Tuesday, May 29, 2012

Myths in the Huffington Post

Let me start out by saying that I have a low opinion of the Huffington Post largely because of its rhetorical approach to psychiatry.  Tales about the pharmaceutical company corruption of psychiatry, ongoing articles about the myth of mental illness, references to very poorly done research that supposedly discredits psychiatry, the idea that the DSM is either a manual for everyman instead of clinical psychiatrists or a book written to manipulate the general public - the Huffington Post has it all and then some.  Interestingly, the Huffington Post lists these postings under "Science" when it is clear that nobody there seems to know the first thing about science or how it differs from personal opinion.  From what I have seen, listing yourself as an authority on science apparently makes it so on the Internet.  "Rhetoric/Politics" would be a much more accurate heading.

Enter Allen Frances commenting in blog form.  I have already responded to one of the Dr. Frances editorials that seem to pop up everywhere.  I find the whole process of taking a scientific debate within a professional society into a public forum somewhat appalling.  In this case, the rhetorical device of applying a decision made about an entirely different process - withdrawing a paper that the author believes was incorrectly done due to a methodological error ( one that is common to much psychosocial research) to the DSM process seems rhetorical to me.  That occurs after the process has been thoroughly politicized in the media.

The arguments themselves are either red herring or they make it seem like the very public decrying of the DSM process has shamed the APA into not declaring grief and psychosis risk to be diagnoses.  The public will never know what the APA process would have decided on these issues and of course every critic wants to take credit for exposing the APA as a group of money grubbing scoundrels whose only mission in life is to appease Big Pharma or generate huge revenue for the organization.

I wish I could count on the public to be as skeptical of these opinions as they are of other political opinions.  Unfortunately after 25 years of practice, I can say with certainty that only a few people know what a psychiatrist is or how they are trained.  Today there is more misinformation than ever about psychiatry via the Internet.

As a reminder, the DSM is for clinical psychiatrists and psychiatric research.  Reading criteria without the associated training is not the same thing as making a diagnosis.  There are many nonpsychiatric mental health professionals and many nonpsychiatric physicians.  In fact, the bulk of psychotropic medications in this country are prescribed by nonpsychiatric physicians.  Access to psychiatrists is tightly controlled by managed care companies and state governments. It is difficult to see a psychiatrist initially and over time.  These same managed care organizations control who is admitted to and discharged from inpatient psychiatric units and the type of care provided there.

The idea that the APA is an omnipotent organization with the power to manipulate and control the provision of mental health care through out the USA is a myth of massive proportions.  The idea that the DSM is a potential tool for that manipulation is another.

You can probably read about that first on the Huffington Post.

George Dawson, MD, DFAPA

Saturday, May 26, 2012

Historic WWII Era Film on PTSD

An historic film by John Huston on PTSD is available at: 


This is an actual film of veterans being treated. Very interesting film from an historic and psychiatric perspective. Also interesting from a propaganda perspective. One of my first teachers in psychiatry was a WWII psychiatrist who went through an expedited residency in order to treat combat neurosis.  The attached notes about the making of the films is also interesting in terms of the way it is structured, the total footage shot to get this final cut version and why this particular facility was used. 

As an example Huston comments on the treatment process at the hospital he chose for the film: " The hospital admitted two groups of 75 patients each week, and the goal was to restore these men physically, mentally and emotionally within six to eight weeks, to the point where they could be returned to civilian life in as good condition—or almost as good—as when they came into the Army…  "  Just doing the arithmetic, with what we know about the scale of WWII, that would suggest that most veterans with PTSD never got treated.

He also commented on the goal of the film: "[The purpose] was to show how men who suffered mental damage in the service should not be written off but could be helped by psychiatric treatment….".  That message seems to continuously escape the politicians responsible for war making and repairing the damage afterwards.

The original film was suppressed by the Army and the US Government who suggested that privacy considerations were the reason.  All the men in the film had signed releases for the filming, but at one point those releases disappeared.  During an attempted screening of the film, military police showed up and confiscated a copy.  The author of the Film Notes suggests a few reasons for the suppression of the film as well as discussing the innovative and artistic points.

