Friday, April 26, 2013

A Grand DSM critique from Health Affairs

There is a large Health Affairs article that just became available online.  It criticizes (what else) the DSM 5.  The article and its initiatives all seem to flow from the conclusion:

"Inadequate interdisciplinary review and collaboration translate into missed opportunities to increase the accuracy of explanations for mental disorders.  They also lead to suboptimal care and outcome disparities for millions of patients at a time when dramatic differences in psychiatric diagnosis and treatment rates by sociodemographic status, ethnicity, and geography have undermined public confidence in psychiatry.” (p 7)

I hope that anyone reading this blog knows what the factors are in the mismatch between psychiatric diagnoses and care.  I hope that anyone reading this blog knows the biases against psychiatry and how that influences the allegations of overdiagnosis, diagnostic reliability, overprescriptions and conflict of interest that are typically leveled at psychiatrists and their professional organization.  The most obvious example and a point that seems to be completely lost on these authors is the rationing of psychiatric services and the resulting fact that most of the diagnostic disparities that they are complaining about are not due to psychiatrists or the DSM.   I hope that any reader here has also noted my running commentary about the real causes of “suboptimal care and outcome disparities”.  It is directly related to managed care, pharmacy benefit managers, and the adoption of these same rationing practices by local, state, and federal governments charged with the provision of mental health and substance abuse services.

The authors seem to lack an understanding of some of the basic social processes that they believe to be impacted by the DSM.  They cite the New York Times as a source for the issue of whether the DSM committee backed down on diagnostic revisions that would have disqualified “half of those who currently receive benefits for autism spectrum disorders” and various other changes.  As a psychiatrist who is intimately familiar with the disability process, the determination of disability is a political process at the level of the Social Security Administration.  A diagnosis is an entry point but it does not assure a disability award or even ongoing disability payments.  I have seen patients who were hospitalized for severe problems who did not get a disability determination in their favor.  I have seen people who clearly misrepresented themselves, did not believe they have a mental disability, and who received disability determinations that they requested.  As far as I can tell, the system is currently set up to favor people with mental illnesses who have been hospitalized at least three times in two years.  There are companies who facilitate applications.  It generally takes a series of two or three appeals that can drag out over a year or two.  If it comes to a hearing, those hearings are uncontested and they are not adversarial in that the government does not have an attorney present to oppose the application and the decision is made by a judge and not a jury.  The most  significant political event in this process occurred about 15 years ago when the government decided it would not consider alcoholism and drug addiction a disability.  Prior to that alcoholism was a leading cause of disability in many states.  With all of those political variables how can a DSM diagnosis be seen as the rate limiting step in that process?

The authors also conclude “Psychiatric conditions result from a combination of biological and environmental factors”.  The arguments that follow suggest that psychiatrists are basically clueless about these phenomenon.  I did not see George Engel or the biopsychosocial model of illness referenced.  In Engel's seminal 1977 paper in Science, he directly addressed the limitations of the biomedical model and changed the paradigm for the future by proposing a biopsychosocial model.  This paper is dramatic in its intellectual scope and it addresses practically all of the issues brought up in the Health Affairs article including several areas that are not addressed such as the experience of the patient.  Engel also addressed the issue of “When is grief a disease?”, a popular current DSM critique:

“…Hence the physician’s basic professional knowledge and skills must span the social, psychological, and biological for his decisions and the actions on the patient’s behalf involve all three.  Is the patient suffering normal grief or melancholia?  Are the fatigue and weakness of the woman who recently lost her husband conversion symptoms, psychophysiological reactions, manifestations of a somatic disorder, or a combination of these.  The patient soliciting the aid of a physician must have confidence that the MD degree has indeed rendered that physician competent to make such differentiations.”  

A reference to Engel would seem appropriate but it detracts from the authors’ contentions that physicians seem to need to have their biopsychosocial horizons broadened and acknowledging that a physician discussed this definitively 35 years ago would detract from their argument.

The authors more direct arguments about the role of “social and institutional influences on diagnosis” can be similarly addressed.  Although they don’t acknowledge the DSM, they discuss post traumatic stress disorder as an example of environmental exposure.  They cite evidence gathered in the psychiatric literature as their proof.  In fact, any psychiatric evaluation should contain a formulation section that considers social, biological, and consciousness based factors in the overall evaluation of the person seeking help.  This is nothing new and every competent psychiatrist is trained to do this.  The now abandoned oral Board exam, used to test these skills.  The idea that these factors are relevant to psychiatric diagnosis have been taught to psychiatrists for decades.  Do we really need to learn that from a panel of social experts who don't talk with people about that information every day like we do?

