Friday, November 13, 2020

The Bureaucratic Takeover of American Psychiatry

 




This interview was posted on the Psychiatric Times web site today.  It contains bit and pieces from blog posts here over the past 8 years. It is a rare opportunity for people to see what is wrong with American psychiatry and that is - it is not run by American psychiatrists. It is run by managed care companies, pharmaceutical benefit managers, and government bureaucrats who all have the common goals of restricting access to psychiatric services.  And by psychiatric services, I am including substance use disorders and their treatment as well as the considerable amount of treatment of organic brain disorders that is provided by psychiatrists. 

I expect that some people will say: "What is special about psychiatry? Aren't these same rationing techniques applied to all of medicine?"  To a certain extent that is true.  Primary care physicians, medical specialists, and surgical specialists have to contend with similar rationing techniques.  It is however a question of scale.  I have talked with physicians who were around when the psychiatric rationing started and psychiatric services were chosen as the target of the express purpose of elevating the stock price of a company.  I was there when the Hay Report was released in the 1990s showing disproportionate rationing of psychiatric services relative to any other specialty.  I saw the original figures released in 2002 showing that Cardiology services were reimbursed at a 20% premium, while psychiatric inpatient services were discounted by 60%.  That led to some immediate closures of psychiatric hospitals and a continued trend of lower and lower bed availability.   There are endless examples of this disproportionate rationing on this blog and as I point out in the interview it is one of many reasons I write this blog.

One of the key questions that any observer of psychiatry should ask themselves is: "Why is George Dawson the only guy writing about this issue?"  Apart from the fact that this rationing has impacted my care of patients nearly every day of my professional life there are some obvious considerations.

1.  The people who self identify as the critics of psychiatry - clearly know very little about the practice environment or its constraints. I have seen two articles now that use the same example that psychiatrists believe that every mental disorder should be treated with a medication and that this is biological psychiatry.  The model of care they are referring to is not how psychiatrists are trained (see the above figure).  It represents a blended government and managed care model of how patients are scheduled, seen, and billed.  That bureaucratic model at one point employed an M code meaning a 5-10 minute visit with a psychiatrist.

2.  The critics similarly ignore highly innovative and individualized therapies that were invented by psychiatrists such as the Assertive Community Treatment  model that I mentioned in this interview as well as the myriad ways that psychiatrists have figured out how to talk in therapeutic ways with patients in rationed time slots and how those relationships result in recovery.

3.  The critics systematically ignore the lack of infrastructure to support psychiatric treatment.  There are very few inpatient units in each state that allow for the treatment of people with severe mental illnesses. By contrast, there appears to be no shortage of state-of-the-art facilities to treat heart disease, cancer, and gastrointestinal problems.  There is no shortage of state-of-the-art surgical facilities to treat any condition where surgery may be indicated.  In the mean time, mental illness and substance use disorders are the number 1 debilitating disease condition in the United States.  Rather than invest in the necessary infrastructure to provide an equivalent level of care, people with severe mental illnesses are incarcerated instead.  Rather than reversing that trend, several Sheriffs in the country propose designated parts of county jails as psychiatric hospitals and treating people in jail who should not have been incarcerated in the first place. 

I could keep going with additional points like I have in the past, but at this point would encourage any interested reader to take a look at the interview at this link.  Then take a look at the summary at the top of this post and consider my point. Psychiatrists are well trained to do a lot for people with mental illnesses and substance use disorders. We want our patients and their families to have access to the same amount of resources that other medical or surgical specialists have. Don't accept any criticism of psychiatry that does not address these basic points.  


George Dawson, MD, DFAPA 


Reference:

Awais Aftab, MD.  The Bureaucratic Takeover of American Psychiatry: George Dawson, MD, DFAPA
Psychiatric Times.  November 13, 2020    Link


Supplementary 1:

Dr. Allen's comment made me realize a critical deficiency in my graphic and also the interview and that is impact on the academic environment. One of the most exciting aspects of medical school and residency was learning to understand the medical literature and apply it to patient care. I met hundreds of physicians and colleagues with their own unique approaches. In training environments in the 1980s and early 1990s the expectation was that you were researching and reading about your patient's problems and diagnoses and were prepared to intelligently discuss it.  As an attending you had to keep on top of the literature to be a competent teacher and also as a marker of professional competence. Teaching rounds, grand rounds and other teaching based meetings were the most exciting aspects of going to work each day.  I modified my managed care timeline to illustrate the impact on the academic side of the work environment.  




