Sunday, September 30, 2012

"Doctors don't label"

In a rare statement of clarity amid the usual sensational spin this comment jumped out at me:

"Doctors don't label...Doctors diagnose, take care of, and treat.  That's not to say that something cannot be stigmatizing, but 'labeling' kind of gets right into the antipsychiatry component of it."  William T. Carpenter, MD  - Clinical Psychiatry News September 2012; p 3.

Dr. Carpenter is right and every psychiatrist knows it.  Psychiatrists don't label.  Psychiatrists diagnose.  Psychiatrists are very aware of the limitations of diagnosis given the the sociocultural and medical  contexts.  The psychiatric orientation is to be helpful to patients and the diagnosis is the focus of that treatment.  Furthermore, all psychiatric diagnosis and treatment is supposed to be confidential and there is no group of physicians who has tried to hold the line more against government and insurance companies eroding patient-physician confidentiality than psychiatrists. 

A significant part of this article about the content of a letter from the Society for Humanistic Psychology (Division 32 of the American Psychological Association).  Read the letter and draw your own conclusions.  The points of contention listed in the letter have been exposed in several other media contexts.  As I read through the letter there are several problems:

"This document was composed in recognition of, and with sensitivity to, the longstanding and congenial relationship between American psychologists and our psychiatrist colleagues."

I don't think that this is an accurate statement.  When I started out in psychiatry and was in my third year of residency the American Psychological Association decided to get more aggressive politically and their target was basically American psychiatry.   I won't rehash all of that ugliness but simply point out that things were far from congenial and in many areas remain problematic.   Much of those political efforts were based on the idea that organized psychiatry had an inordinate amount of control  over the treatment of mental illness.  Any observer - biased or unbiased should recognize that psychiatrists and physicians in general have been marginalized and the American Psychiatric Association is politically ineffective and weak.  Of course any other group of mental health providers is in the same boat. 

"Given lack of consensus as to the “primary” causes of mental distress, this proposed change may result in the labeling of sociopolitical deviance as mental disorder."

This is a comment on the new DSM5 definition of a mental illness, specifically that the new definition does not explicitly say that deviant behavior and conflicts with society are not mental disorders.  The current version states that these conflicts need to be the result of dysfunction within the individual.  It is hard for me to see a situation where this is relevant to the practice of psychiatry.  Is there really a case where I am going to diagnose a person in this situation with a mental disorder?  Definitely not and the reason is that I have been confronted with the situation many times before and pointed out that the conflict was not the product of a mental illness.  The authors here have focused primarily  on a lower threshold for diagnosis and how they are not confident about the clinical decision making skills of practitioners - but do not comment on the threshold part of the definition.  

"Increasing the number of people who qualify for a diagnosis may lead to excessive medicalization and stigmatization of transitive, even normative distress."

The risk of "medicalization" needs to be considered for a moment.  What is "medicalization"?  The implication of this letter at a practical level is that it involves an excessive use of medications.  Suspending the poor quality of many of those studies for a moment, what is the real driver of medication use in today's practice environment?  The minority of people taking any kind of psychiatric medication see psychiatrists.  The managed care industry and the government are clearly the driving force.  Current "evidence based" approaches are linked directly to medication use.  A checklist diagnosis and rating scale approach has been used to rapidly treat patients with antidepressants in primary care settings.  That approach alone has easily outpaced any DSM5 modifications.  Direct to consumer drug advertising compounds the issue of getting as many people on medications as possible.  You don't even have to read the DSM5 to see that medicalization has little to do with medical doctors.  In fact, managed care companies would clearly like to replace as many doctors as possible with "prescribers" who can fill prescriptions according to these protocols.  The pharmaceutical and managed care industries are far more interested in distilling psychiatric treatment down to a pill or a capsule than psychiatrists are.

The associated idea that psychiatrists may be the initiators of this medicalization or at least collude with it ignores psychiatric innovation that does not involve the prescription of medications.  On this blog alone, I have posted excellent examples of work done by Greist and Gunderson on innovative and highly successful non medication approaches to significant problems.  Dr. Greist's ideas have been presented to a wide audience that includes pharmaceutical companies.  His ideas about how to make effective psychotherapy widely available have been successfully applied in other countries.  Ignoring psychiatric innovation outside  of psychopharmacology is a curious phenomena, but it definitely makes it easier to see psychiatrists as the "medicalizers".  I am sure that both Greist and Gunderson would not see medications as the primary treatment for anxiety disorders or borderline personality disorder.

Once again, the focus on problems in the DSM5 leading to medicalization and stigmatization is clearly overemphasized.  There is no group of people more aware of the limitations of the current diagnostic system than psychiatrists.  There is no group of people better equipped to compensate for these deficiencies.  There is no group of people more aware of the stigma of mental illness and addiction.  Psychiatrists have a unique perspective in observing first hand how health care systems institutionalize stigma and use it to reduce the resources dedicated to treat these problems.  There should be no doubt that the DSM5 is being produced in what is considered the best interest of the American Psychiatric Association.  There should also be no doubt that the critiques of the process have their own interests and their opinions should be evaluated in that context.