The idea that social context,  is a relevant factor has also been obvious to psychiatrists for a long time.  Psychiatrists are routinely asked to evaluate and treat patients from various socioeconomic and cultural groups and frequently work with interpreters in the process.  There is no basis in fact for their speculative comment that “Identifying and understanding the causes of diagnostic disparities can lead to improved diagnostic criteria and their more accurate application.”

On the issue of institutional and policy factors the authors also miss the mark.  They make the previous mistake about diagnosis and Social Security disability by suggesting that a specific diagnosis results in a disability check.  They do not point out how the Social Security process rather than a DSM diagnosis may be more important in the issue of disabilities for mental health. Interestingly they are concerned about the “major consequences for payers and patients" and reference a study looking at the prescription of atypical antipsychotic medications for children.  They ignore the fact that the actual treatment of mental illnesses are outside of the purview of the DSM and that overprescription (if this is actually overprescription) is a widespread problem that extends well beyond the field of psychiatry.  As is the case with all critics of psychiatry and the DSM, they give a pass to the real causes of systemic poor treatment and a focus on medications rather than psychosocial therapies and that is the managed care industry and its supporters at all levels in the government.

Their final focus on publicity and marketing is certainly not a problem specific to psychiatry.  It is also a process that is not DSM dependent.  Restless leg syndrome or insomnia do not need to be in the DSM to end up being treated on a large scale by primary care physicians.  All it takes is a pharmaceutical company web site with a checklist.  They provide no insight into why the political process of direct-to-consumer advertising as determined by lobbyists, politicians, and the associated exchange of money should be part of a DSM oversight process.

The authors proposed Psychiatric Diagnosis Review Body and its potential benefits are equally speculative.  Their idea that there would be “greater sophistication” in the explanations of mental illness is doubtful, especially considering the impact that Engel’s biopsychosocial model has had on both the field and DSM development.  Their idea that the work of a review body would “heighten mental health practitioners’ awareness of population level differences in diagnoses, in some instances improving their ability to tailor diagnoses to patient’s demographic characteristics and cultural backgrounds…” is also problematic.  First off, the DSM is written for psychiatrists and a psychiatric diagnosis and formulation is much more than looking at a list of symptoms that possibly identifies a person as being a statistical outlier in a group.  Any person can pick up a copy of the DSM and presume to make a "diagnosis" based on these criteria, but that is not a psychiatric diagnosis.  Secondly, cultural, demographic characteristics, and demographic factors have already been incorporated into psychiatric evaluations for decades.  An even greater question is what broad scale social data would add to the evaluation of the individual patient given the biases that are usually present in those studies.

The authors suggest that the incorporation of feedback from the review body would “increase public confidence in the manual and psychiatry as a medical profession”.  The single most important factor that would enhance psychiatry’s image would be the recognition that rhetorical negative arguments against the profession abound and need to be corrected.  That could start by recognizing what psychiatrists actually do and what a DSM is actually used for.  It would also take a critical look at why 20 years of rationing of psychiatric services by the managed care industry and the government is the single largest factor in why these services have deteriorated and now operate on the premise that getting people on one medication or another is the best way to treat mental illness.  The authors in this case banter about million and billion dollar amounts that are typically used to suggest the impact of the DSM or significant conflicts of interest in psychiatry.  Nobody is focused on the fact that the managed care industry makes far more money than that by denying medical care.  Psychiatric services make up a disproportionately large amount of denied care.

If you are really interested in improving the care of people with mental illness in this country it would seem logical to attack those who routinely deny them care and interfere at all levels with the provision of care rather than those providing the care and trying to improve it.   That is the most important social problem affecting the provision of mental health services and access to psychiatry.  Social scientists seem to be as disinterested in that fact as the average journalist.

George Dawson, MD, DFAPA

Hansen HB, Donaldson Z, Link BG, Bearman PS, Hopper K, Bates LM, Cheslack-Postava K, Harper K, Holmes SM, Lovasi G, Springer KW, Teitler JO.  Independent Review Of Social And Population Variation In Mental Health Could Improve Diagnosis In DSM Revisions. Health Aff (Millwood). 2013 Apr 24. [Epub ahead of print] PubMed PMID: 23614899.

Engel G. The need for a new medical model: a challenge for biomedicine. Science 1977; 196:129-136.

