Sunday, March 31, 2013

A Primer on the Utilization Game


I want to post some references on the issue of "overutilization" but it is necessary to review the concept before I can post those references of make any further arguments about it.  Most people fail to understand that when they are talking about psychiatric practice in the US that it is tightly controlled by large health care and pharmaceutical middle men who make their profits to a large extent by denying care or insisting on cheaper care.  The very first articles using this term in medicine date back to the 1970s and involve policing various health care providers who were ordering unnecessary tests and procedures largely to prevent the loss of taxpayer dollars.  Some of the first articles looked at the problem as a combination of the need to assess quality of care according to certain standards, illegal behavior or intentional fraud, lack of education on the art of the practitioner, and "to ascertain where there is overutilization or underutilization of services perpetrated either by the practitioner or by the patient". 

In this early reference dental, optometry and podiatry services were an areas of focus and the measures of overutilization included too many x-rays, unnecessary fillings, unnecessary prescription of orthopedic shoes, and shorting prescriptions.  Professional services were evaluated by peer review and were categorized as being problematic because of unusual pattern of practice, poor quality of care,  unethical procedure, office facilities, qualifications for practice, abuse of billing codes, fraud, and self referral.  Although the source of the investigations and lack of equivalence of markers were problematic there ws a suggestion that overutilization was a significant problem.  Underutilization was suggested as a significant problem in under served populations but it was not systematically investigated.

The most systematic unbiased investigation of overutilization was done by the Peer Review Organizations in the late 1980s and early 1990s.  These efforts are documented to some extent in the National Academy of Sciences texts.  The protocol in the PROs consisted of a list of generic quality screens applied by nurse reviewers to hospital and clinic records.  The charts were also reviewed for appropriate utilization.  If a chart was flagged by a nurse reviewer it was sent to a physician reviewer for confirmation.  All physician reviewers were rigorously screened for qualifications and conflict of interest.  No reviewer could review records from any clinic or hospital that they were affiliated with.  Reviewers also had be in active practice and everyone knew that you could not make a living from reviewing charts for the PRO.

The result of the PRO experiment is a significant untold story.  A total of 6.3 million cases were reviewed using these protocols by 54 PROs across the country.  The denial rate for overutilization was 2.7%.  The frequency of quality problems was 1.3%.  The total cost of the program was about $300 million per year compared with the total cost of Medicare for the same year being $81.6 billion. I was a physician reviewer at the time and was eventually notified that the PRO program was being phased out because the cost of the program could not be justified by the amount of care denied ($300 million versus $220 million).  

What happens when overutilization is handled by companies that profit directly by denying care and the physician reviewers are either employees or contractors with that company?  As you might expect, the denial rate heads in a predictable direction.  Although it has not been extensively investigated, this article showed a denial rate of about 10% with rates varying with the companies involved.  As expected health plans with greater profit margins had higher denial rates and discounts.  Denial rates of 8-10% were replicated in another large study.  

At some point it became apparent to insurance companies that behavioral health services (their term for mental health and psychiatric services) would be an easy target for rationing and so-called "carveout" approaches.  This was buoyed by the Employee Retirement Income Security Act (ERISA).  ERISA effectively indemnified insurance companies and behavioral health plans against lawsuits over improper care.  Although there have been some suggestions that the courts may reconsider this indemnification, there has never been any significant movement in this area.  Managed care companies have successfully had their methods included in state statutes and have generally established a standard of care where rationing is a significant component.

A study by the Hay Group looked at the results of managed care rationing on mental health benefits as opposed to general medical benefits between 1988 and 1997.  There found a disproportionate decrease in mental health benefits across a number of parameters including:

- Fee for service plans were prevalent at the beginning of the study (92%) but they were largely replaced by managed care at the end of the study (20%)
- The value of general health care benefits decreased by 7.4% across the study but the value of behavioral health benefits decreased by 54.1%.
- As a total percentage of health care costs, behavioral health care decreased  from 6.1% in 1988 to 3.1% in 1997.
- Behavioral health care benefits were clearly rationed including a decreased number of inpatient days, a visit limit on outpatient care with per dollar visit limits and annual dollar limits that did not correct for inflation across the time of the study.
- Outpatient behavioral health care utilization decreased by 24.6%  between 1993 and 1996 while general health care utilization increased 27.4% in the same period.
- Inpatient mental health admissions decreased by 36.4% while general health admissions decreased by 12.7%.

The Hay Group Study was the best early evidence that mental health care was disproportionately rationed by managed care techniques.

If we fast forward to the present, managed care companies have taken the next step to make their rationing techniques as opaque as possible.  At some point some the largest companies have actually acquired the resources where health care is actually produced – clinics, hospitals, and groups of physician employees.   In that scenario they can bring their “overutilization” bias in house and use case managers to police doctors and tell them when to discharge patients.  The case managers are backed up by medical directors who are promoting the company line of a managed care company and who will do what they can to back up case managers if any physician is advocating for a longer length of stay.  They frequently have proprietary discharge guidelines that have not been scientifically validated that they use to establish discharge parameters.  It is no coincidence that the discharge dates all happen to be about the same time that most payers set as the maximum number of hospital days that they will pay for. 

