal behavior that means after the critical incident occurs.  This paper looks at these concepts in the case of suicidal behavior.  As far as I can tell there has been no exhaustive look at a timeline of all of the preventive factors that occur prior to mass shooting events or school violence events.  The usual method of analysis is looking at cases for a common profile and as the IOM report showed - there was none.

This analysis cannot predict whether the NRA stand on guns in schools will be protective or not.  It is much more complex than a statement that guns are a solution to gun crimes.  Based on what we know about these situations a key strategy is preventing the shooter from picking up the weapon in the first place.

George Dawson, MD, DFAPA

1.  National Research Council and Institute of Medicine. (2003) Deadly Lessons - Understanding Lethal School Violence.  Case Studies of School Violence Committee.  Mark H. Moore, Carol V. Petrie, Anthony A. Braga, and Brenda L. McLaughlin, Editors.  Division of Behavioral and Social Sciences and Education.  Washington, DC: The National Academies Press.

2.  Ganz D, Braquehais MD, Sher L (2010) Secondary Prevention of Suicide. PLoS Med 7(6): e1000271. doi:10.1371/journal.pmed.1000271

3.  New York City Police Department.  Annual Firearms Discharge Report 2011.

4.  Meet  the Press Transcript. Sunday December 23, 2013.  Wayne LaPierre discusses current NRA positions on school safety and gun control.

Tuesday, December 18, 2012

Homicide Debate Goes Further Off the Rails

Apparently broadcast news is about as reliable as the Internet these days.  I was watching an "expert" on the weekend discuss the connection between homicide and antidepressant medications.  He apparently believed that there was one.  I understand that Sanjay Gupta made a similar comment today on CNN.  The misinformation is flying out there.  There are several political interests that would like that statement to be true and they appear to be out in full force. What is the short answer to the association between antidepressants and homicide?  Who can you believe?

Well there is always the scientific approach and a review of the medical literature.  Admittedly the literature is a lot drier and less entertaining than Dr. Gupta.

There is also simple arithmetic   The American media like to give the impression that violent crime and homicide are at epidemic levels.  It is always a shock when people discover that in fact we are at a 30 year low:

The homicide rate has actually declined from 10.2 per 100,000 in 1980 to 5.0 per 100,000 in 2009.  What are the odds of that happening if a major new cause of homicide is being added at the same time (namely antidepressants).  How does that compare with antidepressant use?  A recent study estimated that from 1996 to 2005, the number of Americans older than 6 years of age in surveyed households who received at least one antidepressant in the year studies increased from 5.84% in 1996 to 10.12% in 2005.  From the table there was a 24% reduction in the homicide rate during a time that antidepressant use nearly doubled.  One in ten Americans received an antidepressant prescription   The authors of this study noted this trend was broad based and correlated with a lower percentage of people receiving psychotherapy.

But what does that tell us about the observation that antidepressants cause homicide?  Technically there is no current way to demonstrate causality from a negative correlation between homicide rates and the rate of people taking antidepressants.  A large scale significant negative correlation between antidepressant use and lethal violence over a 15 year period has already been reported in the Netherlands.

What about the commentator suggesting that the toxicology of homicide perpetrators shows that they can have psychiatric drugs present that explain their homicidal behavior.  In fact, a study looking at that issue showed that 2.4% of 127 murder-suicide perpetrators had toxicology that was positive for antidepressants.  That is a lower than expected rate of antidepressant use than in the general population.   In a study of elderly spousal homicide-suicide perpetrators, depression was seen as an antecedent to this act but none of the perpetrators tested positive for antidepressants.

Given these observations any claim that antidepressant or any psychiatric drug causes homicidal behavior needs to be backed up with some hard data.  I don't mean a series of cases reported by somebody to make a point and I don't mean a legal decision where lawyers and judges can pretend that scientific data do not exist and make a decision about what they hear in a court room.  I also do not mean listening to somebody claim that we will never know the real relationship until we conduct "prospective double blind placebo controlled studies" of homicidality as a medication side effect.  If it isn't obvious, that study would by definition be unethical and would not pass the scrutiny of any human subjects committee.