From a psychiatric standpoint, the use of drug therapy by psychiatrists in film was cutting edge.  According to Gabbard and Gabbard the first film depictions of drug therapy occurred in 1947 (Possessed) and 1949 (The Home of the Brave).  In their book they mention Let There Be Light (1946) as the third depiction of narcosynthesis.  It  also reminded me of The Snake Pit (1948) in that the psychiatrists are portrayed as being generally effective.

From a cultural and political standpoint, the film and Huston’s intentions stand in contrast to the atmosphere today where psychiatrists are portrayed in the media as inept tools of pharmaceutical companies who thrive on prescribing ineffective treatments.  In the film notes section, Huston describes the transformation of some of the patients as “miraculous”.  At some level, there has to be skepticism on the treatment effort and outcomes.  For example, there is an overall lack of aggression and severe depression in the veterans filmed for this project.  In my experience in several different VA facilities those are common problems as a result of combat stress exposure.

As a kid walking 5 blocks to elementary school every day, I encountered veterans with clear problems that were explained to me at the time as being “due to the war.”  In some cases more specific etiologies were suggested like: “he got malaria in the war”.  That was in the late 1950s.

As a civilian, I had no idea what exposure to combat stress could do until I was a psychiatric resident working in a VA hospital.  By that time we had already been through the Vietnam War and any consideration of the impact that war had on veterans was secondary to the over-the-top politics associated with an unnecessary war.

Maybe things would have been a lot different if the Army had allowed a broad release of this film.

George Dawson, MD, DFAPA

Gabbard K, Gabbard GO.  Psychiatry and the Cinema. The University of Chicago Press, Chicago, (1987) p 70-71. 

Tuesday, May 22, 2012

Adult ADHD treated by Internists

I caught this eye-opening quote in the AMNews the other day: "ADHD is common enough that the average internist has 20-80 patients with this disorder".  The physician interviewed for the article suggest getting collateral data, making the diagnosis over several visits, getting an adequate family history, using a screening instrument and not prescribing stimulants on the first visit.  The final pearl in this column is:"Any patient who gets mad that you are not prescribing a stimulant after one visit should be a red flag."  With about 150,000 internists and another 130,000 family physicians that represents a lot of adults being treated for ADHD.

The physician suggested approach in this case is fairly comprehensive and includes corroborating symptoms in childhood and adolescence, obtaining collateral information, and using a standardized checklist. There is no mention of screening for addiction, discussing prior exposure to stimulants, or the use of performance based testing as opposed to diagnostic checklists. There is also the frequent scenario of a clinic that is set up to do expensive test batteries referring patients to physicians for the purpose of prescribing stimulants and advising the referred patient that they have in fact made the diagnosis of attention deficit hyperactivity disorder.

These are not insignificant problems given the flood of stimulants available on college campuses these days and at least one cultural viewpoint using stimulants as "cognitive enhancers" rather than medications to treat a specific diagnosis. There is also no accounting for clinician to clinician variability in terms of who is prescribed stimulant medication. The largest dividing point is persons with a history of addiction and the associated politics of believing that a stimulant should not be denied anyone with the appropriate diagnosis as opposed to a person with an addiction being placed at risk by stimulant prescription.

The best approach is a network of interested clinicians who have access to uniform diagnostic and treatment methods and who are dedicated to consistent treatment practices that include not treating at least some people with stimulants and using non-stimulant approaches to the treatment of attention deficit hyperactivity disorder.

George Dawson, MD, DFAPA

Christine S. Moyer.  Orchestrating Drug Management.  American Medical News.  May 21, 2012. 55(10): 12-13.

Sahakian B, Morein-Zamir S. Professor's little helper. Nature. 2007 Dec 20;450(7173):1157-9.

Monday, May 21, 2012

DSM5 - NEJM Commentaries

I highly recommend the two commentaries in the New England Journal of Medicine this week.  The first was written by McHugh and Slavney and the second by  Friedman.  Like Allen Frances they are experienced psychiatrists and researchers and they are likely to have unique insights.  I may have missed it, but I am not aware of any of these authors using the popular press to make typical political remarks about the DSM.  Those remarks can be seen on an almost weekly basis in any major American newspaper.