The end result creates a health care system that is firmly entrenched to ration health care on the basis that there is an imaginary number of days or amount of money that can adequately treat a problem.  The only person who can advocate for the patient is their physician but he or she is clearly up against it.  The problem is more than being harassed by an outside company.  Now the physician’s job is on the line as well.  Disagreeing with the medical director on a consistent basis even a few times does not bode well for longevity within an organization.  In the case of hospital care we have physicians who realize that they need to discharge people in 4 or 5 days whether they have improved or not.  I can say from 22 years of inpatient experience that most people admitted to psychiatric hospitals with major psychiatric disorders do not improve to the point that they can be safely discharged in 4 or 5 days.  My conversations with outpatient physicians confirms this.  Typical managed care hospitals are no longer viewed as places where anything productive happens to improve patient stability.  The staff there will often admit it by saying that they are there for “mental health crises”.  But what happens when the crisis does not resolve in 4 or 5 days?

The limits on mental health care have also severely impacted outpatient care.  There is an emphasis on prescribing medication, often based on brief symptom checklists.  This also allows for the recruitment of large numbers of primary care physicians to treat problems once the checklist becomes the defacto mental health diagnosis.  Treating large numbers of people with anxiety and depression is much less expensive for health plans if the treatment is generic antidepressants or benzodiazepines.  Each patient is basically being “treated” for about $4/ month and they can be seen in follow up visits very infrequently.  It is well established in the research literature that different forms of psychotherapy work as well and in some cases better than medication for these conditions.  The research proven therapies generally require a specific course of treatment on the order of 8 – 20 sessions.  It is rare to see much therapy beyond three sessions in managed care settings and that would generally be received by a patient who was already taking a medication.

At this point we have devolved to a system of mental health care that devotes little time and effort to the treatment of mental disorders.  The treatment that does exist out there is clearly biased toward saving money for large health care companies who provide the bulk of it. All of that rationing is based on the premise that there is overutilization of services when the largest and best study shows that it does not approach the level of rationing that has occurred.

George Dawson, MD, DFAPA


1: Bellin LE, Kavaler F. Policing publicly funded health care for poor quality, overutilization, and fraud--the New York City Medicaid experience.  Am J Public Health Nations Health. 1970 May;60(5):811-20. PubMed PMID: 5462556; PubMed Central PMCID: PMC1348897
2: (1990) Medicare:A Strategy for Quality Assurance, Volume I: The National Academies Press.
3:  (1990) Medicare:A Strategy for Quality Assurance, Volume II: Sources and Methods: The National Academies Press.
4:  Hay Group: The Hay Group Study on Health Care Plan Design and Cost Trends, 1988 through 1997. National Association of Private Health Care Systems and National Alliance for the Mentally Ill, 1998.
5.  Dawson G.  The Utilization Review Hoax.  February 2012.




Tuesday, March 26, 2013

On the dangers of psychiatric diagnosis no longer being a process


I am inspired by a post on another blog having to do with the dangers of “premature psychiatric diagnosis”.  The author uses an anecdote to make a point about how a diagnosis of a psychotic disorder and then mismanagement of the treatment leads to a situation where there is no hope for the person affected.

From my perspective there are very few people with even severe psychiatric disorders who are hopeless.  In fact, people with some of the most severe cases of catatonia that I have treated became fully functional and were restored to their roles in their families and society.  That frequently occurred after months of inpatient treatment by a psychiatrist and staff who were interested and skilled in treating severe psychiatric disorders.  Much of what I did in 22 years of inpatient work was restoring hope and maintaining a hopeful atmosphere on my treatment team.

Diagnostic uncertainty is frequently cited as an area where mistakes are made.  Many studies document the medical comorbidity in patients with psychiatric disorders.  Despite anecdotal cases true medical causes of psychiatric disorders are rare.  I should qualify that by saying a brain disease, neurological or endocrine condition that is a direct cause for the psychiatric disorder is rare and I base that on screening patients and reviewing thousands of negative studies.  That said any acute care psychiatrist should know more about medicine and neurology than psychiatrists in outpatient settings because unlike their outpatient colleagues – they are responsible for making that determination.  On the psychiatric side, the potential list of causes of various syndromes is long and the actual diagnosis may not be evident until something happens on a long term basis.   A good example would be a drug induced psychosis.  In the ideal case, the patient is able to remain sober and any medical treatment for the associated syndrome can be tapered and discontinued.  In the real world, the chances of sobriety or even referral to a functional addiction treatment are low.
   