George L. Engel, MD. JAMA.2000;283(21):2857. doi:10.1001/jama.283.21.2857

Thursday, April 18, 2013

Psychiatric care versus gun control - an expected outcome

Just in case you are keeping score the Senate voted down some modest gun control proposals last week.  The issue of coming together over mental health care to address one of the dimensions of mass shootings also did not happen.  In the political calculus, it makes sense that if legislators did not fear the gun control lobby they had a lot less to fear from a mental health lobby ambivalent about dovetailing improved mental health care with gun control.

The pro gun advocates especially the NRA have always underscored the idea that they support law abiding citizens having access to firearms.  Their mantra for years has been that if there are more obstacles to law abiding citizens getting guns then only criminals would have them.  Never mind the significant number of accidental deaths every year and the fact that firearm suicide is consistently greater that firearm homicide in this country.  That detail is not lost on psychiatrists interviewing patients who have told us that they were impulsively looking for a gun to kill themselves and the only thing that prevented it was a background check and a waiting period.  The main provision of the attempted legislation was an extension of background checks.  If the pro gun lobby believes that it is protecting the right of law abiding citizens to purchase firearms, there should be no problem at all with universal background checks.  That should cut across all venues where firearms are bought and traded.  I have not heard a single rational explanation for voting down extended or universal background checks.

Reaction to the failure of this legislation was as swift as the Sunday morning talk shows.  Bob Scheiffer interviewed family members of the victims of the Sandy Hook incident on Face the Nation.  They were clearly upset about the vote in the Senate as captured in this quote from Neil Heslin father of 6 year old Jesse Heslin one of the victims of this incident:

"....As simple as a background check, putting aside the assault weapon ban or limitation or control, it's just a stepping stone of the background check with the mental health and the school security. I think the most discouraging part of this week was to, after the vote, to see who voted and who didn't vote, support it, and realize it's a political game. It was nothing bipartisan about it, at all. And we aren't going to go away. I know I'm not. We're not going to stop until there are changes that are made."

In the vacuum of no discussion of the vote against the bill or partisan rhetoric, very little was said in the press about the money behind the vote. did an excellent job of showing that like most things in American politics it looks like a significant factor.  Their research clearly shows that the pro-gun lobby can outspend the gun control lobby by as much as 15:1 with most of the money going to Republicans.  There are a couple of things working against the pro-gun lobby and all of that money - public support for common sense gun measures like background checks is at an all time high.   The second factor is difficult to say out loud but in American culture you can depend on it.  There will be more incidents and the pro-gun solutions (armed guards in schools, keeping the guns out of the hands of criminals and the mentally ill) are not really solutions.  The pro-gun lobby has demonstrated that they do not take that task seriously.

George Dawson, MD, DFAPA

Senate Blocks Drive for Gun Control.  NYTimes April 17, 2013.

S. 649 Roll Call Vote

Monday, April 15, 2013

Penis Size and the Primitive State of Sexual Consciousness

On the Nature blog this week, there was a summary of an article originally posted in Proceedings of the National Academy of Sciences (PNAS) on the implications of penis size preference and evolutionary pressure for large penises.  If true that may explain why humans have the largest penis size of all primates.  Someone has apparently already figured out that male genitalia were the earliest developed physical traits in the animal kingdom.

In the experiment, researchers showed computer generated life sized projections of 53 frontal images of men of varying heights, flaccid penis size, and body type to a group of 105 heterosexual Australian women.  The women looked at the images and rated them for sexual attractiveness.   Since the original article is not accessible, the results on the Nature blog state that that a range of flaccid penis sizes and male body types were rated the most attractive.  At some point masculine body type (greater shoulder width to hip width) was more important.  There was not a direct correlation with penis size and attractiveness.  The graph of size versus attractiveness was described as an inverted U-shaped curve with attractiveness falling off at both extremes.  There were some remarks on the importance of this finding not the least of which that studies like this may make it easier to talk about an “uncomfortable subject”.  I doubt that the press will take such a nuanced approached.

As I read that last line, I thought about penis references in the popular culture over the course of my lifetime from Woody Allen films to Seinfeld episodes to morning radio shock jocks.  I have gone through the “sexual revolution” and noticed that very little has changed.  If anything the landscape seems to have shifted to a more male dominated perspective with the further objectification of women and much easier access to that content.  In some of that content there is a disturbing portrayal of serial violence (usually homicide) and sadomasochism even in prime time television.  All it takes is showing an MALSV (mature audiences, strong language, sexual situations, violence) disclaimer at the outset to broadcast a blend of sexual violence and gratuitous nudity.  The focus from business interests is producing as much of this content as possible combined with the legitimization of the pornography industry.  What is driving all of this?