Sunday, October 11, 2020

Book Review of The Great Pretender by Susannah Cahalan

 



 This is the second book review of this book on my blog.  I was asked by the editor of The Philosophy Special Interest Group of the Royal College of Psychiatrists - Dr. Abdi Sanati to write another review for this newsletter.  I looked at it as an opportunity to cover some things I may have missed in the first review.  I agreed to not put it on my blog until the newsletter came out.  The latest review follows:

The Great Pretender (1) is written as an exposé of a famous experiment conducted by Rosenhan (2) that purported to discredit psychiatric diagnoses.  The original article was published in in the journal Science in 1973.  Whether you we aware of the original article or not depended on when you were trained and the extent to which you followed that literature. I was just finishing my undergraduate degree at that point and did not complete psychiatric training until 1986.  We had a community psychiatry seminar for 6 months during my last year that was taught by some of the innovators in the field.  It was common to analyze and discuss controversial papers of the day.  A good example would have been the paper that suggested that people with schizophrenia had a much better outcome in the developing countries (3).  At no point did we hear about or discuss the Rosenhan paper.  In fact, for the next 24 years the paper never came across my desk. It was only when I started writing a psychiatry blog that I realized it played a major role in psychiatric criticism and antipsychiatry rhetoric.  At that point, I read the paper and the associated criticism and concluded independently that the methodology was extremely weak and that pseudopatients were not really a good test of medical or psychiatric diagnoses.  I thought it would just fade away on that basis.

I was as surprised as anyone when I heard that investigative reporter Susannah Cahalan had written a book about this experiment, the author, and the methods used.  The investigation begins with a visit to one of Rosenhan’s former colleagues. This colleague shows her a stack of anti-psychiatry books that he thinks “were the key to his thinking”. There is also a file labeled “pseudopatients” that contain the names of all eight pseudopatients and details surrounding their hospitalizations. All the names or aliases and the hospital names had also been changed.

Cahalan’s approach is to write about three parallel subjects.  The most thorough and objective analysis is about the pseudopatient experiment. She covers everything from the available remaining data and the problems with it to the likelihood that the experiment actually occurred the way it was described in the Science paper.  The second broad subject was a character study of Rosenhan.  How did people describe him?  What was he like? Did people especially his colleagues believe that he conducted the experiment.  And finally, the book is a vehicle for Cahalan to comment on psychiatry.  She comes to this work with the direct experience of having experienced autoimmune encephalitis and writing about that experience in the book Brain on Fire.

Reading the original paper is a good starting point for understanding the book.  If you do pull up that article, a few details are immediately evident. The author begins the introduction using the terms “sane” and “insane” as though this is technical language used by psychiatrists. That use of language is interesting because he is listed as a professor of both psychology and law at Stanford.  Since the days of my training, insanity is a strictly legal term and it is without meaning in psychiatry.  The use of these legal terms allows him to point out the unreliability of the “sane”-“insane” dichotomy based on expert witnesses disagreeing in adversarial court hearings.  That has nothing to do with the clinical diagnoses in psychiatry. To what extent were formal diagnoses used in 1973? Rosenhan refers to the Diagnostic and Statistical Manual in the body of his paper.  Interestingly, the authors of my community psychiatry paper (3) reported on the 2-year follow-up of patients from the International Pilot Study of Schizophrenia (1973) and concluded that schizophrenia could be reliably diagnosed so that international comparisons and follow up were possible.  A sanity metric during the same time frame is crude by comparison. There are many additional examples of a lack of objectivity toward the issue of psychiatric diagnosis in the introductory section of the paper (paragraphs 4-7) and the discussion. Excellent critiques of the scientific merit of the paper were available at the time most notably by Robert Spitzer. 