Anyone with potential homicidal thinking needs close supervision and treatment.  They may need inpatient treatment in a unit that specialized in treating homicidal thinking and behavior.  Any clinician working in these settings will tell you that the people being treated generally come in with aggressive and violent thoughts and behavior before they take any medication.  If they have positive toxicology associated with homicidal thinking it is generally alcohol or an illicit drug like cocaine or methamphetamine.  Anyone with this problem also needs close monitoring and management of medication side effects.  Antidepressants can cause agitation and restlessness.  There are some people who do not benefit from antidepressants.  In the case of persons with the potential for aggression and suicide the medication response may need to be determined in a controlled environment before they can be safely treated.  Like all medications antidepressants are not perfect medications and they need to be administered by an expert who can provide effective treatment while managing and eliminating any potential drug side effects.

George Dawson, MD, DFAPA

Friday, December 14, 2012

Guns Are Not Cooling Off Between Mass Shootings

I have previously posted my concerns about mass shootings and the general paralysis on dealing with this problem.  The gun lobby has unquestionable political power on this issue, but that is also due to judicial interpretation of the Second Amendment as it is written.  Today's New York Times describes a mass shooting at an elementary school in Connecticut.  At the time I am typing this, the death toll is 20 children, 6 adults, and the gunman.  This incident occurs three days after a shopping mall shooting in Oregon.

Most people would think that nothing would be more motivating for major societal changes than children being attacked in this manner.  Unfortunately this is not the first time that children have been victimized by mass shooters.  On October 2, 2006 a gunman shot 10 girls and killed 5 before committing suicide.  According to the Wikipedia article that was the third school shooting that week.  Altogether there have been 31 school shootings since the Columbine incident on April 20, 1999.

My question and the question I have been asking for the past decade is what positive steps are going to be taken to resolve this problem?  How many more lives need to be lost?  How many more children need to be shot while they are attending school?  Some may consider these questions to be provocative, but given the dearth of action and the excuses we hear from public health officials and politicians, I am left in the position of continuing to sound an alarm that should have been heard a couple of decades ago.  After all, the elections are over.  The major parties don't have to worry about alienating the pro-gun or the pro-gun control lobbyists and activists.  This will not be solved as a Second Amendment or political issue.  I have said it before and I will say it again - the basic approach to the problem is a scientific one and a proactive public health one that involves the following sequence of action:

1.  Get the message out that homicidal thoughts - especially thoughts that involve random violence toward strangers are abnormal and treatable.  The public health message should include what to do when the thoughts have been identified.

2.  Provide explanations for changes in thought patterns that lead to homicidal thinking.

3.  Provide a discussion of the emotional, personal and economic costs of this kind of violence.

4.  Emphasize that the precursors to homicidal thinking are generally treatable and provide accessible treatment options and interventions.

5.  The cultural symbol of the lone gunman in our society is a mythical figure that needs to go.  There needs to be a lot of work done on dispelling that myth.  I don't think that this repetitive behavior by individuals with a probable psychosis is an accident.  Delusions do not occur in a vacuum and if there is a mythical explanation out there for righting the wrongs of a delusional person - someone will incorporate it into their belief system.  The lone gunman is a grandiose and delusional solution for too many people.  If I am right it will affect even more.

6.  Study that sequence of events and outcomes locally to figure out what modifications are best in specific areas.

One of the main problems here may be the deterioration in psychiatric services over the past three decades largely as a result of government and managed care manipulations.  Ironically being a danger to yourself or others is considered the main reason for being in an inpatient psychiatric unit these days.  I wonder how much of the inertia in dealing with the problem of mass homicide comes from the same forces that want to restrict access to psychiatric care?  Setting up the remaining inpatient units to deal with a part of this problem would require more resources for infrastructure, staff training, and to recruit the expertise needed to make a difference.

The bottom line here is that the mass homicide epidemic will only be solved by public health measures.  This is not a question of good versus evil.  This is not a question of accepting this as a problem that cannot be solved, grieving, and moving on.  This is a question of identifiable thought patterns changing and leading to homicidal behavior and intervening at that level.

George Dawson, MD, DFAPA

Wednesday, December 12, 2012

ADHD and Crime

There has been a lot of commentary on the NEJM article on the association between stimulant treatment of Attention Deficit Hyperactivity Disorder (ADHD) and less crime in a cohort of patients with ADHD.  Two of my favorite bloggers have commented on the study on the Neuroskeptic and Evolutionary Psychiatry blogs.  As a psychiatrist who treats mostly patients with addictions who may have ADHD and teaches the subject in lectures - I thought that I would add my opinion.