There are numerous limitations on psychiatrists.  The obvious one that practically all commentators leave out is managed care.  Is it reasonable to think that the diagnosis and treatment of any severe psychiatric problem like a psychotic disorder can be accomplished in 3 – 5 days?  That is the time frame that most managed care case managers are using to get people out of the hospital.  They often refer to purely proprietary guidelines on hospital lengths of stay that were clearly written by business people rather than clinicians.  I have been in the position of having a patient discharged by an administrator against my wishes so I know that it happens.  Managed care coercion is more subtle.  A managed care reviewer sitting at a desk in another state – reads chart notes and presumes to make a remote diagnosis and suggest that the person should leave the hospital.  They have no responsibility to the patient or their family.  Their only job is to get the patient out of the hospital to save the insurance company money.  Another constraint is at the level of public assistance.  Almost incredibly, many states link the availability of case management services to psychiatric diagnoses and they will clearly say in the statute that the person must have schizophrenia, major depression, bipolar disorder, schizoaffective disorder, or borderline personality disorder in order to qualify.  Having one of those diagnoses at discharge can be crucial to get housing and funded medical rather than be homeless.  That is a strong incentive to get the correct diagnosis sooner rather than later.

The work flow on inpatient units and in clinics is generally not considered.  If you have a psychiatrist seeing 12-15 inpatients and some outpatients and they are seeing 3 – 5 new patients a day that is not a lot of breathing room.  They will be (depending on other members of the team) able to collect collateral information from the family and outside sources, make direct behavioral observations, and relay treatment decisions and recommendations to the family.  In my experience occupational therapists, nurses, and social workers are all indispensable team members and often function in dual roles as a liaison with family members.  They can act as consultants to the family on legal and social issues as well as keeping them apprised of any changes in medical treatment on a day to day basis.

One of the key areas where care becomes fragmented both from a diagnostic and treatment standpoint is anytime there is a transition.  In terms of hospitals that occurs with any admission or discharge.  It also occurs between different outpatient clinics and between psychiatrists and primary care physicians.  I have been in situations where it took me two hours and calls to different physicians, pharmacies and relatives to reconcile a list of 10 medications.  At the end of that two hours I was still not absolutely certain of the patient’s correct medication list. 

The bottom line here is that good psychiatric diagnosis is a process. It is not like taking your car in to a mechanic and the mechanic plugging it in to an analyzer.  The best results occur when the patient and the family can communicate openly with the psychiatrist and any identified treatment team.  The diagnosis needs to take into account all of the available information and by definition it will only be as good as that information.   The critics of psychiatry always seem to think that this is a situation that is unique to psychiatric treatment.  As I have previously discussed it happens in all of medicine.  The basic difference being that many nonpsychiatric conditions lend themselves to analysis by a single observer.  There is something readily visible, audible or palpable that suggests an abnormality.  In psychiatry we are focused on communication, self report, and the observations of others.  We are also generally dealing with more information to make a diagnosis, especially if the patient’s capacity for self report is limited.  Psychiatrists more than anyone else need to be comfortable with diagnostic uncertainty and explaining these nuances to the patient and their family.

When the diagnosis is made it should be fully explainable to the patient and family.  Any stigma or negative reaction to the diagnosis should be discussed.  It should be evident that nobody is reducible to a psychiatric diagnosis given the fact that no two people are alike and each person is a unique individual with unique attributes.  This is true for any medical diagnosis and psychiatric diagnoses do not differ in that regard.   Nobody should leave the encounter with the idea that they are “hopeless”,  particularly in the case of a pure psychiatric diagnosis in the absence of a neurodegenerative disease.

I realize that most of us in one way or another are held hostage by a certain health plan, but if your psychiatrist or more probably your health plan does not follow that basic process – find a new one.  Getting stuck on whether or not a misdiagnosis has occurred without a plausible explanation for what has happened or continues to happen is generally not productive.  If you can’t get out of your health plan talk to the medical director and explain the deficiencies.  If that doesn’t work and you are concerned about the diagnostic and treatment process being rationed, contact your state insurance commissioner and file a complaint against the health plan.

Quality psychiatric care is possible, but it has been demonstrated that in many cases you have to fight for it.

George Dawson, MD. DFAPA

Sunday, March 17, 2013

More on Homicide Prevention – LA County Style


I have been developing a theme of how to prevent homicide and mass killing for more than a decade.  As previously posted, I think that this needs to be done independent of the firearms issue with a public health focus on both primary and secondary prevention.  There have been a couple of developments recently that I would like to highlight and whether or not they are consistent with the public health approach.

The first is an article in the NY Times today on a unique approach to school threat assessment and intervention.  The article describes LA County’s School Threat Assessment Response Team.  Several threat scenarios are described that trigger a multidisciplinary response from team members representing law enforcement, school officials, and mental health.  The way the program is described it is unique in terms of engagement.  Threats at school generally result in one dimensional and fragmented approach to the problem.  The school has a protocol that may result in suspension.  Referral to mental health providers is frequently a limiting step due to the lack of appointments, insurance problems, or debate over whether the school system or the health care system is responsible for assessment and treatment.  This patchwork system is a set up for people with severe problems falling through the cracks.