The author describes his pseudopatient experiment as consisting of 8 people – three women and four men of various occupations. Cahalan identifies Rosenhan as pseudopatient number 1.  Twelve hospitals in various locations were chosen.  One was a private hospital.  Pseudopatients were supposed to call the hospital, present for an intake appointment, and then complain that they were hearing voices. When asked to elaborate they were supposed to say the voices were unclear except for the words “empty”, “hollow”, and “thud”.  Rosenhan provides a rationalization for this symptom choice about how on the one hand these symptoms were supposed to have existential meaning and yet there was not a single report of existential psychosis in the literature. Once admitted, the patient was supposed to cease simulating any symptoms and give their actual social history and behave “normally”. They were to take notes and be as cooperative as possible to get discharged. The length of stay was 7-52 days with an average of 19 days. 

Rosenhan also claims in the body of this paper that a second experiment occurred at a “research and teaching hospital” where the staff were informed ahead of time that pseudopatients were going to seek admission during a 3-month period.  Staff were asked to rate whether a patient was a pseudopatient or not.  Of 193 admissions during that time 41 were ranked as likely being a pseudopatient. In this case, Rosenhan did not send any pseudopatients to the facility and claims this false experiment represents “massive errors”.  

One of the elements of the paper that is really never discussed is it structure. The primary data points were eight pseudopatients were admitted and discharged from psychiatric hospitals without being discovered. The secondary data points were a series of observations of the staff that is largely unstructured, highly anecdotal, and contrasted with other situations that seem to lack relevance. The bulk of Rosenhan’s discussion is judgmental and there is no discussion of the limitations of the experimental design or data. Instead the author leaps to clear-cut conclusions that are in some cases only peripherally connected to the data.

Cahalan expends a lot of effort to try to identify and find the pseudopatients and ask them what their experience was like. She locates the records of Rosenhan’s own admission as a pseudopatient. The first real sign of a departure from the research protocol described in Science, occurs in Rosenhan’s recorded admission interview. He recited the voices script and said the symptoms had been going on for four months. He was admitted on an involuntary commitment and discharged nine days later. The hospitalization ended in 1969 - four years before the article came out. The first major sign that the experiment described in Science was not quite the way it was described in the paper occurs when Cahalan looks at the record of the admission interview. In addition to the vague description of hallucinations, Rosenhan states that he believes he can “hear what people are thinking”, that he has tried to “insulate out the noises by putting copper over my ears”, and that he has “suicidal thoughts”. These are all more serious psychiatric symptoms than factitious “existential hallucinations”. Rosenhan also altered his occupational history during one assessment to say that his psychiatric illness led him to give up a job in economics 10 years earlier. At one point he stated that his wife is probably unaware of how useless he felt and that “everyone would be better off if he was not around”.  Considering the seriousness of his fake history, I was surprised that he was discharged in 9 days.

What about the other 8 pseudopatients?  Cahalan was able to locate two – only one of whom was part of the research protocol and shared Rosenhan’s experience. The second patient started out as a psychologist and co-authored a couple of papers with Rosenhan. The author was surprised at how little preparation went into the pseudopatient role. Patient 2 was taught to cheek medications and spit them out. He was reassured by Rosenhan that he had filed a writ of habeus corpus to get him out of the hospital at any time.  When Cahalan tracked down that attorney who said the writs had been discussed but never prepared and that he did not consider himself to be “on call” to get pseudopatients immediately released. Patient 2 was also in the hospital for 9 days and basically released upon his request.  There was no reason for discharge given on the official form but he recalled a psychiatrist approaching him prior to discharge and making remarks to suggest that there was still some concern that he may still be suicidal. Despite that concern there was apparently no discharge plan.

The third pseudopatient discovered by Cahalan was interesting in that he was eliminated from the original protocol and not counted by Rosenhan.  Cahalan discovered that the ninth uncounted pseudopatient was a research psychologist named Harry Lando.  Dr. Lando is well represented in the smoking cessation literature and had published an article in the Professional Psychologist (4) stressing the positive aspects of his pseudopatient experience.  His observations were in direct contrast to Rosenhan and he states as much in the observation: “My overall impressions of the hospital are overwhelmingly positive. The powerlessness and depersonalization of patients so strongly emphasized by Rosenhan simply did not exist in this setting.” He goes on to suggest that using better hospitals as models may be a way to improve the quality of care.  He also questions the ethics of placing pseudopatients in “already overcrowded and understaffed institutions”.  Lando does express a concern about the diagnostic process since all three pseudopatients received diagnoses of schizophrenia.