There are two areas relevant to psychiatry that are the object of very little research and they are sex addiction and sexual consciousness.  Consciousness in general has not been much of a focus by psychiatry since the advent of DSM atheoretical descriptors that in effect limited the focus of study to extremes of human behavior.   The consciousness that I am referring to is the unique conscious state of individuals.  The current diagnostic system does not presume to diagnose individuals

Sexual addiction and other "behavioral addictions" like eating and gambling are all the rage right now.  The neurobiological theories of reward, initial impulse control involving positive positive reinforcement, and subsequent compulsive behavior based on negative reinforcement are thought to apply in traditional chemical addictions but can the same models apply to sexual behavior?  The problem is that there are vast uncharted areas connected to the midbrain and basal forebrain structures that are thought to be substrates for addictive behavior.  Not all of the details of neurotransmission within the system are known even though we have several cartoon versions.  An analysis from reference 3  suggests in a rat model of sucrose self administration that up to 28 regulatory proteins in various cell structures may form the basis for the signaling involved.  Despite several papers suggesting that behavioral and chemical addictions may have the same substrates, I have not seen any compelling evidence that this might be true.  If sex can be addicting, what are the risks of exposure and can we help people with serious problems involving their sexual behavior? 

The state of consciousness in psychiatry these days is at an all time low.  Biological reductionism and a poor understanding of the importance of modern psychoanalysis in exploring unique conscious states may be part of the problem.  The other part of the problem is a single minded focus on problems with human behavior that are clearly two standard deviations from the norm.  This basically leaves out the unique conscious state of the individual and the fact that many people are clearly affected by problems that can't be reduced to a psychopathological model.  Human sexual behavior and all of the behaviors it is associated with are excellent examples at both an individual and cultural level.   Those authors who have taken on this task; most notably the late Ethel Person, MD have described a continuum of male sexual fantasy and behavior from the perspective of psychoanalytic theory and treatment of associated problems.   One of the more interesting considerations to me is the omission of practically all considerations of fantasy and daydreaming in the DSM as if these important functions have no explanation and are not as grounded in prefrontal cortex as the working memory is.  Do we know the basic differences in the sexual consciousness of men and women?  Not from anything that I can find.

These considerations are as important for culture as they are for psychiatry and psychiatric research.  The current cultural attitude seems to be that we need a mechanical understanding of sex.  It is the mechanical approach that is presented as sex education in school.  Here are the parts, here is how they work, here is how you get pregnant, and here is how you get diseases.  No relevant discussion about associated emotions, human attachment, desire, or love.  No appreciation of scientific differences in the sexes.  No discussion about how the really big organ in the head is orchestrating everything.  Figuring out how to address these important issues is a lot more complicated than voting on the most attractive present day penis. 

George Dawson, MD, DFAPA

1.  Nuzzo R.  Bigger not always better for penis size.  Nature News April 8, 2013.

2.  Mautz BS, Wong BBM, Peters RA, Jennions MD. Penis size interacts with body shape and height to influence male attractiveness.  Proc. Natl Acad. Sci. USA (2013). 

3.  Van den Oever MC, Spijker S, Li KW, JimĂ©nez CR, et al. A Proteomics Approach to Identify Long-Term Molecular Changes in Rat Medial Prefrontal Cortex Resulting from Sucrose Self-Administration.  Journal of Proteome Research 2006 5 (1), 147-154

4.  Ethel Spector Person, MD.  The Sexual Century.  Yale University Press, New Haven, 1999.

Sunday, April 14, 2013

Bipartisan Agreement on Treating Mental Illness - Believe It when You See It

The New York Times has an incredibly naive article on how legislators may be split on gun control but both parties support better care for people with mental illnesses. The article alludes to a bipartisan plan that would "prevent killers .....from slipping through the cracks."  The next paragraph says that the plan: "would lead to some of the most significant advancements in years in treating mental illness and address a problem that people on both sides of the issue agree is a root cause of gun rampages."

That would be groundbreaking news if it were true, but let's be realistic.  The history of funding treatment for addictions and mental illnesses in this country has been a downhill spiral for at least 30 years and there are no real signs that will changed.    Congress has essentially been at the root of the problem.  Congress after all is responsible for the disproportionately poor level of funding for the treatment of mental illness.  Congress basically invented the managed care and pharmacy benefit manager industry that has increased the rationing of psychiatric services that has led to the current deterioration.  Rather than focus of providing quality in the services that federal, state, and local governments typically provide (like community mental health centers, case management, civil commitment, protective services, and crisis intervention) they have adopted the managed care model of rationing services.