George Dawson, MD, DFAPA

Wednesday, September 26, 2012

Why antidepressants are not addictive

I recently noticed that a blogger posted his theory on the addictive properties of antidepressants. He pointed out that people get "psychologically addicted" and that using the term "addiction" for physical addiction seemed too restrictive. His supporting evidence is a newspaper article about how Glaxo Smith Kline dropped its claim on a patient information pamphlet for paroxetine saying that the drug was "not addictive".  David Healy is quoted as saying "If there is withdrawal, then there is physical dependence. There will be some people who will never be able to halt this drug, there will be some for whom halting will not be awfully difficult and some for whom it is a real issue". The article goes on to say that although SSRIs are not like opiates they are "more comparable to the benzodiazepines such as diazepam, which is now prescribed only with great caution because of withdrawal problems".

Working in the addiction field this entire line of thinking is rhetorical. There is significant psychiatric comorbidity in people with addictions with anywhere from 40-75% having co-occurring disorders. Most of those co-occurring disorders are anxiety disorders and depression and they are well known triggers for relapse as well as initiating drug and alcohol use in the first place. Contrary to public denial,  addictive disorders have huge liabilities in terms of morbidity and they are often lethal illnesses.  My goal is to reduce the risk of relapse by treating the co-occurring disorder while the person is being treated for addiction. SSRI medications are one of the mainstays of treating anxiety and depression these days. They are effective medications. I would not be prescribing them if they caused "psychological addiction". Furthermore, many treatment programs for addiction teach the concept of cross addiction and nobody studying that concept would want to take an SSRI if it caused any kind of addiction.

A better starting point would be to look at more comprehensive definition of what an addiction is. That starting point would be the October 2011 definition issued by the American Society of Addiction Medicine.  Paragraph 2 of the short definition will suffice and reading those four lines should make it very clear that the use of antidepressant medications does not lead to addiction. The real hallmark of addictions is uncontrolled use and there is no evidence that modern antidepressants are used in an uncontrolled manner.  Additional evidence is that antidepressants have absolutely no street value and therefore are in the majority of 34 million chemical compounds listed in Chem Abstracts of which only about 322 are addicting.

If your doctor has recommended that you take an antidepressant medication certainly be aware of the fact that there may be discontinuation symptoms. Discontinuation symptoms are not an addiction.  Needing to take an antidepressant for a chronic mood or anxiety disorder is not an addiction.  Contrary to Dr. Healy's opinion there are a number of nonpsychiatric medications can be discontinued and cause severe discontinuation symptoms.  The term "physical dependence" suggests an addiction or the inappropriate use of a potentially addicting drug where in fact that is not the case with antidepressants.  Comparing antidepressants to other clearly addictive compounds like benzodiazepines or opioids is not an accurate comparison across any dimension.  I agree that any person considering an antidepressant drug needs to be aware of the fact that mild to moderate symptoms can respond to psychotherapy as well as medication.  ANY medication can lead to rare but very serious complications.  Any person considering treatment with medications needs to be working with a physician who is skilled in the use of these medications and who can address any potential side effects.  My personal experience in treating people who have severe anxiety and depression is that they reach a point that anyone with a severe chronic illness reaches in making a decision about medication. That point generally involves asking themselves: "What else am I going to do?".

As physicians we can never minimize the importance of that question.

Response to Dr. Willenbring

I wrote this response to Mark Willenbring's post on his blog.  I reposted it here because the links do not work in the reply section of his blog in case anyone is interested in the references:

I generally agree with what you are saying.  I think the no fault aspect of the illness is very difficult for many to grasp - most importantly the policy makers and health plan administrators.  I think it is captured very well in the latest ASAM definition.  I think that Sellman’s Top Ten list and the responses to it are also instructive especially item 7 “Come back when you are motivated” is no longer an acceptable therapeutic response’ is part of your message.

From a systems standpoint, the lack of a full array of services to treat addiction is striking.  Over the course of my career I have seen detox services essentially moved to mental health units and then to the street.  I wrote a post about this several weeks ago that was read by current detox staff who agreed with it.    It is hard to believe that in many if not most cases people with addictions are sent home from the ED, sent home with a handful of benzodiazepines, or sent to a facility with no medical coverage for a complex detox process.  I think the test of any health care system is whether a primary care doc can ask themselves if they have a safe detox procedure for any of their regular patients who are addicted to opioids and benzodiazepines and needs surgery.