McHugh and Slavney focus interestingly enough is the issue of comprehensive diagnosis and opposed to checklist diagnoses.  It reminded me immediately that the public really does not have the historical context of the DSM or how it is used.  It also reminded me of the corrosive effect that managed care and the government has had on psychiatric practice with the use of "templates" to meet coding and billing criteria in the shortest amount of time.   Finally it reminded me of the bizarre situation where we have managed care companies and governments combining to validate the concept of a checklist as a psychiatric diagnosis and court testimony by experts suggesting that it is negligent to not use a checklist in the diagnostic process.

McHugh and Slavney summed up in the following three sentences: “Checklist diagnoses cost less in time and money but fail woefully to correspond with diagnoses derived from comprehensive assessments. They deprive psychiatrists of the sense that they know their patients thoroughly. Moreover, a diagnostic category based on checklists can be promoted by industries or persons seeking to profit from marketing its recognition; indeed, pharmaceutical companies have notoriously promoted several DSM diagnoses in the categories of anxiety and depression.” (p. 1854)

In my home state, the PHQ-9 is mandated by the state of Minnesota to screen all primary care patients being treated for depression and follow their progress despite the fact that this was not the intended purpose of this scale and it is not validated as an outcome measure.  The PHQ-9  is copyrighted by Pfizer pharmaceuticals.

The authors go on to talk about the severe limitations of this approach but at some point they seem to have eliminated the psychiatrist from the equation. I would have concerns if psychiatrists were only taught checklist diagnoses and thought that was the best approach, but I really have never seen that. Politicians, managed care companies, and bureaucrats from both are all enamored with checklists but not psychiatrists. They also talk about the issue of causality and how that could add some additional perspective. They give examples of diagnoses clustered by biological, personality, life encounter, and psychological perspectives. Despite its purported atheoretical basis, the DSM comments on many if not all of these etiologies.

Friedman's essay is focused only on the issue of grief and whether or not DSM5 would allow clinicians to characterize bereavement as a depressive disorder. That is currently prevented by a bereavement exclusion and DSM-IV and apparently there was some discussion of removing it. He discusses the consideration that some bereavement is complicated such as in the situation of a bereaved person with a prior episode of major depression and whether the rates of undertreatment in primary care may place those people at risk of no treatment.

There can be no doubt that reducing a psychiatric diagnosis to a checklist loses a lot of information and probably does not produce the same diagnoses. There is also no doubt that the great majority of grieving persons will recover on their own without any mental health intervention. Both essays seem to minimize the role of psychiatrists who should after all be trained experts in comprehensive diagnoses (the kind without checklists). They should be able to come up with a diagnostic and treatment formulation that is independent of the DSM checklists. They should also be trained in the phenomenology of grief and the psychiatric studies of grief and realize that it is not a psychiatric disorder.  If they were fortunate enough to be trained in Interpersonal Psychotherapy they know the therapeutic goals and treatment strategies of grief counseling and they probably know good resources for the patient.

The critiques by all three authors are legitimate but they are also strong statements for continued comprehensive training of psychiatrists. There really should be no psychiatrist out there using a DSM as a "field guide" for prescribing therapy of any sort based on a checklist diagnosis. Primary care physicians in some states and health plans have been mandated to produce checklist diagnoses.  The public should not accept the idea that a checklist diagnosis is the same as a comprehensive diagnostic interview by psychiatrist.

That is the real issue - not whether or not there is a new DSM.

George Dawson, MD DFAPA

McHugh PR, Slavney PR. Mental illness--comprehensive evaluation or checklist?
N Engl J Med. 2012 May 17;366(20):1853-5.

Friedman RA. Grief, depression, and the DSM-5. N Engl J Med. 2012 May

Sunday, May 13, 2012

Why Allen Frances has it wrong

Allen Frances has been a public critic of the DSM process and as an expert he frequently gets his opinions out in the media.  Today he has an op-ed piece on the New York Times that is a more general version of a more detailed post on the Health Care blog.  His main contention is the stakeholder argument and that is that there are too many stakeholders both public and professional to allow the American Psychiatric Association to maintain its "monopoly" on psychiatric diagnosis.  I will attempt to deconstruct his argument.