The LA County response is for the team to make a rapid same day assessment at the point of the threat and at the student’s home including looking at their room.  How many times have we read about the marginal teenager who is thrown out of school for threatening behavior and they end up sitting in their room focused on the same thought patterns or watching other forms of violent activity on the Internet or in video games?  Getting right into that environment seems like a powerful intervention to me and one that is likely to yield better results.  The main reason for failure in situations where a threat has been identified is that lack of follow up.    People who are threatening and aggressive are not likely to care if they are thrown out of school and they are not likely to follow through with mental health interventions.  The response team also spends time educating people about how to communicate in emergency situations where there are many misunderstandings about confidentiality.

The LA approach is innovative and exactly what is needed to assess and intervene in crisis situations involving threats and dangerous behavior.  In situation after situation, tragedies occur when people people come to the attention of someone and there is no clear map for assessment and treatment.  That is true in the school system, in colleges and universities, in the workplace and in family situations.  I have personally talked with people who said that they either did not know what to do or they actively tried several resources and were told that there were no appointments available or that the person was not dangerous enough to treat and unless they agreed to a voluntary assessment and treatment that nothing could be done.  But it doesn’t stop at that point.  I am also aware of situations where there clearly was enough evidence that the person was dangerous enough to meet criteria for an emergency assessment but it was not done of the person was released for the emergency department.  In many of these cases there was an adverse outcome.  What is the problem?

There is a significant bias against aggressive and violent people.  To some extent that bias is self protective.  Any reasonable adult knows the obvious advantages of avoiding conflicts or even irrational behavior.  There are always plenty of stories in the news about the lack of Good Samaritans in situations where an aggressive act is being perpetrated in public.  Many psychological explanations of this behavior are offered but I think the obvious motivation is avoiding the conflict and possible injury.  That same code of silence often applies in cases where there have been sudden changes in behavior and the person involved has a treatable problem.  A second level of bias is the moralistic approach to aggressive and violent behavior that equates this behavior with bad moral conduct.  That applies in situations where criminals use aggression to intimidate people and get what they want.  It does not apply when the aggression is a symptom of mental illness.

The bias extends beyond members of the general public.  The health care system is activated by a legal concept called “dangerousness” or “imminent dangerousness”.  Every state has different statutory requirements and those statutes are interpreted on a highly variable basis across every county in the state.  In some counties it comes down to some of the public officials involved seeing themselves as protectors of people’s rights.  In other counties, assessment and treatment are more of a priority.  At the level of the health care system there is another layer of bias.  The overwhelming bias these days is that people should not be assessed or treated in a psychiatric facility for more than 4 or 5 days and any assessment or treatment should be kept to the bare minimum.  It is easy to find different clinicians make entirely different decisions when presented with the same potentially dangerous patient.  The end result is a patchwork of acute care settings where people can go for help.  Because of all the biases involved unless an aggressive act has been committed the likelihood of an intervention occurring is basically a coin toss.

That is why the LA County response is so important.  It is an intervention that activates a rational response to threats from people who are likely in distress and possibly mentally ill.  There is no dangerousness standard initially and that is a critical departure from the current nonsystem.  The goal of the LA County response is to engage the person and their social network and not make a one-time assessment and decide to admit or discharge the patient based on a dangerousness concept.  The LA County response is unique in that it is based on behavior and the goal is to help the person involved rather than decide on whether or not they should be committed.  The overall approach is very similar to community psychiatry case management teams except LA County teams seem to have more latitude because they are not limited initially by commitment standards.

The is an excellent approach to the problem and I hope that it is researched, expanded to mental health crisis teams and widely adopted if effective.  I don’t know why it would not be effective.

George Dawson, MD, DFAPA

Erica Goode.  Focusing on Violence Before It Happens.  NY Times March 14, 2003.

Sunday, February 24, 2013

Crickets from the APA



"The best way to predict the future is to create it." - Peter Drucker



The annual convention is approaching and the American Psychiatric Association (APA) has decided to train a few psychiatrists from each district branch to teach about the new DSM5.  They think that is sufficient to fill the demand from organizations and groups who want assistance with DSM5 training and implementation.  They also think that the threat of litigation is enough to protect the DSM copyright and prevent other self declared trainers from going around the country and training people about the DSM5.  That is more critical than you might think.  Let me explain why both of these thoughts are problematic wrong and describe a more optimal course of action that could still be implemented before the May convention.

First of all let me say that the ideas I am posting here are not new.  I have inquired directly from the APA as a member both at their Washington Offices and through my District Branch (DB).  The lack of response prompted the “Crickets” title from the APA because cricket chirping is about all I am hearing about any initiative other than the APA’s original plan.  There are many sources of failure possible by restricting the training.  The obvious one is that psychiatrists are busy.  The failed billing and coding system generally means that psychiatrists are seeing a lot of patients and spending even more time on billing, coding, and documentation.  That leaves very little time each week to study for recertification exams, train future psychiatrists and medical students, and participate in other professional activities.  Given how thin psychiatrists and other physicians find themselves spread, it might be reasonable to have a bureau of trained DSM5 experts at each DB to cover the potential demand.