Medical systems in general have a very poor attitude toward people with addictions.  I think that these healthcare systems and their personnel are much more likely to take a moralistic attitude toward addicts and not treat them well.  I have seen that theme repeated across multiple care settings.  Many rationed care settings disproportionately reduce resources necessary to treat addiction.  I think it is safe to say that most cardiology patients with suspicious chest pain get a $10,000 evaluation and reassurance or appropriate treatment.  Most patients with addictions do not even get a $300 evaluation.  They may actually see a physician who provides them with medications that fuel their addiction.  Institutionalized stigma plays a big role in that.  There are no billboards in the Twin Cities advertising state-of-the-art addiction treatment.  There are many advertisements for heart centers.

I am less pessimistic about the effects of 12-step recovery and time in a residential setting whether it is a high end recovery facility or a state hospital.  I think if you are in a setting where there is no active treatment or sober environment you are probably wasting your time.  I have seen people who were declared hopeless recover with time away from alcohol and drugs on the order of months.  Vaillant’s study of severe alcoholism is a great example of the different paths to recovery and there are many.  His subsequent analysis of how AA might work suggests that affiliation rather than blaming may be the most curative element.  AA is difficult to study but I think that the message is positive and embodied in #3 of the Twelve Traditions.  Up to that point the founders were looking at the issue of exclusion but decided against it because alcoholism was a life threatening disease and they could turn nobody away. 

George Dawson, MD, DFAPA

Sunday, September 23, 2012

What replaces DSM5? Whither RDoC?

"However, in antedating contemporary neuroscience research the current diagnostic system is not informed by recent breakthroughs in genetics; and molecular, cellular, and systems neuroscience. Indeed it would have been surprising if the clusters of complex behaviors identified clinically were to map on a one-to-one basis onto specific genes or neurobiological systems." NIMH 2011.

With the thorough politicization of the DSM5 and the dichotomous debates in the media it is surprising that nobody talked about what is in the works to replace it at the largest government funded think tank - The National Institute of Mental Health (NIMH). The proposed solutions in the media were generally to do nothing or to let a wide variety of professionals have input into criteria that have essentially been static for the past 30 years.  There was very little comment about how the DSM5 is not a very good framework for incorporating recent scientific discoveries from brain imaging, molecular biology and genomics in addition to the typical subjective descriptions of each disorder.  That is where NIMH's Research Domain Criteria (RDoC) come in.

Looking at the "Draft Research Domain Criteria Matrix" - it is hard to envision a standard 60 (or usually 30) minute clinical interview as a starting point for diagnosis or treatment.   For example, with an initial episode of psychosis, there will probably be a lot more work done trying to identify cognitive endophenotypes or other transitional phenotypes within the current subjectively derived domains.  A very conservative estimate suggests that this alone will take take least one hour of testing.  There will probably need to be a lot of time and effort expended on determining when a person is testable.  An RDoC diagnosis will be both time and resource intensive.  It won't be a template or a checklist.

I am sure that the antipsychiatry/myth of mental illness crowd and some of the thinly veiled variants of this philosophy will be disappointed.  After all,  this is a diagnostic approach that directly assails one of the most typical arguments from them: "There is no "test" for mental illness."  When the RDoC comes to fruition there will not just be one test.  There will be many tests.

Like most things psychiatric, the biggest threat to the realization of a more comprehensive diagnostic system for our most complex illnesses is not the obvious detractors.  It is the current political culture that applies junk science to the management of the health care system.  It remains an incredible fact that political ideology and not medical science dictates medical treatment in this country.  The current political consensus is that psychiatric care (like medical care) can be managed for both cost and quality by companies who can profit by rationing care.  The care they ration the most is for the treatment of mental illnesses and addictions.

Will an Accountable Care Organization (ACO) in the future spend what it necessary to thoroughly evaluate an initial episode of psychosis if it takes as many or more resources than Cardiology  currently uses to assess heart disease?  The answer to that lies in whether the stigma against mental illness and addictions in health care and governing organizations can be overcome.  Despite all of the lip service - it is that stigma that supports the current system of care that is predominately brief hospitalizations orchestrated by case managers and 15 minute "medication management" approaches to the treatment of mental illness.

You can't implement an RDoC in that environment.

George Dawson, MD, DFAPA

Saturday, September 22, 2012

Concentration of Effort, Academics, and Managed Care

I follow the Nephron Power blog because I have maintained a life long interest in Nephrology or at least since I found out what it was in Medical School.  The conventional wisdom at the time was "Oh you're going into psychiatry - take as many medicine electives as possible because you will never have the chance to do medicine again."  If there are any medical students reading this - I ended up doing another 22 years of following renal function, treating people who were delirious and in renal failure, treating manic patients who were in renal failure waiting for a kidney transplant, and consulting with Nephrologists.  I  can say without a doubt that the Nephrologists who I worked with are some of the brightest, most thoughtful and hardest working people I have ever known.

I still  consider the Renal Service where I worked in medical school to be the model for academic medicine and how to teach medical students and residents.  It was located in two adjacent hospitals and headed up by a cranky old guy.  I say "old" realizing that he was probably about the same age that I am right now and he had the appearance of being cranky like a lot of old guys can get.  You could tell he was very bright, very interested and not above giving the medical students a hard time.  He made sure that on all of the consults we had conducted the appropriate "liquid biopsy" by performing our own urinalyses on patients we were seeing.