He discusses the earlier DSM versions as revolutionizing the field and the associated neuroscience but then suggests that diagnostic proliferation has become a central problem and the only solution is political arbitration.  What about the issue of diagnostic proliferation?  The number of diagnostic entities per DSM are listed below:

DSM-I, 268 entities
DSM-II, 339 entities 
DSM-III, 322 entities
DSM IIIR, 312 entities
DSM-IV, 374 entities
DSM-V,  370 - 400 entities (depending on final form)

In terms of the total diagnostic entities, I have not seen any stories in the media pointing out that the total number of diagnoses may end being less than DSM-IV.  I have also not seen any discussion of major diagnoses where that is clearly true, such as the elimination of schizophrenia subtypes.   Other issues on diagnostic proliferation that are not discussed are the other required diagnostic system in medicine - the International Classification of Diseases 9th Revision or ICD-9.   The recent modification the ICD-10 has undergone a revision and the total number of diagnoses has increased from 14,000 to 68,000 diagnosis codes.  A fourfold increase.  The number of potential codes for a fractured kneecap has gone from 2 to 480 or more than the total potential codes in DSM5. 

I have also not seen any discussion of the role of psychiatrists in making a psychiatric diagnosis.  Psychiatric diagnosis does not depend on looking up a diagnosis in a catalog of symptoms.  It involves being trained in psychopathology and knowing the patterns of these illnesses.  The patterns of psychotic disorders and the other main diagnostic groupings have basically been unchanged across DSMs.  Psychiatrists make clinical diagnoses based on these major groupings and not the total number of diagnostic entities.

Further evidence that the total number of diagnostic categories is unlikely to have any impact on the number of people diagnosed with mental illness in any given year comes from the distribution of diagnostic codes in an outpatient setting. For 2006-2007, there were approximately 58 million ambulatory care visits for mental disorders. 92% of those visits were for 10 major diagnostic categories that have not changed in recent DSM revisions. It is not likely that new diagnostic categories will significantly impact the remaining 8% or 4.8 million visits per year.

In a study more specific to psychiatry, the number of psychiatric ICD-10 codes used in Danish Psychiatric Central Registry.  The data  represented 1,260,097 diagnoses from 1,041,589 discharges of 653,754 patients from in- and outpatient treatment episodes.  Forty nine of the diagnostic codes accounted for 75% of all the diagnoses (Munk-Jørgensen, et al)

The "medicalization of normality" is another argument.  The media routinely runs stories about the percentage of the population that is "mentally ill" based on DSM diagnoses.  One of the common stories is the estimate that as many as 50% of the population has a DSM diagnosis over the course of the year.  There is never a critical look at that statistic.  The first dimension is whether any percentage should be too high or too low.  For example, would anyone be surprised to learn that 100% of the population has a medical diagnosis in the previous year?  With a high prevalence of gastroenteritis and respiratory infections - probably not.  The second dimension speaks directly to the issue of threshold for an illness.  One of the key papers in this area shows that although the one year prevalence using DSM criteria may be high, limiting the diagnoses to severe disorders reduces the prevalence to 8%.

The use of high prevalence numbers for mental illness based on DSM diagnoses also ignores the extensive Epidemiological Catchment Area (ECA) work that estimated lifetime prevalence.  Readers are generally not told that the methods used include addictive disorders and neurological disorders that cause cognitive impairment.  Would anyone doubt that 32% of adults would report a psychiatric disorder that included an addiction or cognitive impairment at any point in their lifetime?

Similarly there has been the repeated criticism that psychiatrists were going to start treating grief like clinical depression.  I have never seen that approach anywhere in my career spanning psychopathology seminars, journal articles, and continuing education courses.  Any psychiatrist with a clue knows the difference between grief and depression and at some point they have probably been tested on that difference.  What psychiatrists know that is not public knowledge is that a small number of grieving people actually develop a depression that is indistinguishable from clinical depression and it may have to be treated that way.  Knowing the difference is part of psychiatric expertise and you really cannot write it down as sentences in a manual.  In fact, it is a grave  mistake to equate a manual of diagnostic criteria with the clinical expertise and methods of psychiatry.

