Monday, January 27, 2014

WIll Integrity Save Psychiatry?

The answer is - it  depends on how it is applied.

In the last two days, I have seen the integrity argument pulled out.  Allen Frances is still using his bully pulpit on the Huffington Post, where it seems that anything critical of psychiatry is readily posted.  In this case, he used the text of a blogger and the timeline created by this blogger to illustrate how there was no disclosure of a conflict of interest by a group of researchers, one of whom was the chair of the DSM-5 Task Force.  The APA investigated this and acknowledged the non-disclosure of the conflict of interest.  Apparently the acknowledgement in the form of an apology from the research group and the investigation by the APA is not enough for these critics.  The blogger Dr. Nardo suggests that an "outside panel" be appointed to review his findings and the original materials again.  I cannot think of how an "outside panel" could be convened.  I have never really seen an objective analysis by an outside panel and wonder who might be selected.  And yes I am suggesting that any outside panel would naturally have a significant conflict of interest.  There appear to be many critics of psychiatry and only weak defenders.

He refers to a post by an anonymous web professional Neuroskeptic who summarized the state of things in his post as there being "no smoking gun."  He also concludes that the idea of a psychiatric critics benefiting from book sales with the same theme suggests "by which logic, every author in history has had a financial conflict of interest in their own ideas." As a student of conflict of interest that IS a logical conclusion, especially when I see links to two of Dr. Frances' books listed right below the Huffington Post article.  It is also an obvious fact that people routinely deny that applies to all human endeavors.  If I am heavily invested in any subject my "ideas" can be counted upon to be fairly subjective and consistent with my self interest whether that is academic or financial.  That is why I have read thousands of articles in Science, Nature, and medical journals in the past three decades and very few have panned out.  At a larger level it is why Ioannides could declare that most published research is false.  It is why you can count on seeing significant side effects from practically every medication approved by the FDA as safe and effective.  So yes, I am afraid that same standard applies to the critics as well as the people doing the heavy lifting and trying to prove something in the first place.  I would even take it a step further and suggest that the same transparency rules should be applied.  How much money can you make as a critic of psychiatry or the DSM?  My guess is plenty.

Both Dr. Frances and Dr. Nardo seem to be suggesting that all of the conflict of interest issues of academic psychiatrists and the way the APA handles them is sending psychiatry to hell in a handbasket.  This is a historically incorrect view of the dismantling of psychiatry in the United States.  Every day people in this country are getting inadequate psychiatric care.  It has nothing to do with the ethical behavior of academic psychiatrists.  It has a lot to do with the fact that the APA is not a very politically savvy organization and there are massive conflicts of interest interfering with the delivery of psychiatric care.  Here are a few scenarios:

1.  A depressed or psychotic but nonfunctional person is discharged from the emergency department because of a lack of "acute dangerousness" criteria.  The family is outraged but they are told: "Look there is nothing we can do because he/she is not imminently dangerous to themselves.  Upon further investigation the state has a "gravely disabled" criterion in the commitment statutes but it is practically never used.  They find that local hospitals and courts never use that criteria because the patients admitted are too difficult to treat and place.

2.  A person with acute alcohol and benzodiazepine withdrawal is sent home from the ER with a bottle of lorazepam and advised how to detoxify themselves.  They go home and take the entire bottle to get high.

3.  A person with alcoholism and depression is admitted for suicidal behavior.  She was intoxicated, depressed and staring at a handgun.  The next day the attending physician is contacted by a psychiatrist/utilization reviewer from the insurance company who has concluded the patient is no longer suicidal and they can be discharged.  He will no longer authorize payment for inpatient treatment. 

4.  A pharmacy benefit manager refused to refill a 2 week prescription by a patient's psychiatrist.  They have the pharmacist faxes a form to the psychiatrists office saying that they will only accept a 3 month prescription.  The psychiatrist takes time to explain first to the pharmacists and then 2 different people at the PBM (total time 30 minutes) the rationale for not giving a large supply of medication to a chronically suicidal patient.  The PBM refuses to change their position.

5.  A managed care company refuses to cover psychotherapy provided by a psychiatrist.  The psychiatrist explains that he is an expert in this type of therapy and the patient has been referred to him by the patient's primary psychiatrist.  The managed care company authorizes 3 "crisis sessions".  

