Tuesday, May 12, 2015

APA's Feelgood Move of the Year?

I noticed on another blog that there were expected praises and a few sarcastic comments for the American Psychiatric Association (APA) announcement that they had signed on with another 600 organizations to support the AllTrials initiative.  In case you are unaware of this initiative, Google the name and it will bring you to the web site.  The web site will give you more than enough information on why transparency and enforcement of pharmaceutical company behavior is important and why you should sign the petition.  It will even provide you with a section on "Myths and Objections"  to dispel any concerns that you might have about - well, myths and objections.  It really did not address my concerns about the fact that clinical trials technology as we know it is incredibly crude, they are practically all short term, and they have little to do with how the medication is used in clinical practice.  To me it seems like an exercise to try to keep the pharmaceutical companies honest.  If it also succeeded in keeping the useless meta-analyses of flawed studies out of the literature and prevented the same people who produce those studies from drawing even more flawed conclusions about psychiatry, I would be all for it.  But I doubt that is going to happen.  I also doubt that it will have any effect on the drugs marketed in the USA.  It should be fairly clear from observing FDA behavior that their decisions aren't based on good studies or even the reviews done by their own scientific committees.  You could list any study in the AllTrials database and it could lead to FDA approval whether it was positive, equivocal or negative.

My biggest objection to the APA using its vanishing street cred to sign on to this feelgood initiative is that doesn't do me any good as an APA member, it doesn't do my patients any good and it has no implications for the future of the field.  It is like signing on to any feelgood initiative, you seem to get credit along with all of the other do-gooders, and all you have to do for it is sign your name.  That would bother me a lot less if I did not pay the APA $935/year for professional membership and if they would return my calls once in a while.  It would also bother me a lot less if they actually addressed real problems that their membership was concerned about.  The kind of heavy lifting that might really cost something.  Ignoring these problems is also costing them something right now in terms of members who are walking away.  It doesn't take too many members walking away at $935 apiece to have an impact on the organization.   I have discussed the problems many times before on this blog but here are a few items that should be APA priorities:

1.  MOC/MOL -

The maintenance of certification issue is not fading away with benign neglect at this time.  Interestingly, the revolution in this area is being led by the generally more conservative internists and internal medicine specialists who have eloquently described how little sense it makes to oppress the most oppressed and most accountable professionals out there and pretend that "the public" is demanding more testing and arbitrary exercises to maintain board certification.  As if that is not enough, the idea that this MOC can be converted into a necessary step in licensure (Maintenance Of Licensure would really put a lock on that unnecessary industry.  Until very recently the APA has been completely deaf to member's efforts in the area.  I don't know some recent interest reflects members voting with their feet and just walking away or the message that some specialists are not going to cave in on this issue and will go so far as starting their own organization for MOC.

2.  Managed care - utilization review -

Managed care companies and pharmaceutical benefit managers harass psychiatrists to  greater degree than other physicians.  These companies have destroyed the infrastructure for inpatient care and any concept of quality in psychiatric care.  Practically all psychiatric care in this country is now dictated by these companies and the arbitrary rules they have set in place to ration it.  The APA made some initial attempts to explain managed care and advise their members about how to "get along" with these methods.  At no point was it suggested that there was a severe ethical problem with allowing for profit companies to dictate psychiatric care.  At no point was there any strategy to illustrate the difference between quality care and rationed care.  Instead, we read stories of the mentally ill being incarcerated by the thousands and the inappropriate care they receive in jail.

3.  Managed care - PBMs -

Billions of dollars are wasted every year as pharmaceutical benefit managers ration generic drugs and tie up physicians and their office staff in order to make more profits.  There is no other group of professionals anywhere who are basically forced to work for a managed care company for free in order to help them ration medications and turn a profit.  The only action I have seen from organized psychiatry was a half measure about a standard prior authorization form that for some reason could never be adequately enacted.  There is always something within federal law that favors managed care companies and gets in the way of addressing this.

4.  Organization wide support for models of care other than collaborative care -

There are massive problems with the collaborative care model that is being promoted by the APA along with SAMHSA, the managed care industry and their partners in government.  The hype is at about the same level as the promotion of the managed care industry was in the 1980s and '90s.  It is obvious how that turned out.  The reason people train as specialists is to provide specialty care, not to sit in a primary care clinic and supervise the prescription of antidepressants based on a rating scale without personally assessing patients.  The real pipe dream here is that primary care clinics under the accountable care organization model will hire psychiatrists to provide the academically proven cost savings to their primary care clinics.  I guess that was a media moment lost on the APA; the models used to hype the care model and sell it to politicians are not the ones eventually implemented by the "managers".   Expect the same rationing and either the complete elimination of psychiatric services to save money or psychiatrists offering their services on their own.  The APA should at least be prepared for that and be involved in preparing their members.

5.  Lack of recent professional guidelines -

Contrary to what a lot of people think, the DSM-5 has nothing to do with treatment.  The APA has treatment guidelines, most of which are in need of a serious update.  They also need guidelines to cover most specific practice situations such as the treatment of aggressive or suicidal patients.  A serious update and an ongoing effort to stay current is necessary in order to prevent the illusion that some guidelines put together by a business organization is as good as and somehow represents professional standards.

These are a few of the things that psychiatrists and the members of the APA need right now!  I doubt that any of us are going to be impressed with the sign on to the AllTrials initiative.  I would not be surprised to find out that most APA members haven't heard about it.  I am a member and I am on the APA listserv and the APA Facebook feed and did not get any notification about this happening.

I don't see anything wrong with the APA signing on to a feelgood initiative on the face of it.  But over the years the membership has paid a lot of money for an organization that supports professional education, standards and advocacy.  Signing a mass petition for an initiative that is not likely to do anything to advance the science or patient care is a politically correct symbolic gesture.

We need a lot more than that and we have for years.

George Dawson, MD, DFAPA


  1. Your thoughts on the plain language DSM from the APA?


    Useful and necessary or redundant and a quest for more revenue?

    Or none of the above.


  2. Thanks for the blurb on the book. I have not read it and don't know if I will.

    The press release is interesting because it suggests it will be useful for patients to use in battling against managed care. As you can tell from reading this blog my position would be that an activist APA fighting managed care would be more useful. The APA could do a lot more by setting standards of care and declaring utilization review and prior authorization as questionable endeavors.

    On the diagnosis side, the issues of overprescribing and overdiagnosing need to be addressed head on. In a diagnostic manual that comes down to the difference between reading some criteria and believing that you "have them" versus having significant life problems associated with a syndrome and seeing a physician who has made the diagnosis hundreds of times.

    That is what I would like to see, but nobody at the APA consults with me.

  3. I agree it won't have much impact on typical practices, but I approach the APA like a Skinnerian. I have been intensely critical of that organization, so much so that I list NOT being a member of the APA on my CV as a badge of honor. When they do something right, I think they need to be lauded for it to encourage them to make more moves in the direction that helps the psychiatrist in practice. I also feel a personal need to be balanced and not reflexively negative since some of their pearl-clutching defenders have accused me of that. If they ever get serious about MOC and mangled care, and knock off the collabo-care nonsense, I might even join after shunning them for thirty years. Not holding my breath. The silver lining is that dues money saved and compounding returns adds up over a few decades.

    This is at its heart a lack of empathy problem...the academics who run the organization are simply immune from the pressures of the private practitioner and can't or won't understand the problems of someone who isn't tenured or salaried. Some are frankly hostile to private practice. I can't imagine more tone deaf and naive than that Lieberman collabo-care video. I don't see this changing given how leadership is organized.