We rounded three times a day seeing all of the hospitalized patients in the morning, clinic patients in the afternoon, and hospital consults in the evening and at night.  My last action as a medical student was staffing two Renal Medicine consults at about 8PM the night before I graduated.  The other team members included another two attendings, two fellows, three Internal Medicine residents, and another medical student.  The physical layout of the service was two hospital wings and a very busy clinic with a separate day for a Hypertension clinic.  The hospital service was in the same hospital as the transplant team and we would also care for patients with transplant complications.

The  atmosphere on this service was electric.  Everyone was on time, interested, bright, academic and effective.  To this day - I consider this team from the 1980s to be the prototype for what a teaching service in a Medical School should be and in many ways how serious medicine should be provided.  When I left the hospital that night after the last two consults staffings of my medical student career I can remember thinking - should I have gone into medicine and become a nephrologist?  My fantasy in psychiatry became to recreate this model or at least parts of it in psychiatry.

Flash forward 26 years.  Most people would be fairly surprised to find out that you can come close to my fantasy in very few psychiatric units.  The patient flow into and out of many psychiatric units generally does not depend on academic considerations like providing the best medical and psychiatric care to patients.  In most cases patient flow does not depend on the judgment of psychiatrists.  My ability to care for patients with the most severe illnesses did not come about because there is an elite cadre of psychiatrists who are academically interested and have the necessary resources to provide that level of care.  It came about because the system where I worked needed a place to put these folks and I happened to be a psychiatrist who was interested in all of their problems.

I got very close to recreating at least the inpatient side of my old Renal Medicine service, but these days there are just too many administrative problems along the way.  It is impossible to take a learned approach to medicine and psychiatry with administrators breathing down your neck about an absurdly short length of stay.  It is a clash of paradigms and as far as I can tell the administrators have won.  You cannot possibly address complex problems when someone is telling you that the only reason a patients should be in the hospital is that they are "suicidal" or "homicidal" - both very loosely defined business terms for getting the patient out in time to capture about a 20% profit on the DRG payment.  Let's suspend the reality that this person is just  too ill to function or that their illness has created an impossible situation at home or they are not able to care for their new medical diagnoses until they have recovered their cognition to some extent.

If you are really interested in a rigorous approach to tough problems these days you will run afoul of a huge managed care infrastructure that is there to process patients in and out of hospitals based almost entirely on business decisions.  That makes life a lot less interesting for physicians and a lot more frustrating for patients.  Patients coming out of the managed care environment have an almost universal experience that they were hardly seen in the hospital and when they were, there was not a lot of interest in solving their problems.  They end up saying what they think people want to hear in order to be released and after they have been discharged realize that nothing has changed.

In the final analysis these are contrasting models but nobody pays much attention to the contrast.  An academic full spectrum of care model versus a severely rationed model where care is based on an administrators notion of "dangerousness".  Clinicians aware of the full spectrum of illness, grappling with all of the nuances and offering the necessary care versus a doctor sitting in an office prescribing pills as fast as they can.

That is what we are talking about and in that context - I will take the Renal Service any day.

George Dawson, MD, DFAPA

Saturday, September 15, 2012

More On Homicide Prevention

As the number of mass homicides becomes even more noticeable it is getting some attention in the psychiatric press. This months Psychiatric News has a story that looks at the issue of "explanations" for mass killings. There were a couple of new terms that I was not familiar with such as "rampage violence" or "rampage", "autogenic", or "pseudo-commando" killings.  The perspective in the article was generally public health research or the perspective of forensic psychiatrists. Inconsistencies were apparent such as:

"... Much research has shown that mental illness in the absence of substance abuse does not lead to violence and that most crimes are committed by people who have not been diagnosed with mental illness."

Followed by:

"Even when behavior reaches a level troubling to family or neighbors, getting an affected individual into treatment is difficult, especially in a society that highly values individual liberty..."

Are they referring only to those people who are abusing substances or only those people who become violent as a result of mental illness? My experience is that both categories are important and that is illustrated within the same article that refers to a study of five "pseudo-commando" murders where common traits were noted including the fact that all of the subjects were "suspicious, resentful, narcissistic, and often paranoid".

The overall tone of the article is that we may be too focused on mass homicide because only a small number of people were killed in these incidents compared to the 30 to 40 people per day who die from homicide and that violence prediction may be a futile approach. There is also commentary on why neither the Democrats or Republicans want to comment on this issue. An uncritical statement about the "support for gun ownership" being at an all-time high is included in the same paragraph.  Like most things political in the US, all you have to do is follow the money.