Much of my time these days is spent seeing adults who are also being treated for alcoholism or addiction. I also teach the neurobiological aspects of these problems to graduate students and physicians.  In the clinical population that I work with - ADHD is common and so is stimulant abuse/dependence and diversion.  Cognitive enhancement is a widely held theory on college campuses and in professional schools.  That theory suggests that you can study longer, harder, and more effectively under the influence of stimulants.  They are easy to obtain.  Stimulants like Adderall are bought, sold, and traded.  It is fairly common to hear that a feeling of enhanced cognitive capacity based on stimulants acquired outside of a prescription is presumptive evidence of ADHD.  It is not.  It turns out that anyone (or at least most people) will have the same experience even without a diagnosis of ADHD.

There is very little good guidance on how to treat ADHD when stimulant abuse or dependence may be a problem.  Some literature suggests that you can treat people in recovery with stimulants - even if they have been previously addicted to stimulants.  Anyone making the diagnosis of ADHD needs to makes sure that there is good evidence of impairment in addition to the requisite symptoms.  Ongoing treatment needs to assure that the stimulants are not being used in an addictive manner.  I would define that as not accelerating the dose, not taking medications for indications other than treating ADHD (cramming for an exam, increased ability to tolerate alcohol, etc), not attempting to extract, smoke, inject, or snort the stimulant, not obtaining additional medication from an illegal source, and not using the stimulant in the presence of another active addiction.  Addressing this problem frequently requires the use of FDA approved non stimulant medication and off-label approaches.

With the risk of addiction that I see in a a population that is selected on that dimension, why treat ADHD and more specifically why treat with medications?  The literature on the treatment of ADHD is vast relative to most other drugs studied in controlled clinical trials.  There have been over 350 trials and the majority of them are not only positive but show very robust effects in terms of treatment response.  The safety of these medications is also well established.

Enter the article from the NEJM on criminality and the observation that stimulants treatment may reduce the criminality rate.  This was a Swedish population where the research team had access to registries containing data on all persons convicted of a crime, diagnosed with ADHD, getting a prescription for a stimulant, and to assign 10 age, sex, and geography matched controls to each case.  Active treatment was rather loosely defined as any time interval between two prescriptions as long as that interval did not exceed six months.  The researchers found statistically significant reductions during the time of active treatment for both men (32%) and women (41%).      

I agree that this is a very high quality article from the standpoint of epidemiological research - but my guess is the editors of the NEJM already knew that.  This study gets several style points from the perspective of epidemiological research.  That includes the large data base and looking for behavioral correlates of another inactive medication for ADHD - serotonin re-uptake inhibitors or SSRIs.  There is a robust correlation with stimulants but not with self discontinued SSRIs.  They also analyzed the data irrespective of the order of medications status to rule out a reverse causation effect (treatment was stopped because of criminal behavior) and found significant correlations independent of order.

Apart from the usual analysis clinical and researchers in the field ranging from neurobiologists to researchers doing long term follow up studies do not find these results very surprising.  The Medline search below gives references of varying quality dating back for decades.  The pharmacological treatment certainly goes back that far.  The accumulating data suggests that where the disorder persists, it requires treatment on an ongoing basis.  A limited number of studies suggest that cognitive behavioral therapy (CBT) may be useful for adults with ADHD but not as useful for children or adolescents.  The practice of "drug holidays" prevalent not so long ago - no longer makes sense when the diagnosis is conceptualized as a chronic condition needing treatment to reduce morbidity ranging from school failure to decreased aggression to better driving performance.

One of the typical criticisms of epidemiological research of this design is that association is not causality, I think it is time to move beyond that to what may be considered causal.  In fact, I think it may be possible at this time to move beyond the double blind placebo controlled trial to an epidemiological standard and I will try to pull together some data about that approach.

George Dawson, MD, DFAPA

Lichtenstein P, Halldner L, Zetterqvist J, Sjölander A, Serlachius E, Fazel S, Långström N, Larsson H. Medication for attention deficit-hyperactivity disorder and criminality. N Engl J Med. 2012 Nov 22;367(21):2006-14. doi: 10.1056/NEJMoa1203241.

Criminality and ADHD:  Medline Search

Friday, December 7, 2012

Paradigm Shift or Typical Rhetoric?