The only relative bright spot in mental health legislation was a parity law spearheaded by Senators Wellstone and Domenici.  The actual boilerplate is one thing and there was always a question about managed care would react to the parity law and if they could continue their successful rationing techniques.  Events in the past week suggest that they are as evidenced by the New York State Psychiatric Association and the Connecticut Psychiatric Society joining in a class action lawsuit against United Health Care and Anthem Health Plans for violations of the Mental Health Parity and Addiction Equity Act (MHPAEA).  The interesting aspect of the alleged "violations" is that they are standard rationing tactics that have been used by this industry for decades.

There are surprisingly few details of "improved mental health care" provided in this article.  There are many legislative tricks to make it seem like something has happened when it really has not.  The mental health issue seems like a safe haven for legislators who don't really want to address the gun issue.  I have posted some of the rhetoric on the issue here and some of it is fairly grim.  The President's initiative in the article involves over $100 million for screening.  There is no good evidence that screening adds much more than getting people on medications as fast as possible - probably too many people.

A related issue with Congressional lawmaking is that they rarely seem to consult anyone with expertise.  Many consider themselves to be experts in something even though they have never trained or worked in the field.  The people with the most significant access are business lobbyists and in many cases they are writing the laws or at least very satisfied with what is happening.  The focus is generally on improving the wealth of the folks with the lobbyists.  That is unfortunate because there are numerous ways to improve the provision of psychiatric services for severe mental illness without giving away more money to managed care companies.  The idea that "the most significant advancements in years in treating mental illness" will come out of Congress and business lobbyists sets my teeth on edge.

George Dawson, MD, DFAPA

Jeremy W. Peters.  In Gun Debate No Rift On Care for the Mentally Ill.  New York Times April 12, 2013.

Sunday, April 7, 2013

The “Spike” in ADHD diagnoses

There was the usual furor in the press earlier this week about a CDC Study that suggested that ADHD diagnoses have spiked up to 11%.  A previous post on this blog suggests that the real prevalence of ADHD is closer to 6-8%.  The  press predictably implicates overdiagnosis, overprescribing, a Big Pharma based culture that suggests there is a pill for everything, and of course the DSM5 – even though it has not yet been released.  What is really going on?

Before getting into my theories let me express my profound disappointment in the Centers for Disease Control (CDC).  As far as I can tell they have no actual research document on this issue, at least they did not sent me that document or link when I requested it.  The closest I can come is the web page that suggests that it may contain the data.  You can find for example – the full text of the survey that was used for this data.  If you are interested in that actual data that lists several data files that require specialty software.  So we apparently have a “scoop” by the New York Times based on getting and analyzing the data files and other interested people (like me) do not have access to the original data.  That is really not acceptable for a government funded agency.  If I am wrong here – please send me the link or the raw data, but I am very clear that the CDC did not respond to my direct request for clarification and they always have in the past.

Rather than debate the limitations of the study which is not possible because there apparently is no published version of the study, the easiest thing to do is accept that the increase is diagnoses as estimated by surveys is in fact true and go from there.  When I think about drugs that are truly overprescribed by comparison, the first class that comes to mind is antibiotics.  This trend is so well known that the CDC has run a campaign about it since 1995.  There is some consensus that progress has been made but a recent commentary describes the overall effort as a failure with antibiotic overuse as high as 50-100% in some areas and suggests a comprehensive strategy.  The table below highlights a few problems especially with regard to treating infections caused by viruses with antibiotics in the past two years.

Acute sinusitis
3 million outpatient visits/yr in US
Antibiotics prescribed in 83% of visits
50% of patient diagnosed received a macrolide or quinolone and only 20% received amoxicillin – the recommended drug
Fairlie T, Shapiro DJ, Hersh AL, Hicks LA. National Trends in Visit Rates and Antibiotic Prescribing for Adults With Acute Sinusitis.Arch Intern Med. 2012;172(19):1513-1514.
Acute Strep Pharyngitis
56% received an antibiotic and only 19.5% had a confirmed diagnosis
Nakhoul GN, Hickner J. Management of Adults with Acute Streptococcal
Pharyngitis: Minimal Value for Backup Strep Testing and Overuse of Antibiotics. J Gen Intern Med. 2012 Oct 6.