The same issue was covered in the September issue of Psychiatric Times.  Lloyd Sederer, MD takes the position that apathy fueled the lack of a sea change in gun control following the incident when Congresswomen Gifford was shot and several people at that same event were killed.  He includes an apathetic quote from Jack Kerouac and a nonviolent activist quote from Gandhi.  Allen Frances, MD makes the reasonable observation that understanding the psychology of a mass killer will not prevent mass homicide, but proceeds to stretch that into the fact that this is a gun issue:

"We must accept the fact that a small cohort of deranged and disaffected potential mass murderers will always exist undetected in our midst."


"The largely unnoticed elephant in the room is how astoundingly easy it is for the killers to buy supercharged firearms and unlimited rounds of ammo.  The ubiquity of powerful weaponry is what takes the US such a dangerous place to live."

He goes on to suggest that there are only two choices in this matter: accept mass murder as a way of life or adopt sane gun policies with the rest of the civilized world.

I don't think that gun laws are the best or only approach.  The idea that "supercharged" firearms are the culprit here or the extension to banning assault weapons as the solution misses the obvious fact that even common widely available firearms - shotguns and handguns are highly lethal.  Anyone armed with those weapons alone would be unstoppable in a mass shooting situation.  Secondly, the effects of stringent firearms laws have mixed results.  The mass shooting in Norway is an example of how tight firearm regulation can be circumvented.  It is well known that there are a massive amount of firearms under private possession in the US, making the effect of firearm legislation even less likely.  There are also the cases of heavily armed citizenry with only a fraction of the gun homicides that we have in the US.  Michael Moore's comparison of the US with Canada in "Bowling for Columbine" comes to mind.

The previous posts on this blog suggest clear reasons why gun ownership is at an all-time high. The problem is that much can be done apart from the gun ownership issue and the solutions are available from psychiatrists who are used to assessing and treating people with mental illness, severe personality disorders, threatening behavior, or history of violent or aggressive behavior. The critical dimension that is not covered is the issue of prevention and the necessity of an open discussion about homicide and how to prevent it. Education about markers that are associated with mass homicide is useful, but the focus needs to be on how to help the person who starts to experience homicidal ideation before they lose control.  That is also consistent with a humanistic approach to the problem.  I have treated many "deranged and disaffected potential mass murderers" who went back to their families and back to work.  We need a culture that is much more savvy about the origins of violence and aggression.  It is too easy to say that this behavior is due to "evil" and maintain attitudes consistent with that approach.  Time to develop research on the prevention of mass homicide, identify the individuals at risk, and offer effective treatment.

George Dawson, MD, DFAPA

Aaron Levin.  Experts again seek explanations for mass killings.  Psychiatric News 2012 (47)17: 1,20.

Lloyd I. Sederer.  The enemy is apathy.  Psychiatric Times 2012 (29)9: 1-2.

Allen Frances.  Mass murderers, madness, and gun control.  Psychiatric Times 2012 (29)9:1-2.

Borderline Personality Disorder - DBT versus GPM

I just got back from a Mayo Clinic CME course "Clinical Management of Borderline Personality Disorder". I went to see John G. Gunderson, MD.  He and I go way back in a peripheral sort of way to the days before the Internet.  About 20 years ago I sent him a letter and he mailed me a copy of his "Diagnostic Interview for Borderlines." That was about three years after Marsha Linehan mailed me a rough copy of her research protocol for Dialectical Behavior Therapy. I like to see and hear from the experts.

The course was excellent and the logical summation of work done in this field for the past two decades. It was accessible and the faculty that included Dr. Gunderson and Brian Palmer, MD were enthusiastic and optimistic about treatment outcomes. Dr. Gunderson pointed out that sampling bias has led to therapeutic nihilism and stigmatization in the past and that more recent outcome studies show very positive results. The basic tenets of therapy that you learn in psychiatry school can go a long way. Therapeutic neutrality, and active interest in with the patient has to say, the therapeutic alliance, and technical skill with specific interventions are common elements in working with patients across all diagnostic categories.  If the diagnosis is accurate psychopharmacology is a secondary intervention.  The primary focus is psychotherapy and case management.

One of the significant points in the presentation was the concept of General Psychiatric Management (GPM) in the treatment of borderline personality disorder. In the years since I received the DBT manual, in many areas that therapy has become the de facto standard of care for borderline personality disorder. There is research evidence that it is effective.  DBT treatment programs seem to have popped up everywhere in the past decade. My experience in inpatient units led me to observe that many of these patients seem to have been misdiagnosed or DBT was being applied to the wrong diagnosis. There are fairly specific selection criteria for DBT, but it seems that anyone with a difficult problem was being put in a DBT program.