6.  A person completes a PHQ-9 scale in their primary care clinic and they score an 18.  They see their primary care physician and say they would like to see a therapist.  They are told to take an antidepressant and to come back in two weeks to fill out another PHQ-9.  Total time of the visit is 5 minutes.

7.  A person is seen in their primary care clinic and in 20 minutes is told by their nonpsychiatric physician that they have bipolar disorder.  They are prescribed quetiapine, citalopram, and divalproex.  Within several days they are too sedated to function at work.

The are just a few examples of thousands of people everyday who are receiving grossly inadequate care based on a specific ethical principle of physician behavior.  That is the physician makes an assessment and prescribes care in what he or she believes is the best interest of the patient.  That is the contract.  There is no insurance company or government bureaucrat involved.  There is no restricted access to mental health care or pretending that primary care physicians are psychiatrists.  There is no remote "assessment" by a physician employed by a managed care company that prioritizes the financial well being of that insurance company or pharmacy benefit manager over the patient.  In fact,  I do not understand how that is ethical behavior at all.

That is the basis of the decline of psychiatry in this country.  It has taken a proportionately larger hit than any other specialty.  It is documented in detail on this blog and in E. Fuller Torrey's recent book.  The adventures or misadventures of academic psychiatrists are relevant only insofar as the APA seems to use the President of the APA as a position that academics cycle in and out of.  The idea that "psychiatrists in the trenches" are poorly represented by such a system is accurate with two possible exceptions that I can think of.  Psychiatrists in the trenches are also poorly represented by criticism of academic psychiatrists and their conflict of interest agreements and personal employment contracts.  It does nothing to address the central problems of the specialty, provides no tools that front line psychiatrist can use against all of the real conflicts of interest they face on a day by day basis, and is generally demoralizing.  Before any critics suggest that I am supporting a "whitewash" - put yourself in the position of a psychiatrist who has just put in a 12 hour day taking care of 20 inpatients and putting up with passive aggressive and aggressive MCO and PBM reviewers who have been wasting your time and interfering with your care.  You go home to read the paper and suddenly there is a major story of how unethical psychiatrists are - based on the appearance of conflict of interest.  You try to remember that last time you saw a CME event that was sponsored by a pharmaceutical company.  Then you check your files to make sure you have enough CME credits for relicensure.  As an added piece of information that same psychiatrist doesn't really care about Section 3 in the DSM-5 or the issue of dimensional versus categorical diagnoses.  They have not blinked an eye with the release of DSM-5 and won't in the future.

That is how the psychiatrist in the trenches experiences this academic exercise in conflict of interest.  I say if you want to pull out an ethical argument and use that to help front line psychiatrists, it needs to be focused on the obvious targets in managed care and the government bureaucracies that support them.

You know - the real forces dismantling psychiatry (very effectively I might add) over the past three decades.

George Dawson, MD, DFAPA


  1. << I say if you want to pull out an ethical argument and use that to help front line psychiatrists they need to be focused on the obvious targets in managed care and the government bureaucracies that support them.

    You know - the real forces dismantling psychiatry (very effectively I might add) over the past three decades.>>

    And all but one APA President in the last 20 years went along with this. The current APA President hearts Obamacare and Mangled Care. He makes videos that show he is a man with happy magical thoughts about big government and MCOs and pretends that mental illness is the stigma that it was a generation ago. Basically the same speech that Paul Fink made in 1980.

    If that organization was even decently competent or effective, your days at the office would be a lot easier.

    They are not only unethical, but also misguided, naive, and ineffective. And incredibly morally vain, which they haven't the right to be earned given their troubles I see them as the enemy of private practice. But why should those at the top care? Tenure and all that. Would be different if their economic interests were the same as the rank and file.

    Unlike the mentally ill, APA deserves all the stigma it gets from Frances and 1boringoldman.

    1. I am hopeful that at some point there will be more grass roots activism in the APA (as there clearly has in the past) and it will be more effective for psychiatrists. You will get no argument from me that about the lack of focus on the real problem areas. The APA has been suing some of these companies recently, but they need to build on that momentum. But most of all they need to start taking the obvious position that psychiatrists are the solution here and not the problem. The MOC issue factors in here as well. You can't tell members that we can't do anything about your miserable practice environment and then heap more misery on top of it by going along with the ABMS on a totally unnecessary set of hurdles.

