Saturday, July 5, 2014

The Fifth Inconvenient Truth

Thomas Insel, MD the current head of NIMH captured a few sound bites in a recent edition of Psychiatric News.  In it the following Inconvenient Truths were mentioned:

1.  The field has failed to “bend the curve” in the prevalence and cost of mental illness;

2.  More people are getting more treatment, but outcomes are not getting better.

3.  The current knowledge base is insufficient to ensure prevention, recovery, or cure for too many people with serious mental illness.

4.  A transformation of diagnostics and therapeutics is necessary to make significant progress in treating mental illness.

Any head of a politically funded agency has to carefully parse his or her rhetoric in a manner consistent with his main goals.  I would see his main goal as getting funding for NIMH and in that role he needs to speak to the politicians who hold the purse strings.  That is really the only reason why cost is included in his first sentence.  The cost estimates both within the United States and world wide have been calculated many times and they are staggering.  There are well known estimates of disability that show the disability due to mental illness and addictions are routinely in the top ten causes.  But what  about the cost of treatment?  The cost of treatment has been flat to decreased for about three decades now largely as a result of managed care rationing with a disproportionate hit being absorbed by psychiatric services.  I have argued repeatedly that cost needs to be taken off the table in these discussions at least until the mental health infrastructure gets on even par with cardiology or oncology.  The whole idea that you can produce equivalent results with practically no resources strikes me as absurd.  The only thing more absurd is that we are supposed to be even more cost effective.  Compared with the rest of medicine we are looking at cost effective in the rear view mirror.  We crossed into the "on the cheap" zone a long time ago.  As expected, cost effective is synonymous with low quality.  Since we have abandoned quality reviews with managed care we have abandoned that word.  A more appropriate observation would have been:

The field has failed to “bend the curve” in the prevalence and quality of care of mental illness.

The second issue is a brief lapse into rhetoric of vagueness.  Who is "the field" here?  Are we referring to psychiatry, other mental health professionals, primary care physicians who do 80% of the psychopharmacology,  or the managed care systems and systems with the same techniques that rigorously ration mental health care?   The meaning of the sentence changes dramatically by substituting each of those words.

To the second point on more treatment not leading to better outcomes it is fairly easy to show why this is the logical outcome of rationing.  I have posted many times about how inpatient psychiatry has become sham treatment based on dangerousness criteria and corporate priorities.  You don't need any research to show that if you are cycling people with serious mental illnesses in and out of short stay psychiatric units in 3 - 5 days and basing their stay there on whether or not they are "dangerous" and using treatments that take weeks to work that by definition you are appearing to treat many more patients but providing adequate treatment to very few.  You don't need any research to show that when you shift mental health care from psychiatric units run by psychiatrists to county jails that the outcomes will be worse.  You don't need any research to show that when people do not get research based psychotherapies in the manner that they were designed and instead get a few crisis oriented sessions that do not address their basic problems that outcomes cannot hope to be better.  When your attitude is that all mental health treatment can proceed by treating common problems with definite social etiologies with medications as fast as possible and not having an intelligent conversation or working alliance with the person affected - it is logical that treatment outcomes will not improve.  Treatment outcomes do not improve if you do not provide effective treatment and that is the mental health landscape at this time.

Dr. Insel's third point should read:

The current knowledge base is not used to ensure prevention, recovery, or cure for too many people with serious mental illness.

I am not by any means suggesting that it cannot be improved upon.  There is no place in medicine where that is not the case.  When services are globally rationed and we are still beating the drum about "cost-effectiveness" we cannot expect inmates to have access to DBT or GPM to treat their borderline personality disorder.  We cannot expect them to get exposure therapy to treat PTSD from psychological trauma.  We can also not expect managed care patients to get this from 2 or 3 sessions of crisis counseling when they need a more specific research based psychotherapy.