Dr. Gundersen referenced an article in the American Journal of Psychiatry comparing GPM versus DBT.  General Psychiatric Management is a variation of what we used to call supportive psychotherapy and it was defined by the researchers as:

"General psychiatric management was implemented as a comprehensive approach to borderline personality disorder, developed and manualized for this trial, consisting of psychodynamic psychotherapy, case management, and pharmacotherapy (P.S. Links, Y. Bergmans, J. Novick, J. LeGris, unpublished 2009 manuscript). The psychotherapeutic model in this approach emphasized the relational aspects of the disorder and focused on disturbed attachment patterns and the enhancement of emotion regulation in relationships. Case management strategies were integrated into weekly individual sessions. No restrictions were placed on ancillary pharmacotherapy in either condition; in general, pharmacotherapy was based on a symptom-targeted approach but prioritized mood lability, impulsivity, and aggressiveness as presented in APA guidelines (16)." (see link below to McMain 2012)"

The study showed that the outcomes of both treatment modalities across several outcome measures (suicidal and non-suicidal self injurious behavior, depression, anger, interpersonal functioning) were comparable.  GPM was delivered as once a week hourly psychotherapy with additional case management and coordination of care.  This is important research because the logical extension of this research is to look at ways to improve functional capacity as well as symptomatology.

Take a look at the references and attend the seminar in the future if you have the chance.

George Dawson, MD, DFAPA

John G. Gunderson and Brian A. Palmer.  Clinical Management of Borderline Personality Disorder.  Mayo Clinic CME, September 14, 2012.

McMain SF, Links PS, Gnam WH, Guimond T, Cardish RJ, Korman L, Streiner DL. A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. Am J Psychiatry. 2009 Dec;166(12):1365-74. Epub 2009 Sep 15.

McMain SF, Guimond T, Streiner DL, Cardish RJ, Links PS. Dialectical behavior therapy compared with general psychiatric management for borderline personality disorder: clinical outcomes and functioning over a 2-year follow-up. Am J Psychiatry. 2012 Jun;169(6):650-61

Thursday, September 13, 2012

Medscape Has Not Stopped Anonymous Postings

I had to put this comment here because my attempt to post it on the Psychiatric Times was unsuccessful.  I tried to put this comment in response to an article by Ronald W. Pies, MD on anonymous posters that are abusive and in some cases threatening.  He discusses situations where psychiatrists who are not anonymous are subjected to these tactics by anonymous posters.  He  goes on to say:

"It was therefore with great satisfaction that I learned of a new (6/27/12) policy on the popular medical Web site, Medscape; ie"we have removed the ability to post comments anonymously in our physician-only discussion forum, Medscape Connect, and in all Medscape blogs."

I am familiar with the discussion area on Medscape for quite a long time.  There are anonymous posters there who are somewhat disagreeable.  There are anonymous posters there who clearly have a lot of time on their hands.  There are posters there whose main goal is to denigrate psychiatry and psychiatrists.  Interestingly posts against psychiatrists and psychiatry have never been censored, no matter how off the wall they are.  One psychiatrist fighting back, made several posts that were pulled.  The abusive anonymous posters there usually fall back on "freedom of speech" as their right to say whatever they want about psychiatry.  As far as I know only a psychiatrist was ever censored in that forum - but in that case an entire series of posts was pulled.

I have always advocated for physicians posting under their own name in any Internet discussion by physicians.  When that does not happen there is always a predictable amount of rhetoric and name calling.  At times the posts on Medscape were at such a level it was difficult to believe that they were made by physicians.  Of all the specialty discussion boards on Medscape, it is probably no surprise that psychiatry was the only specialty under attack.

The problem currently is that despite their advertised policy, posting on Medscape's physician discussion forums really have not changed.  I just looked at the forum and anonymous posting is alive and well.  Bashing psychiatry is alive and well.

Old antipsychiatry habits die hard.

George Dawson, MD, DFAPA

Ronald W. Pies, MD.  Is it time to stop anonymous (and abusive) posting on the Internet?  Psychiatric Times; August 16, 2012.

Why Are There No Detox Units Anymore?

Acute withdrawal from drugs and alcohol can kill you in the worst case scenario and at best can prevent you from initiating the recovery process.  So why are there no detox units anymore or at least very few of them?  You can still end up in a hospital going through detoxification or in a county facility where the priority is more containment of the acutely intoxicated than appropriate medical detoxification.  There are probably a handful of detoxification facilities where you will see physicians with an interest or a specialty in addiction medicine using the best possible standards. Why is the government and why are the managed care systems that run healthcare in the United States not interested in "evidence-based" medical detoxification?

As a person who has seen the system devolve and who has successfully treated a lot of people who needed detoxification this is another deficiency in the system of medical care that is never addressed. Over the course of my career I have seen patients admitted to internal medicine services for detox in the 1980s. When insurance companies and managed care companies started to refuse payment for that level of treatment intensity patients requiring detoxification were then admitted to mental health units.  When mental health units started operating according to the managed care paradigm of no treatment for people with severe addictions, they were either sent home from the emergency department or sent to county detox facilities.  Those county detox facilities were often low in quality and one incident away from being shut down.