"Humanism and science cannot be based on rhetoric and wishful thinking. They require hard work and dedication to both scientific methodology and humanistic concerns."  - Akiskal and McKinney - 1973  

Well I decided to interrupt a post I was working on to respond to more noise about everything that is wrong with psychiatry - at least according to one blogger and an author that he is reviewing.  The basic argument is that there is a push to "remedicalize" psychiatry because of pressure on psychiatrists from non physician providers.  Apparently psychiatrists are an expensive commodity- especially if they really don't know anything.  That argument is so poorly thought out - it is difficult to know where to start.

The medical basis of psychiatry is well recorded starting in European asylums.  At one point German psychiatry was firmly focused on brain studies and Alzheimer, Nissl and others were searching for the neuroanatomical basis of mental illnesses in the late 19th century.  Psychiatrists were the first physicians responsible for the large scale treatment of epilepsy and neurosyphilis.  Whenever a previously intractable condition became more treatable it seems like it was no longer under the purview of psychiatry.

If anything there was a push to demedicalize psychiatry with the advent of Freudian and later therapies - that for the most part were good literary efforts but seem to offer very little in terms of modern treatment apart from a few very broad guideposts. It probably persisted right up to the heyday of biological psychiatry in the US and I would put that sometime in the early 1980s.  A well read friend of mine suggested that when Freud was waiting for a call from the Nobel committee, it probably should have been the committee on Literature rather than Medicine.  Given Freud's subsequent impact on English literature - I think that was a keen observation.  It certainly had little to do with medicine.

The medical basis of psychiatry is well documented and all I have to do is  spin around in my chair and look at the texts I have on my book shelves.

The original work on delirium by Lipowski.  Three editions of Lishman's Organic Psychiatry.  Countless texts on consultation liaison psychiatry, geriatric psychiatry, addiction psychiatry, sleep medicine, psychosomatic medicine, and specialty volumes on Alzheimer's disease and other brain conditions.  Classic chapters in Lahita's Systemic Lupus Erythematosus on the cognitive and psychiatric aspects of SLE.  Every psychiatrist needs to know if there is a medical cause for the psychiatric problem being evaluated, if it is safe to treat a person given their medical comorbidity, and how to assure the medical and psychological safety of that patient they are treating.  That has always included the ability to make common and rare medical diagnoses, interpret physical findings, and interpret test results.  That last sentence is frequently minimized but it requires the ability to recognize patterns and manage information that is on par with any other specialist.

The idea that psychiatry requires "remedicalization" or has been "remedicalized" is another myth of the ill informed, but it does have a basis.  The basis is in how the managed care cartel has taken over and dumbed down the field.  Managed care companies would like nothing more than psychiatrists sitting in offices doing cursory interviews and handing out antidepressants.  Reviewers from managed care companies have essentially disclosed this to me over the years with comments like: "Psychiatrists are not supposed to manage delirum".   My reply:  "That's funny because the Medicine service transferred me this patient as 'medically stable' and with no delirium diagnosis."  Who in the hell else is going to manage delirious bipolar patients with hepatic or renal failure?

Of course I realize that managed care companies really don't care about my patients and in this case it was fairly explicit that they could save the "behavioral health" cost center a lot if they could shame me into transferring the patient back to Medicine.  My response was basically - you convince them to accept the patient and I will transfer them back.  It never happened.

The only "paradigm shift" required here is to let psychiatrists practice medicine at the level they are competent to provide, rather than rationing their services.  The quality of care will dramatically improve and that includes associated medical care and diagnoses determined based on the ability of psychiatrists to communicate with patients.  What is probably difficult to accept by the "paradigm shifters" no matter who they may be is that psychiatry is a difficult field.  You do have to know plenty of medicine and like all other medical specialties you need to know the theory.  When I trained in in medical school there was plenty of theory that we had to learn that never made it into mainstream practice.  Much of the neuroscience and genetics that applies to psychiatry already exceeds the applicability of what I was taught about theophylline in medical school.

The most difficult part about psychiatry is that you always have to be patient centered and know how to talk to people.  That falls flat if you don't have the expertise to recognize all of their their illnesses and help them get better.  The only real crisis in psychiatry is that it is being starved into non existence by the government and managed care companies.  They don't care what psychiatrists know and what they can do.  They don't want you to see one.

George Dawson, MD, DFAPA

Akiskal HS, McKinney WT Jr.  Psychiatry and pseudopsychiatry.  Arch GenPsychiatry 1973 Mar;28(3):367-73.