I first got interested in this issue when a large health care organization asked me about the availability of consultants to assist them in their nationwide implementation.  The DSM IV is currently implemented in their electronic medical record (EMR).  Several calls directly to the APA did not produce any results.  I identified myself as a member and that did not make a difference.  I contacted my excellent DB Executive who I had worked with during my term of being the DB President.  She is extremely knowledgeable and widely networked within the organization.  The question I proposed was whether the APA would consider opening up the convention session to all psychiatrists through the DB and certifying anyone who has taken the course.  Still no response.

Absent the response I have the following suggestions about how to train DSM5 trainers in the interest of the APA and its mission and preserve the copyright integrity of the DSM5:

1.  Expand the training in May to all DBs and to as many psychiatrists as want to take the training.
 
2.  Provide password access to all of these psychiatrists to the DSM5 web site for the purpose of ongoing learning.  The DSM5 site was quite good in providing the rationale for suggested changes and prospective trainers could benefit from ongoing access to this material.

3.  Provide educational materials (PowerPoints) to all of the trainers through access to a training web site.

4.  Develop a course specific to administrators and companies who need IT implementation information and have that readily available.

5.  License DSM5 to corporations in the same way that psychiatrists with online subscriptions can access it.  UpToDate has provided a good example of the continuously updated online reference rather than serial textbooks being the direction forward.  There should be no need for update cycles and massive political events to herald updates.  The DSM and all psychiatric guidelines need to be systematically reviewed and updated if APA technology is to be seen as the definitive reference for the biomedical diagnosis and treatment of major mental disorders.  Updating every 10-20 years will not survive in the day of Internet technology.  There is also a lot less drama involved when UpToDate updates its content.  That is consistent with being a resource for physicians and by physicians.  

All of these recommendations can be done and anything less than following through on these recommendations leaves the APA seriously compromised and not competitive in the future.

George Dawson, MD, DFAPA


The Ultimate Antipsychiatry Movie?


Side Effects may qualify as a new level of antipsychiatry film.  I went to see this film last night with a vague notion that it was a thriller with some surprise plot twists and that it may have something to do with psychiatry. I walked out one hour and 46 minutes later with the impression that I had seen an antipsychiatry movie on a grander scale than previously observed. My previous standard was the psychiatrist who happened to be a serial killer and cannibal. The psychiatrists portrayed in this film were not as aggressive but certainly had their fair share of criminal activity, unethical behavior, and boundary violations.  The sheer scope of that behavior was striking.


The plot unfolds as we get to know Emily Taylor (Rooney Mara).  She appears to be depressed and even suicidal at times. This depression occurs in the context of significant life stressors including the incarceration and subsequent release of her husband Martin (Channing Tatum) for securities fraud. There is an overall impression that the couple lost quite a bit of status and financial resources as a result of that problem. We see her struggling at work and eventually intentionally injuring herself. That leads to her initial encounter with Dr. Jonathan Banks (Jude Law).  Dr. Banks initiates treatment with antidepressant medication and Emily seems to be experiencing intolerable side effects from the initial SSRIs.  In the meantime, Dr. Banks is in touch with Emily's previous psychiatrist Dr. Victoria Siebert (Catherine Zeta-Jones) who suggests a new recently approved antidepressant.  Emily takes this new medication and appears to be experiencing even more side effects right up to the point that she kills Martin while she is apparently “sleepwalking” as a medication related side effect.

From the initial perspective, it seemed like a heavy-handed “psychiatrists corrupted by Big Pharma” film until that point. After all Emily seems to be clearly made ill by the drugs and that point is emphasized cinematically by slowing down the entire scene in what seems to be her drug addled perspective.  Her psychiatrist seems indifferent to the problem and the fact that her spouse is getting more angry about the situation.  At one point the representative of a pharmaceutical company offers to pay Dr. Banks a considerable sum of money for doing research on the new antidepressant. There is a suggestion that Dr. Banks is already spread too thin. In that same scene, the representative emphasizes that she can buy psychiatrists meals and they banter about consulting fees.  Dr. Siebert hands Dr. Banks a pharmaceutical company branded pen with the name of the new drug printed on the side.  The sum of the cinematic effect at that point is to suggest that antidepressants are very toxic drugs, psychiatrists inflict more problems on people with these drugs, and that psychiatrists essentially prescribe these drugs because they are pawns for Big Pharma.  Admittedly nothing more than you might read in the Washington Post.

The plot lurched forward at that point to the issue of a not guilty by reason of insanity defense and the interactions of Dr. Banks with his patient even after she was sent away to a forensics facility. There was also considerable emphasis on the interaction between Dr. Banks and Dr. Siebert.  I will try to point out problems that occur along the way without giving away the rest of the plot. The first problem at that point in the movie was both the defense attorney and the prosecuting attorney suggesting that Dr. Banks should consult for their side. The fact that Dr. Banks has a treatment relationship with Emily makes his consulting with either side a clear conflict of interest, even in a non-criminal matter. He continues to see Emily at the state forensics facility.  At that time he is seeing her only to advance his interests and they no longer have a therapeutic relationship.  He threatens her, essentially blackmails her, and administers a questionable treatment in an unethical manner.  We later learn that Dr. Siebert also has an inappropriate relationship with Emily and has been involved in criminal activity with her.