I currently teach physicians about the management of opioids and chronic pain in outpatient settings.  I am impressed with the number of addicted patients who are taking opioids for chronic pain.  This population frequently has problems with benzodiazepines.  There is a general awareness that we are in the midst of an opioid epidemic and in many counties across the United States the death rate from accidental drug overdoses exceeds the death rate from traffic fatalities. The question I get in my lecture is frequently how to deal with the addicted pain patient who is clearly not getting any pain relief from chronic opioid therapy and has often escalated the dosage to potentially life-threatening amounts.  In many chronic pain treatment algorithms this is the "discontinue opioids" branch point.   During my most recent lecture I posed the question to these physicians: “Do you have access to a functional detoxification facility?"  Not surprisingly  - nobody did.

I can still recall the denial letters from managed care companies when I was taking care of patients with alcoholism and addiction in an inpatient setting. They had been admitted to my inpatient mental health unit and many were also suicidal. The typical managed care comment was "this patient should be detoxified in a detox unit and not admitted to a mental health unit.”  This is an example of the brilliant concept called "medical necessity" as defined by a managed care company. In the majority of these cases, the patient's county of residence did not have a functional detox unit and there were also clear-cut reasons for them to be on a mental health unit.  County detox facilities do not take people with suicidal thinking or associated medical problems.  I wonder how many letters it took like the ones I received to permanently disrupt the system so that patients with alcoholism and addictions could no longer get standard medical care.

The end result has been no standards for medical detoxification at all. Some patients are sent out of the emergency department with a supply of benzodiazepines or opioids and advised to taper off of these medications on their own. That advice ignores one of the central features of substance abuse disorders and that is uncontrolled use. Without supervision I would speculate that the majority of people who are sent home with medications to do their own detoxification take all that medication in the first day or two and remain at risk for complications.

Appropriate detoxification facilities staffed by physicians who are trained and interested in addictive disorders would go a long way toward restoring quality medical care to people who have a life threatening addictions.  It would restore more humanity to medicine - something that business decisions have removed.  As far as I can tell, people struggling with addictions and alcoholism continue to be neglected by both federal and state governments and the managed care industry.

George Dawson, MD, DFAPA

Sunday, September 2, 2012

Happy Labor Day - To All the Docs On The Assembly Line

When I first started working in medicine I was the Medical Director of an outpatient mental health clinic.  We had a staff of 8 psychotherapists, 2 nurses, and 2 case managers.  There were three transcriptionists to type up all of our notes.  Every person I saw had a typed note to document the encounter and all of the charts were paper.  There was no electronic health record.  If a person needed a prescription, I would write one or call the pharmacy and that was the end of it.  The majority of my time was spent speaking directly with patients and I could generally do all of the dictations in about 2 hours per day.

After three years I moved to a hospital setting.  There were three inpatient units with 6 psychiatrists and two transcriptionists.  One of the transcriptionists specialized in paperwork specific to probate court proceedings.  There was an additional pool of transcriptionists available 24/7 on any phone in the hospital for immediate documentation of any clinical encounter.  The admission notes were typed on two or three sheets and inserted in the chart.  Daily progress notes were typed on adhesive paper and pasted into the chart.  After I signed the note, a billing and coding expert came through and submitted a billing fee for the work that had been done.  The same process was in place with pharmacies.  Call them or send them a written prescription and it was taken care of.   Every Sunday I would go to the basement of the hospital in the medical records department and sign all of the areas I had missed to complete the charts.  It was the early 1990s and the administrative burden was certainly there but it was a manageable ritual.

Over the next decade things got much, much worse.  Even in the blur of a retroscope it is hard to say what happened first.  I would guess it was the political theory that health care fraud was the main driver of health care costs and the misguided effort by the federal government to crack down on doctors.  That led to the elimination of the billing and coding experts.  Doctors now had to waste their time in seminars devoted to making them experts in what is an entirely subjective process.  No two coders agree on the correct bill to submit.  How can you teach that lack of objectivity to doctors?  The end result is that the billing and coding people were eliminated or reassigned and doctors took on another job unrelated to medicine.

The next phase was the electronic health record (EHR).  It required that doctors learn the interface (more seminars and training).  Once that was accomplished it was decided that they could also learn to enter their own notes - either really clunky ones using EHR derived phrases or more natural ones with a fairly frequent embarrassing typo using voice recognition programs.  That eliminated the transcriptionists and required much more training. During the transition period I still went in to medical records every Sunday.  I expected to see a staff person there who I had seen every Sunday for 15 years but one Sunday she was gone - a casualty of the EHR.  The end result was doctors with a couple of new jobs and the elimination of both transcriptionists and medical records people.

At about the same time, managed care companies started to ratchet up the pain.  In an inpatient setting you could get one or two "denials" per day.  A denial is the managed care company saying that they refuse to cover the cost of care because the admission was not "medically necessary".  That is managed care rhetoric for "we have decided not to pay you."  These denials are purely arbitrary and have nothing to do with whether a person needs care or not.  The best examples at the time were people with alcoholism or addiction who were suicidal and needed to be detoxed and reassessed.  The standard managed care denial at the time was "This patient should be treated in a detox facility."  The obvious problem was that not every county has a detox facility and those that do will not accept people making suicidal statements.   So the next new job became battling with these companies who were essentially getting free care for their health plan subscribers if you did not jump through all of the hoops necessary to appeal.