Febrile Respiratory Illness (AFI)
The context (number of cases recently seen and pandemic status) affected whether or not physicians prescribe antibiotics for AFI.
Courtney Hebert, Jennifer Beaumont, Gene Schwartz, Ari Robicsek; The Influence of Context on Antimicrobial Prescribing for Febrile Respiratory IllnessA Cohort Study. Annals of Internal Medicine. 2012 Aug;157(3):160-169.
Unnecessary fluroquinolone use in hospitalized patients
39% of fluroquinolone use was unnecessary as defined as excessive duration of therapy or use for non bacterial infection.
Werner NL, Hecker MT, Sethi AK, Donskey CJ. Unnecessary use of fluoroquinolone
antibiotics in hospitalized patients. BMC Infect Dis. 2011 Jul 5;11:187. doi:

A direct comparison of antibiotic over prescription and the possible over prescription of stimulants is instructive from several perspectives.  It may not be obvious but a clinician faced with whether or not a patient has a bacterial infection or whether they have ADHD has similar problems.  In both cases, the therapy may precede the diagnosis.  By that I mean it is often impossible on purely clinical grounds to determine whether an infection is caused by bacteria or the patient's behavioral or cognitive complaints are cause by ADHD.  If at the end of an assessment the physician comes to the conclusion of bacterial infection or ADHD a medication is prescribed.  Nobody makes a probability statement and there is often the element of an “empirical trial” – if the patient improves the treatment and the diagnosis were correct.   Since any misdiagnosed viral infections will usually improve and most people given stimulants will experience cognitive enhancement whether they have ADHD or not – the empirical trial is a highly flawed approach but one of many biases in an area of diagnostic uncertainty.

Another issue is the expectations of the patient.  Pediatricians often face irate parents if they don’t prescribe antibiotics for certain infections that are likely to be viral.  Internists and family physicians face the same problem explaining why acute bronchitis generally does not require antibiotic therapy.  Patients often have stories about multiple antibiotic failures to treat their bronchitis when it is likely that the process was viral and happened to resolve on its own after the most recent antibiotic trial.  Many patients taking stimulants for no clear reason have similar reactions when their use of stimulants is questioned.

There is the issue of complications of both therapies.  I do think that the potential harm of antibiotic overprescribing far exceeds the harm of stimulant overprescribing and that is the basis for the CDC having an initiative in this area for nearly 20 years.  On the basis of acute complications and medical side effects stimulant medications are some of the safest around.  On the other hand, I have also treated stimulant abusers who were routinely taking several times the recommended dose for years or who went on to use cocaine or other stimulants regularly and had the expected complications from addiction.

An important area of divergence between these classes of prescription drugs is the potential for addiction with stimulant medications and the new cultural movement that has been described as “cognitive enhancement”.  Both of these factors add the dimension that patients can misrepresent themselves to physicians with the intent of getting a stimulant prescription.  That does not happen with antibiotics, but the scope of the problem in terms of which drug is overprescribed more seems decidedly in favor of antibiotics at this time.  That does not bode well for the potential for even higher rates of stimulant overutilization in the future and in fact it seems obvious to me that there is no reason why it would not rise to at least the same level of antibiotics.

The reaction to these parallel problems in the press is instructive.  Rather than seeing the possible over prescription of medications as a problem inherent in the practice of medicine (like antibitotics) – a common reaction in the press is that this is a problem with over diagnosis and leaps to suggesting that the unreleased DSM5 will lead to even more diagnoses.  They quote several experts who respond strictly on the issue of whether the numbers are “real” or not.  The Director of the CDC – Thomas R. Frieden, MD makes an accurate comparison of the problem to both antibiotics and pain medications but concludes:  “The right medications for A.D.H.D., given to the right people, can make a huge difference. Unfortunately, misuse appears to be growing at an alarming rate.”  Clear diagnostic criteria for bacterial infections has not been the solution nearly 20 years of antibiotic over prescribing.  From what we know about trends in overprescribing, I would expect stimulant prescriptions to continue to increase irrespective of the release of the DSM5.  It will prove to be an easy scapegoat for a poorly understood problem.

The unfortunate focus of the New York Times article is the familiar: “Are drugs good or bad?”  The appropriate focus for physicians is focusing on the process and how individual and group practices can be modified to reduce overprescribing.  In most cases that would involve four additional steps – a discussion of cognitive enhancement and why it is not a good idea, screening for an addiction diagnosis, making sure that there is a clear level of functional impairment, and urine toxicology.  The effects of an assembly line approach to managing physicians and inadequate time for complex diagnostic thinking cannot be minimized.  A central collaborative model used by the University of Wisconsin for the diagnosis and treatment of dementia could be adapted to a network of clinics to treat ADHD.  This could provide the best solution to practice drift and provide clear markers for uniform prescribing.