The fourth statement is the only one that I have no issue with.  It is a statement that is generally true for most chronic illnesses.  I have many posts here about asthma for example.  Asthma is an illness that many primary care physicians believe that they really have made inroads in treating.  It is a great comparison for mental illness and even chronic mental illness because the fact is that most asthmatics are chronically symptomatic despite treatment.  The reason is a combination of a biologically complex disease, partially understood disease mechanisms, and a medical treatment model that involves seeing the patient every 3-6 months and prescribing them medications that are often partially effective at best.  There is really minimal medical intervention beyond that except for acute hospitalizations.  That is the exact level of care that we provide for mental illness in this country.

A lot of people fault Dr. Insel for being an advocate of neuroscience.  I may be one of the few who does not.  As a student of the brain and brain plasticity things are incredibly complex.  As politics get projected onto that complex system - science is often left in the lurch.  People see the results of a complex situation simplified as a meta-analysis and see the results as supporting both ends of a political argument.  I would go back to the asthma example.  The signaling in that disease is much less complex than signaling in the brain and there are far fewer cell types involved.  Asthma endophenotypes followed the elaboration of endophenotypes in schizophrenia and so far nether has resulted in clinical innovation.  I would argue that the treatment outcomes in most mental illnesses are on par or better than the treatment of asthma.  And yet there is no national research administrator of Dr. Insel's stature talking about the lack of progress.  I think the reason is clear - there are not nearly as many political arguments projected onto asthmatics.

If I fault Dr. Insel for anything it is for not knowing what has happened to the mental health system of care in the USA.  It is not due to a lack of technology, but an obstruction of current technology transfer.  He is not alone in routinely ignoring this as the central problem with psychiatric services today.  Any number of people do and in the process usually promote their own theories of why we are mired in the current environement.

That Fifth Inconvenient Truth?  Must be obvious by now but in the event that it is not:

Ration mental health and addiction treatment, ignore current research proven treatments, and reduce treatment to the prescription of medications and poor outcomes will follow.

You can take that to the bank.

George Dawson, MD, DFAPA


  1. "reduce treatment to the prescription of medications and poor outcomes will follow"

    Dr. Insel went from residency directly into an NIMH lab, then to Yerkes Primate Center, then to an administrative post in a translational center, then back to the NIMH. In his career [1979-present], he has spent zero time remotely connected to mentally ill patients or any system related to their care. His remoteness from clinical practice is nowhere more apparent than in this particular piece where he harvests what he knows of patients from reports like the global burden of disease. His concept of treatment is analogous to understanding baseball as a game of home runs. As you point out, he starts by accepting that "care" is defined by industry [pharmaceutical and managed care] meaning prescriptions written based on symptom inventories. And he proposes finding some future medications that will fit that bill. Rather than being an ombundsman for the mental health of the nation [as in National Institute of Mental Health], he ends up being an agent for one industry or another while participating in the further erosion of what little mental health care we can muster.

    1. Mickey,

      Thanks for your response.

      But can you be absolutely sure?

      In 1986, I responded to an ad in the NEJM. A researcher at the University of Wisconsin was looking for fellow for his research Unit. I applied and got the job. He was active in both primate and rodent research and patient care. He had a successful research career, but was also a good clinician and specialized in mood disorders. There were several other psychiatrists on the same research and clinical path there. Another one of them was one of my clinical supervisors.

      My point is that you can do both.

  2. I think you nailed the major point that he missed. How good would AIDS antiviral therapy be if 80% of it were prescribed by psychiatrists? Probably a lot better than treatment for depression when 80% of antidepressant prescription is done by generalists. But still a lot worse than it should be if the right people were doing it.

    BTW, I would point out that all of the very real problems he writes about are only going to get a lot worse under the collabo-care model that past president of the APA Jeffrey Lieberman loves. There's no change to make an impact when you are sitting on the bench.

    As an aside, I would not that he is a bit too optimistic what has been accomplished with heart/vascular disease.

  3. BTW I agree with Insel on his observations, but maybe not with the conclusion. If there is no difference in outcomes in the past thirty years, maybe we are doing some good. How can I make such a statement? Well, simply put, its hard to deny that people in general are mentally less healthy than they were when the family was intact. Millions of people come from toxic family environments and have personality disorders or free floating anxiety and anger they can barely contain.

    The fact that suicide rates haven't radically increased is actually astounding.