Slightly later, managed care decided they could apply the same denial strategy to pharmaceuticals on the basis that cheaper drugs are as good and all drugs in the same class are equivalent.  It turns out that nether of those assumptions is accurate, but in America today business and politics always trumps medical decision making.  This prior authorization process created a blizzard of paperwork that ties up a lot of clinic time.  One study estimated 20 hours per week (across all employees) per physician  on average.  That means if your clinic has 5 doctors in it - 100 hours per week of the total hours worked is used strictly to deal with insurance companies.  It also adds another job to what the doctor already does.

So in the time I have been practicing medicine let's add the number of jobs that have been accreted into the administrative side of medicine for all physicians.  Billing and coding expert + transcriptionist + EHR interface user + voice recognition user + utilization review responder + prior authorization responder totals 6 new jobs in the past two decades, none of which came up in medical school.

With all of that "efficiency" we should expect health care costs to plummet or at least stay the same.  As we all know that has not happened.  The politics and business interests driving this are in the business of making money.  Physician and hospital reimbursement is essentially flat.  One of the easiest ways to make a buck is to have the physicians doing way more administrative tasks and fire the employees that used to do them.  You can also make money by putting up the usual obstacles to doctors doing their jobs of treating patients in hospitals or clinics until they just give up.  I have been so burned out at times that I put a cursory note in the chart to say exactly what I did.  That note did not meet coding requirements so I did not submit a bill.  At some point you just have to stop working.  I know that I am not alone in getting to that point.

So congratulations to all of the docs who are now laboring on this vast assembly line that we now call American medicine.  It is the ultimate product of what Congress, the White House and big business can do.  We can only expect continued "improvements" or "efficiencies" under the new health care law.  It is an assembly line that discourages quality or innovation and that also makes it unique.

Happy Labor Day!

George Dawson, MD, DFAPA

Saturday, September 1, 2012

A Neurologist Gets High

Well known neurologist and author Oliver Sacks has written an essay in the New Yorker about his drug experiences in the 1960s.  From about 1963-1967 Dr. Sacks ingested various compounds including cannabis, amphetamines, intravenous morphine, LSD, morning glory seeds, Artane (trihexyphenidyl hydrochloride) and massive doses of chloral hydrate with an accompanying withdrawal state.  He does an excellent job of describing various intoxication and delirium states.  As an example he describes his experience reading a text on migraines from 1873 while taking amphetamine:

"...In a sort of catatonic concentration that in 10 hours I scarcely moved a muscle or wet my lips, I read steadily through "Megrim"....At times I was unsure if I was reading the book or writing it...." p. 47

In my current professional iteration as an addiction psychiatrist these are familiar scenarios.  At some level Sacks realizes that he is lucky to have survived chloral hydrate withdrawal induced delirium tremens and amphetamine-induced tachycardia up to the 200 beats per minute range with an unknown blood pressure.  Vivid visual and auditory hallucinations and a distorted sense of time are described.  There is also the familiar interpersonal dimension that gets activated when a person's life is affected by drug use - concerned colleagues that implore him to seek help and take care of himself.

Dr. Sacks is an intellectual and this is presented in an intellectual context that may not have been very evident at the time of the experimentation.  He describes the sociocultural antecedents of a need for chemical transcendance that has been present throughout human history.  He proceeds to describe some of the relevant historical writings of physicians and other intellectuals.

The usual debate about whether or not there is any utility in taking life threatening amounts of drugs occurs in the text and on the podcast.  Not surprisingly, intellectuals derive insights from their experiences and taking drugs is no exception.  In  the article, the revolution in neurochemistry was one of the preludes to the period of experimentation.  The problems with psychotic symptoms and manic states are well described as well as what states might be the preferred ones.  We learn on the podcast that these experiences have provided insights into possible brain mechanisms and that this might be part of the basis for the author's new book Hallucinations that comes out in the fall.

Dr. Sacks describes himself as an observer and explorer of psychotic symptoms and how that seems to be protective when he is tripping.  What is missing here compared to the people I have talked with is a highly subjective response that increases the risk for drug use.  I typically hear about intense euphoria, high energy, and increased competence in physical, intellectual and social spheres.  Not having that response may be protective and may allow one to avoid the risks of ongoing chemical use.  In some cases there may just be a compulsion to recreate the drug induced state.  The essay may have been a lot more complicated or written by someone else if those descriptions were there.

George Dawson, MD, DFAPA

Oliver Sacks.  Altered States - Self experiments in chemistry.  The New Yorker, August 27, 2012: 40-47.

Oliver Sacks.  Podcast: The New Yorker Out Loud.