At one point, Dr. Siebert attempts to ruin Dr. Banks’ professional reputation and relationship with his wife by releasing a letter from a former patient and manipulated photographs of Dr. Banks and Emily. His partners react strongly and fire him from their practice. An investigator from the state medical board seems suspicious of Dr. Banks.  Part of this side plot seems to be the only plausible aspect of this film and only insofar as complaints against physicians and psychiatrists are common and greatly outnumber the incidence of inappropriate physician behavior. The reaction of Dr. Banks’ partners to this material as well as an adverse outcome is overdone.  Any psychiatrist treating people with severe mental illnesses has adverse outcomes.  Most reasonable people agree that an adverse outcome in medicine and psychiatry does not imply either negligence or criminal intent.

I am generally focused on the purely cinematic aspects of any film that portrays psychiatrists. I explained my rationale for this approach in a previous review.  My approach is based on the low likelihood of seeing an accurate cinematic portrayal of a psychiatrist.  I imagine that other professionals have the same experience. The problem with this film is that the actions of psychiatrists are the major part of the plot and it is difficult to focus on the motivations and personalities of the other characters.  The character of Emily is not developed very well and her actions are difficult to understand.  Dr. Banks and Dr. Siebert are certainly much more active but their de novo sociopathy and unethical behavior have no context.  This lack of character development, dominant scenes by psychiatrists, and the implausibility of those scenes makes this a difficult film to watch.

Regarding the entire issue of why I referred to this as an anti-psychiatry movie that is based on the classification from the Oxford Textbook of Philosophy and Psychiatry. It can be found in the footnote to this post (reference 2).  This film is a good illustration of the biomedical psychiatry as political control cliché.  The psychiatrists in this film are unhindered by any legal, ethical, or professional barrier in promoting their own self interests.  Their obnoxious behavior seems on par or worse than the actual crimes that were the focus of the story line and seems to be more than the typical antipsychiatry bias that is expected in the media. 

The psychiatrist as bogeyman is alive and well at the cinema.

George Dawson, MD, DFAPA

Monday, February 18, 2013

The run on guns and ammunition - is this mass psychogenic illness?


I was watching my usual Sunday morning news programs two weeks ago when I heard that Wal-Mart had such a run on their ammunition supply customers that they were limiting sales to three boxes per customer per day.  That brings up the image of tens of thousands of people going to Wal-Mart every day to buy their three boxes of ammo.  What is it about the American psyche that drives this behavior and the recent stockpiling of guns?

It reminded me of the Y2K situation from over a decade ago.  Do you remember that scenario?  In the antithesis of the Terminator series, computers would be crippled by inadequate programming to account for the change to the 21st century.  The power grids would collapse.  The logistics of food and medical supplies would be paralyzed.  There would be chaos in the streets.  In Minnesota in the middle of winter that translated to a run on electrical power generators.  It got to the point that one of the big home stores cancelled their return policy for generators.  I never noticed it but I wonder if the generator aisle at the Home Depot ever looked like this gun shop display.

All of the signs point to this being a record year for gun and ammunition sales.  The National Instant Criminal Background Check System (NICS) has a record number of checks.  Nine of ten of the top highest days and 10/10 of the top ten highest weeks for gun checks since the system was started in November 1998 have occurred within the past two months (see below).   The charts below give the NICS checks month by month since then and the actual listing of top days and weeks for checks.  Although there is usually a disclaimer about how checks do not necessarily equate to gun purchases, the issue has been studied and for each check there is about a 70% chance that a firearm will be acquired taking into account all of the possible outcomes. (click to enlarge)







Another perspective comes from the Bureau of Alcohol, Tobacco, Firearms, and Explosives.  They keep a record of firearm manufacturing in the US by the type of firearm and also whether or not a firearm is exported.  The data going back to 1998 is available on their web site.  I plotted that data for rifles, pistols, revolvers, and shotguns on the following graph.  Some interesting trends noted include the fairly recent increase in rifle production. There were relatively flat revolver and shotgun sales, and a sharp increase in pistol production over the past decade.   The year 2004 is also an interesting inflection point for rifle sales since that was the year that the ten year ban on assault rifles expired.   Without knowing the exact breakdown of rifle sales, the rise at that point combined with flat rate of shotgun sales suggests that the rising rate represents sales of assault rifles or military style weapons that are not necessary for hunting.





All of the signs point to a greater prevalence of guns in homes and communities especially hand guns.  Not only that but it appears that Americans are arming themselves at a much higher rate than at any time since we started to keep these statistics.  They also appear to be arming themselves using handguns and possible military style weapons that are not typically used for hunting.  Hunters are frequently mentioned in NRA and pro-gun rhetoric but they certainly are not responsible for the huge increase in hand gun sales.  If we are ruling out hunters who is buying the guns?