  2. Ultimately the market decided drugs sold better then psychotherapy. The DSM played a determining role in creating that market by creating the insurance indications for reimbursement.

    Today the World Health Organization's ICD lists those indications, and the DSM expands them.

    As for the American Psychiatric Association; they don't seem to be interested in civil rights issues any more then the disability and suicide statistics. They choose only to hide them. Critics of their manual are merely ignored or dismissed as 'anti-psychiatry'. With every new release, the number of mental disorders is expanded. They essentially tell their own members to screw themselves - leaving them to deal alone with continuing human rights violations, and increasing managed care.

    Suppose it turns out to be the case that the symptoms that group together to make up Mental Disorders are caused at random by physical illness in general? Much like the side effects listed for psychotropic medications. After all, the nervous system is connected to other organs which support it. When those dysfunction, so does the nervous system. Everything is connected together.

    I have heard some people say that "psychiatry is committing suicide" - by market.

  3. Dr. Dawson, your blog posts are always insightful and provide so many important angles to the discussion around issues in psychiatry that are not voiced often enough. I am a frequent reader of these neuro/psych critic blogs, and while I enjoy and highly respect their opinions, and feel as though the sides that you offer are underspoken. Moreover, I am currently a medical student with an undying interest and passion for psychiatry, but I am always disheartened by the critical commentary that I read on psychiatry, especially since they are coming from what I see as reputable sources themselves (not the mainstream media, but psychiatrists and scientists themselves). I only wish that the advocacy that you do for the profession could be heard by more people, as I strongly believe they are very intelligently reasoned and ultimately addressing the actual barriers to real improvement in mental health care.

    Hope you always continue to keep writing.

    1. Thanks very much. The perspective that you describe is the reason that I started to write this blog. I am also motivated by the discrimination I experienced in medical school on some rotations when they learned I had applied to psychiatric or psychiatric/internal medicine residencies and that was 30 years ago. There are a lot of reasons for the one sided criticism of psychiatry I have tried to touch on them all on this blog. I also like to see a next generation coming in who can see the same problems that I do and encourage you to write about this problem as well. So spread the word.

      And don't worry - I'll keep writing until they pry the keyboard from my cold dead fingers.

  4. I'm happy to have stumbled on this blog. I am in my fourth year out of residency and just finished my first year in community psychiatry and you pointed out some real problems here in this post that I also have been confronted with. I was not sure anyone else was bothered by sending manic patients home from ERs because they aren't suicidal but are clearly not functional and having to try to treat patients who are not at the appropriate level of care. And many more problems. I'm glad to know someone else believes insurance companies dictating care is a problem. I was in academics before this move to rural Illinois for my spouses job and it's certainly different than the ivory tower though many of these problems have penetrated there too. Shortening length of stay for example for patients regardless of the severity of their illness and wasting time with medication authorizations for patients who risk destabilization if changed to a different antipsychotic. I agree advocacy for these issues is very poor.

    1. Extremely poor - and yet for the past years all we have heard about it conflict of interest with Big Pharma. I knew Big Pharma was a problem 25 years ago when they wanted to hire me to present a CME lecture during half time in the luxury box seats at a professional football game. My response then was it is still is today- What!

      So it has been comical for me to see the Big Pharma zealots developing over the past 20 years and tell the rest of us how to deal with conflict of interest. In the meantime, almost everyone is blind to conflicts of interest that are destroying psychiatry and denying care to almost anyone with a severe psychiatric disorder.

      One of the best examples is the phony "dangerousness" criteria to get admitted to a psychiatric unit that will throw you out untreated in 4 or 5 days. They should just hang a sign over the emergency department: "Be dangerous or Go Home".

      That business attitude is an insult to anyone with a severe mental illness who can no longer function at home. It is an insult to anyone with an acute - never before diagnosed psychiatric disorder. It is an insult to a person with a mental disorder and and addiction who needs real treatment and perhaps adequate detoxification. It has no place in psychiatry and it is time we get the word out.