George Dawson, MD, DFAPA

Allen Schwartz, Sarah Cohen.  ADHD Seen in 11% of US Children as Diagnoses Rise.  NYTimes March 31, 2013.

Merikangas KR, He J, Rapoport J, Vitiello B, Olfson M. Medication Use in US Youth With Mental Disorders. JAMA Pediatr.2013;167(2):141-148. doi:10.1001/jamapediatrics.2013.431.

Rubin D. Conflicting Data on Psychotropic Use by Children: Two Pieces to the Same Puzzle. JAMA Pediatr. 2013;167(2):189-190. doi:10.1001/jamapediatrics.2013.433.

Fairlie T, Shapiro DJ, Hersh AL, Hicks LA. National Trends in Visit Rates and Antibiotic Prescribing for Adults With Acute Sinusitis.  Arch Intern Med. 2012;172(19):1513-1514. doi:10.1001/archinternmed.2012.4089

Gonzales R, Ackerman S, Handley M. Can Implementation Science Help to Overcome Challenges in Translating Judicious Antibiotic Use Into Practice?: Comment on “National Trends in Visit Rates and Antibiotic Prescribing for Adults With Acute Sinusitis” and “Geographic Variation in Outpatient Antibiotic Prescribing Among Older Adults”. Arch Intern Med.2012;172(19):1471-1473. doi:10.1001/2013.jamainternmed.532

Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009 Aug 7;4:50. doi: 10.1186/1748-5908-4-50. PubMed PMID: 19664226; PubMed Central PMCID: PMC2736161.

Hebert C, Beaumont J, Schwartz G, Robicsek A. The influence of context on antimicrobial prescribing for febrile respiratory illness: a cohort study. Ann Intern Med. 2012 Aug 7;157(3):160-9. doi: 10.7326/0003-4819-157-3-201208070-00005. PubMed PMID: 22868833.

The Duty to Warn, Law Enforcement and the Public Health

The issue of reporting dangerousness to law enforcement was in the news this week with a story 2 days ago about the accused Colorado theater shooter James Holmes.  I happened to catch it on public radio where it was announced that NPR had been one of the news organizations who had petitioned the court for access to suppressed information about the psychiatrist’s role.  The New York Times story states that the psychiatrist – Dr. Lynne Fenton contacted campus police about Holmes' potential dangerousness and they deactivated his student ID and access to campus building.  Various sources state that he was threatening his psychiatrist by e-mail.  The new information is more detailed than an original article from the Denver Post on August 30, 2012.

In the original article Dr. Fenton testified that her physician-patient relationship with the patient ended on June 11.  At that appointment there are some reports that Holmes told Dr. Fenton that he fantasized about killing a lot of people.  The shooting occurred on July 20.   The newly unsealed documents show that the psychiatrist “told a police officer that her patient had confessed homicidal thoughts and was a danger to the public.”  The documents also show that the psychiatrist was being threatened by both e-mails and texts.  Dr. Fenton also advised the police officer that she was fulfilling her legal requirement by making the report to the police.  A related article states that police officer asked Dr. Fenton if she wanted the subject apprehended and placed on a 72 hour hold and she said that she did not.

In addition to the public health concern about homicide prevention, psychiatrists in this situation have a concern about the need to prevent their patients from harming others.  That forms the basis of at least one dimension of most state civil commitment laws.  Most state laws describe a duty to warn potential victims, but forensic psychiatry texts talk about more general responsibilities.  For example, Gutheil and Appelbaum state:

“Psychiatrists have always faced the potential of suits as a result of negligently allowing patients to be released or to escape from inpatient facilities when these patients later cause harm to others…” (p. 148)

In a typical outpatient setting, the modern duty to protect identifiable persons dates back to the Tarasoff case or Tarasoff v. Regents of the University of California.  In this case a psychologist was informed by his patient that he intended to kill a young woman.  The psychologist contacted campus police and advised them that the patient had schizophrenia and should be detained and committed.  The police temporarily detained the subject but he was released and several months later and killed the identified victim.   The courts found that there was a duty to warn the identified victim that superseded confidentiality.  I encourage anyone to read the details of the original review of the case to notice how negligence in this case passes from the mental health professionals to the police and back.  I think that there may be a more straightforward analysis and I would invite any evidence to the contrary.  My understanding is that the legal profession studies negligence from the perspective that there is no one who is free from responsibility.  In any complex activity like needing to report dangerousness, there will always be some sharing of responsibility if there is a bad outcome.  From a physicians perspective the probability of that happening increases with the presence of liability insurance.