Dr. Frances correctly points out that the other common media theory that DSM diagnoses are driven by the pharmaceutical industry is a myth.  He continues on to suggest that the public and other mental health professionals somehow have a stake in the DSM and that organized psychiatry has frozen them out.  He concludes: “Psychiatric diagnosis is too important to be left exclusively in the hands of psychiatrists.”  I don’t understand how the specialty who invented the technology, who is trained and tested on it, and who is focused on a comprehensive view of psychopathology that extends beyond it should somehow give way to political considerations.  As he points out – there are always political considerations – even in science.  I would suggest that there is no such thing as “independent scientific review” of anything that psychiatry does.  There are many ways to address issues of professional bias in terms of including a diagnosis or not.

The arguments against the DSM and psychiatric influence vary across the usual spectrum of there being no such thing as a psychiatric diagnosis to there are too many diagnoses to the fact that psychiatric diagnoses are nonspecific.  There is no practical way to incorporate that spectrum into a diagnostic manual that is designed for psychiatrists to make clinical diagnoses and do research.  The single most important fact that is left out of these debates is that psychiatrists are effective in treating serious mental illness and they are undoubtedly more effective now than they have been in the past.  That is the only reason we need a DSM and that is why it stays squarely in psychiatry.

George Dawson, MD, DFAPA  

Frances A.  Diagnosing the DSM.  New York Times May 11, 2012.

Frances A.  DSM5 begins its belated and necessary retreat.  Health Care Blog May 10, 2012.

Kessler RC, Avenevoli S, Costello J, Green JG, Gruber MJ, McLaughlin KA,
Petukhova M, Sampson NA, Zaslavsky AM, Merikangas KR. Severity of 12-month DSM-IV disorders in the national comorbidity survey replication adolescent supplement
Arch Gen Psychiatry. 2012 Apr;69(4):381-9.

Munk-Jørgensen P, Najarraq Lund M, Bertelsen A. Use of ICD-10 diagnoses in Danish psychiatric hospital-based services in 2001-2007. World Psychiatry. 2010 Oct;9(3):183-4.

Regier D, Kaelber CT.  The Epidemiological Catchment Area Program:  Studying the Prevalence and Incidence of Psychopathology. in  Textbook in Psychiatric Epidemiology eds.  Ming T Tsuang, Mauricio Tohen, and Gwnedolyn EP Zahner.  John Wiley and Sons, 1995. p141.

Schappert SM, Rechtsteiner EA. Ambulatory medical care utilization estimates for 2007. National Center for Health Statistics. Vital Health Stat 13(169). 2011. (see Table 7.)

Wednesday, May 9, 2012

Radicals and Reformers for Managed Care

I was struck by a post on the Critical Psychiatry blog this AM.  Duncan Double discusses his experience at a meeting of the radical caucus at the APA on Sunday.  His main argument was the need to abolish psychiatric diagnostic systems - specifically the DSM, but he mentions that you can apparently provide psychiatric services without an ICD diagnosis in the UK.  But then he makes this astonishing comment: " The American psychiatric system has become very dependent on DSM for billing purposes, but I'm sure the insurance companies could develop an alternative system unrelated to DSM. "

I am positive that the American insurance industry would like nothing better than to establish their own "alternative system unrelated to the DSM'.  In fact, they are doing it already with a host of measures that they can use to basically deny care or dismantle systems of care.  The managed care industry in the US has selectively discriminated against psychiatric services for the past 20 years to the point that most states have little service availability.  The motivation for managed care is clear - shift hundreds of billions of dollars away from providing care to persons with mental health and chemical dependency problems and into the pockets of the insurance industry.  We are talking about an industry where the CEOs can make an annual salary of millions of dollars and in a famous case the CEO received a $1 billion dollar bonus.

Stated in another way, the "American psychiatric system" is no system at all.  There is hardly any availability of psychotherapy services.  Most people are restricted to a handful or less of 15 minute visits with a psychiatrist every year.  The length of stay in hospitals is appallingly short by UK or European standards and people are asked to leave if they are no longer "suicidal".  It is psychiatrists on the one hand being severely restricted in attempting to provide care and a predatory insurance industry trying to make disproportionately more money off policy holders with mental health problems on the other.   The government is not a passive player in this effort with most state governments abdicating their role in caring for the indigent and the uninsured often by using managed care tactics.  All of this happens independent of any DSM or ICD diagnosis.  At the national level, there is a long list of interests who favor the same tactics in order to maintain leverage over doctors and the clinical care advocated by doctors.