My guess is that it comes down to people arming themselves because they believe that they need protection.  Although a previous post here clearly shows that the violent crime rate is at an all-time low there are numerous self protection ideologies.  At one time or another I have heard the following arguments:

1.  Protect yourself against violent criminals (even though there are fewer of them and they seem to be committing fewer violent crimes than at any point in the past 30 years).

2.  Protect yourself against terrorists.  My guess is that terrorists would not be foolhardy enough to walk into any well armed American neighborhood and start a gun fight

3.  Protect yourself against the government.  This is an interesting argument because it basically is the same thing as treason.  When I argued that point with a famous gun advocate he pointed out that it would depend on "who won".  Some conservative and liberal politicians of both parties have made this argument, including Minnesota's well known liberal Senator Hubert H. Humphrey.  The basic argument is that if the government becomes completely unresponsive to the people for one reason or the other - we should have enough firepower to overcome it.  I guess if we can't vote the bums out - there is always another way.

4.  Protect yourself against your neighbors.  This is the survivalist argument.  The survivalists believe that we are always "9 meals away from chaos".  It is therefore logical to stockpile food.  When the apocalyptic event happens, you need enough guns and ammo to shoot anyone who threatens you or your food stockpile.

5.  Protect yourself against the zombies.  That's right - you thought the zombie apocalypse was just fiction.  I happened to catch an episode of Doomsday Preppers that was full of information ranging from how zombies might scientifically happen to staircase design that would slow them down long enough so that you could administer the old "double tap". 

An inspection of the above list suggests that there are many more imagined than real threats.  Possibly several orders of magnitude greater if you are considering that all of your neighbors who ignored your warnings about the apocalypse are either coming for your food or have contracted the virus that turns them into zombies and want to eat you for food.  In that scenario - how much ammo is enough?  All of this would be more fodder for the film industry if it was not true at some level.  Very few real threats and many imagined would seem to be driving the current gun buying frenzy.  After all - what would happen if any of the mass scenarios unfolded and we did not have enough guns and ammo?

I don't want to go too far out onto a limb here.  For all of you DSM5 detractors - don't worry there is no diagnostic category to critique.  I think that there is room for studying the problem, but it would involve collecting data from the gun purchasers and we all know that would not fly.  Anyone knows that if you can be identified - the government can kick your door down and take your guns.  

George Dawson, MD, DFAPA


FBI NICS Web Site

FBI Instant Background Checks November 30, 1998- January 31, 2013.

ATF Annual Firearms Manufacturing Report and Export Report 2011.

ATF Statistical Web Site

Sunday, February 10, 2013

kappa statistic rhetoric

This post was inspired by a post on the Neuroskeptic.  The impression I get from that blog is that the average reader thinks that psychiatrists are a bunch of chuckleheads who know very little and that is probably why they are so ignorant of science.  The Neuroskeptic himself seems to be slighlty more tolerant but like most bloggers he has to stir the pot.  The focus of this post was to take a look at kappa statistics given in the article by Freedman on DSM5 field trials and a graphic supplied by the boringoldman blog and conclude that DSM5 reliabilities were not good, they were not as good as DSM-IV, and thankfully psychiatrists could just ignore the DSM if they wanted to.

On the face of it all this seems like damning criticism.  Is there any defense from the neuroscientific opinion?  It turns out that there is and it comes from two sources.  The first is the common experience that most people have had who have any medical diagnosis in their lifetime.  Were you ever misdiagnosed?  Did you ever get a second opinion and find that the diagnoses by both doctors were so far apart that it was difficult to make a plan to address the problem?  I can give you one of many examples from my lifetime.  When I was a second year medical student I had several incidents of ankle pain.  I was assessed and ended up at an orthopedics clinic.   I had my ankle casted a couple of times, even though I had no history of trauma.  I finally woke up one night with excruciating left ankle pain and went to the emergency department.  I saw orthopedics again and they aspirated the joint.  They also asked my  wife to leave and asked me if I had possibly contracted gonorrhea somewhere.  I was given acetaminophen with codeine and discharged after about 8 hours.  A couple more weeks of pain and I finally got in to see one of the top experts in Rheumatology who finally made the diagnosis of gout.  At that point I had seen 4 or 5 other doctors and none of them had been able to correctly diagnose the cause of my ankle pain.  Calculating a kappa statistic for a comparison between the expert and the previous physicians would have resulted in a very low number.

But the story doesn't end there.  As anyone with gout knows, it has varied presentations including inflammation that often seems to extend outside of the joint.  During my residency training a few years later I had acute right wrist pain.  The internist I saw decided he needed to aspirate my wrist joint and ended up aspirating a piece of the wrist joint into the syringe.  No diagnosis despite this procedure.  I demanded treatment for gout and of course it worked.  Several recurrences of wrist pain have resulted in misdiagnoses of cellulitis.  Keep in mind that I am not testing these doctors.  I am presenting to them and telling them I have gout and I think my wrist pain is an acute gout attack.  They are saying: "Well gout doesn't usually affect the wrist. I think this is cellulitis."  I have walked out of clinics and thrown the prescription for antibiotic away as I walked out the door.  I finally just got a supply of the anti-inflammatory medication that I need and treat these episodes myself rather than risk misdiagnosis by a physician who does not know much about gout.