On a personal level, occupational stress goes through the roof in situations like this.  Imagine that you are seeing patients in a clinic and trying to be as helpful as possible and you have just seen a person who you think is dangerous.  The situations is more complex if that patient has threatened a specific person, threatened you and your family, or brought a weapon into the clinic.  The first order of business is to try and calm down.  In some cases you may have colleagues available for consultation, but in many cases a psychiatrist is on their own.  The next step is figuring out whether you are in a situation that requires a duty to warn and what must be done to fulfill that obligation.  State statutes are complicated and not uniform.  In a recent review of state Tarasoff laws, the statutes of all 50 states and the District of Columbia were categorized into whether or not reporting was mandatory, discretionary, or no law at all. The definition of mandatory for this classification was a requirement to warn.  Discretionary allows for a breach of patient or client privileges for the purpose of warning.  Using this analysis 33 states have a mandatory duty, 11 states are discretionary and 7 states have no law.  Psychiatrists at this point may seek legal consultation due to the complexity of the situation and may still receive vague advice.  A good example is something along the lines of: “Well I would rather defend you for this rather than that.” – based on their preceding legal advice.  The first time I bumped up against that advice I realized that doctors were cannon fodder for the legal profession. 

The second critical point is the call to the police.  In both of the cases mentioned so far campus police were involved.  Are there courts where that would be questioned?  I don’t think that duty to warn laws specify any particular law enforcement.  Despite that lack of specificity, the police have widely variable capacities to respond to these calls.  The police can be notified and nothing can happen.  As illustrated in this post, the police can be notified and decide on their own that the patient is not dangerous and release them.  That also applies to what type of protection the police can offer potential victims.  I have seen the police go directly to a the person issuing the threats and tell them there will be clear legal problems if they do not stop to mailing a fax of a handgun receipt of transaction where the potential perpetrator who had already issued threats had acquired a handgun.  There is often a significant gap between any report to the police and palpable decrease in danger to those threatened.  In many cases an entire clinic is threatened and a safety plan needs to be put in place.  

The final consideration is whether the person needs an acute evaluation and emergency hospitalization for psychiatric assessment.  I have several previous posts giving my perspective on the issue of homicide prevention and how acute psychiatric treatment can prevent aggression and violence, but it takes a functional commitment court and facilities that have the expertise to provide this level of treatment.  Many decisions seem to be made based on existing resources rather than any absolute quality marker.  Should any person who is homicidal because of an acute psychiatric disorder not be hospitalized because the local community hospital does not treat aggressive individuals?  Should that decision be made on a decision by Medicare or the managed care industry on how many days of hospital care they will pay for?  Hospitalizations for these patients typically outrun the funding by 2 – 3 weeks.

Like all of the piecemeal approaches to involuntary treatment there is an easy fix.  I did not digress into the tremendous amount of stress these situations cause and how that stress can drag on for weeks to months.  If there is an adverse outcome the stress level is even worse.  What is needed is a clear pathway that maintains the boundary between law enforcement and psychiatry.  A uniform law implemented across the country should clearly say that a psychiatrist has a duty to report to law enforcement and at that point law enforcement has a duty to assess and potentially detain the person making the threat.  That would include transporting them to a hospital that does civil commitments for emergency treatment as necessary.  Law enforcement also needs to warn the potential victim and protect them.  Psychiatrists should have no duty to track down identified victims or apprehend or take threatening patients into custody.  That is clearly the purview of law enforcement.

The technical details of the interface between the law and psychiatry in the case of a threatening or potentially violent patient needs a great deal of improvement.  There are very few situations as stressful in the rest of medicine.  Some psychiatrists will encounter these situations only a few times in their career and others are immersed in aggression and violence.  Improving the approach will enhance assessment and treatment of the problem and also make it easier to recruit talented people to focus on the problem.

George Dawson, MD, DFAPA

Edwards, Griffin Sims, Database of State Tarasoff Laws (February 11, 2010). Available at SSRN: or

Gutheil TG, Appelbaum PS.  Clinical Handbook of Psychiatry and the Law.  Lippincott, Williams & Wilkins.  Phialdelphia (2000): p  148