Critical psychiatry would rather "Occupy American Psychiatric Association" rather than "Occupy Wall Street" .    I guess we can add them to the managed care  list.  That is exactly the type of reform that the politicians want.

Saturday, May 5, 2012

Vision Quest "6 minutes" - Why We Watch Sports

Another clip that goes a long way toward explaining why we watch sports, go to concerts, read good books:


In this clip Louden Swain, a high school wrestler preparing for the match of his career goes to see why Elmo the cook who he works with took the evening off of work to go to his wrestling match.  Elmo's soliloquy here about sports still strikes me as the best single reason why I watch sports.

I have never seen it studied, but it seems that there are several reason for why sports play a central role in society.  The social elements are apparent and many people see themselves as a larger community tied to a particular team.  I used to be  New York Yankee fan, despite the fact that I did not set foot in New York City (or the state of New York) until I was about 26 years old.  My father was a Yankee fan and so was I, so identification is important.  Somewhere in my late 20's I realized that a certain team winning was no longer important.  I started watching "This Week in Baseball" just to watch all of the best plays.  I tuned in to see Nolan Ryan pitch.  I watched the Tour de France and the Olympics to see the best athletes in the world compete.  I can still remember my excitement as I watched Johann Olav Koss in the 1,500, 5,000, and 10,000 meter events at Lillehammer. It was the first time that they had a motorized camera following the speedskaters. We learned that he had some last minute technical problems with the blade angle on his skates but Koss's form was perfect.  I was ecstatic.  I had become Elmo.

I have never seen a study that looked at the percentages of people who watch sports for the purposes of seeing a certain team win versus those who are looking for the best possible human performances.  But for the later - there is no better explanation than Elmo's soliloquy in this clip.

George Dawson, MD. DFAPA

Wednesday, May 2, 2012

A Consciousness Based Model

One of the criticisms of psychiatric treatment in particular drug therapies is that essentially nothing is known about psychopathology, neurobiology, or human genetics and therefore claiming that drug therapy is treating a pathological state is erroneous (1). "Chemical imbalance" can be used as a red herring along the way and I will try to address that in a later post.  In that post, I also hope to address the issue of disease states and whether or not they need to be strictly measurable.

For now, I want to discuss a model that I have used in clinical practice for the past decade that addresses both the issues of recovery and whether or not the drug altered state or treating an underlying pathological state is really the issue.  Let me start by saying I think it is irrelevant for the purposes of treatment.  I am first and foremost a clinical psychiatrist and not a researcher and my priority is at all times patient care.   My goal is to treat alterations in a person’s conscious state and restore their level of functioning with medications and/or psychotherapy that have been shown to work.   My goal is also not to introduce any new problems such as sedation, mood changes, rage, perceptual problems, ataxia, false memories, vertigo, or any number of subjective changes commonly seen as "side effects".

I found that the best way to proceed is to have an explicit discussion of the person’s conscious state and whether it has undergone any transformation associated with the reasons why they are seeing me.  I focus on the typical stream of consciousness that occurs each and every day and how it may have changed over the previous weeks or months or years.   I ask about whether or not getting back to that conscious state is a reasonable goal.  I point out that the phenomenology associated with a person's cognitive and emotional changes (2) can be followed in at least two dimensions at once - the psychopathological and the normal.

There are obviously problems with my approach. The subjective assessment of a psychopathological state and the subjective assessment of the baseline conscious state are difficult to do and they take time.  There are a large number of markers of psychopathological states but not so many for normal conscious states.  I often end up discussing broad outlines that include the typical stream of consciousness, fantasies, daydreams, defense mechanisms, distracting thoughts and typical thought patterns in certain situations such as driving into work each day.   I also ask about a global assessment and whether at any point during treatment the person feels like their original conscious state has been restored.   It adds another goal to treatment that is focused on restoring the self rather than just treating symptoms.

George Dawson, MD, DFAPA

1: Moncrieff J, Cohen D.  How do psychiatric drugs work?  BMJ. 2009 May 29;338:b1963.

2: Andreasen NC. DSM and the death of phenomenology in america: an example of unintended consequences. Schizophr Bull. 2007 Jan;33(1):108-12. Epub 2006 Dec 7.