You could say this is all anecdotal.  I have more anecdotes about how I have been personally misdiagnosed and the anecdotes of an additional thousand people at this time.  I heard Ben Stein say: "At some point the anecdotal becomes the statistical" and this is a good example from medicine.  But what does the literature say about the reliability of diagnoses.  The diagnostic criteria for gout have been around longer than the DSM.  Another frequent criticism of psychiatric diagnosis is that there are no confirmatory tests for the diagnosis.  Numerous confirmatory tests for gout did not prevent misdiagnosis in my case.  

That brings us to the second line of defense - kappa values that are documented in the medical literature.  Let me preface that by saying that compared to psychiatry, there are literally a smattering of kappas from other specialties.  The following table is a sample from this literature search:
  


observation
kappa
reference
Scaphoid bone fractures diagnosed by radiologists
0.51
 de Zwart AD, et al.  Interobserver variability among radiologists for diagnosis of scaphoid fractures
by computed tomography. J Hand Surg Am. 2012 Nov;37(11

Reproducibility of serrated polyp diagnosis by pathologists
0.38-0.557
Ensari A, et al. Serrated polyps of the colon: how reproducible is their classification? Virchows Arch. 2012 Nov;461(5):495-504. doi: 10.1007/s00428-012-1319-7.

Detection of anomalous origin of coronary arteries by CT
0.65
Jappar IA, et al. Diagnosis of anomalous origin and course of coronary arteries using non-contrast cardiac CT scan and
detection features. J Cardiovasc Comput Tomogr. 2012 Sep-Oct;6(5):335-45.

Skeletal muscle CT to idenitify various muscular dystrophies
Overall 0.27 but in some cases 0.51 and 0.59
ten Dam L, et al.  Reliability and accuracy of skeletal muscle imaging in limb-girdle muscular dystrophies. Neurology. 2012 Oct 16;79(16):1716-23.

Criteria standards to diagnose CHF
0.59-0.74
Collins SP, et al. A comparison of criterion standard methods to diagnose acute heart failure. Congest Heart Fail. 2012 Sep-Oct;18(5):262-71.

Spoke sign for otitis media
0.21 (residents)
0.24 (staff)
0.61 (ENT residents)
Sridhara SK, Brietzke SE. The "Spoke Sign": An Otoscopic Diagnostic Aid for
Detecting Otitis Media With Effusion. Arch Otolaryngol Head Neck Surg. 2012 Oct
15:1-5.

Pediatric residents diagnosis of otitis media compared to ENT experts
0.3
Steinbach WJ, etal. Pediatric
residents' clinical diagnostic accuracy of otitis media. Pediatrics. 2002
Jun;109(6):993-8.

Abnormal cardiac exam during sports screening
0.1 (cardiology fellows)
0 (fellows compared to staff)
O'Connor FG, et al. A pilot study of
clinical agreement in cardiovascular preparticipation examinations: how good is the standard of care? Clin J Sport Med. 2005 May;15(3):177-9







What jumps out at you from the table?  The kappas from other specialties are widely variable and certainly no better than criticized values from psychiatry.  The fact that some of these kappas are based on interpretations of more uniform test data (radiology images or pathology specimens) seems to make little difference.

Low interobserver consensus seems to be the rule rather than the exception in medicine.  Psychiatry is the only specialty that openly admits this.  Misdiagnosis is a universal phenomenon and I would argue that it is a basic element in the process of medical diagnosis.  Some have referred to it as the "art" of medicine, but I prefer a more scientific explanation.   From a neurobiological standpoint there is certainly the phenomenon of significant variability between people.  Medicine from the outset has always presented itself to practitioners as a field where rational analysis produces a logical result.  With the degrees of freedom inherent in biological systems that degree of certainty is an illusion at best.   Pretending that psychiatry is less reliable than any other field is an equally problematic illusion, but I guess it makes for good rhetoric.

George Dawson, MD, DFAPA


Freedman R, Lewis DA, Michels R, Pine DS, Schultz SK, Tamminga CA, Gabbard GO, Gau SS, Javitt DC, Oquendo MA, Shrout PE, Vieta E, Yager J. The Initial Field
Trials of DSM-5: New Blooms and Old Thorns. Am J Psychiatry. 2013 Jan
1;170(1):1-5.
Maclure M, Willett WC. Misinterpretation and misuse of the kappa statistic. Am J Epidemiol. 1987 Aug;126(2):161-9. Review. PubMed PMID: 3300279.

Yoshizawa CN, Le Marchand L. Re: "Misinterpretation and misuse of the kappa statistic". Am J Epidemiol. 1988 Nov;128(5):1179-81. PubMed PMID: 3189294.

Singh H, Giardina T, Meyer AD, Forjuoh SN, Reis MD, Thomas EJ. Types and Origins of Diagnostic Errors in Primary Care Settings.JAMA Intern Med. 2013;173(6):418-425. doi:10.1001/jamainternmed.2013.2777