The key question about why the data of the ninth pseudopatient was omitted from the original paper is answered as a footnote number 6 on page 258 of the original paper:

“Data from a ninth pseudopatient are not included in this study because although his sanity went undetected, he falsified aspects of his personal history. Including marital status and parental relationships. His experimental behaviors therefore were not identical to the other pseudopatients.” 

That footnote is exactly what Rosenhan did when he was admitted as pseudopatient 1 as documented in the existing medical record.  Rosenhan’s lapses were discovered and discussed by Cahalan and are included in the following table.

 

 

Rosenhan’s Lapses

 

1.  Data was improperly recorded. The two pseudo-patients interviewed by Cahalan pointed out that their durations of stay in the hospital were not correctly recorded.

2.  His private notes indicated strong influence by Szasz and Laing. Prior to the pseudopatient experiment he assigned work to his students describing psychiatric hospitals as “authoritarian”, “degrading”, and “illness-maintaining”.

3.  He told a pseudopatient that a writ of habeas corpus was prepared and an attorney was on call to get them out of the hospital if necessary. That was not true.

4.  Professional and possibly “unethical” mistakes (p. 173) about length of stay in pseudopatient number two (7 days versus 8) and pseudopatient number 9 (26 days versus 9 days), patient population in the hospital 8,000 vs 1,510), the specific discharge diagnoses of pseudopatients 2 and 9, and details of staff behavior on the ward.

5.  Sending a pseudo-patient into a hospital that was in disarray because it was closing.

6.  Rosenhan at one point lied in correspondence to Spitzer about his stay in the hospital and said it was part of a “teaching exercise” that had nothing to do with research(p. 180). Cahalan describes this as “an outright lie”.

7.  During his admission Rosenhan “goes off script” and gives far more fabricated symptoms and history than the “empty, hollow, thud” existential hallucinations he described in the protocol. Additional symptoms suggest a significant psychiatric disorder. He describes suicidal ideation and significant conflict with his employer – the same falsification of personal history that led him to eliminate the data of the ninth pseudopatient.

8.  Rosenhan fabricated an excerpted portion of the medical record and both the original record and the excerpt are published for A - B comparison on page 190. Cahalan concludes that the facts “were distorted intentionally by Rosenhan himself.”

9.  Inadequate preparation of the research subjects. Patient 2 ended up taking a dose of chlorpromazine and patient 9 was given liquid chlorpromazine so it could not be cheeked as instructed.  Pseudopatient 9 estimated the preparation time for hospital admission by Rosenhan was about 15 minutes.

10.  When patient 9 was eliminated from the study none of the data about pills dispensed or staff contact time in the paper was changed.

11.  In an National Public Radio program that aired before the publication of his paper (December 14, 1972) he misstated his time in the hospital as a pseudopatient (several weeks versus 9 days) and the amount of medications dispensed to pseudopatients (5,000 pills versus 2,000 pills) while building to the conclusion that psychiatric hospitals are non-therapeutic and should be closed (p.234)

12.  Pseudopatient 9 commented that what Rosenhan had written about him in the experiment was “total fiction” (p.269)

13.  Rosenhan did not complete a book about the pseudopatient experience, despite an advance from the publisher, a subsequent lawsuit from the publisher and what is described as plenty of publicity around the time the paper came out in Science. He also never published on the topic again (p. 295). 

 

Rosenhan did continue to publish a description and discussion of his study in the text Abnormal Psychology (5). The discussion emphasized that the simple hallucinations described with nothing else being unusual would have been detected outside of a hospital. In the context dependent setting it was not.  In other words – he maintained one of the same themes as in the original paper.

One of the areas that really piqued my interest was why Science published this paper in the first place.  Cahalan got the opinion from an academic psychologist that the peer review in a non-psychology journal would be less rigorous.  When she approached the journal she was told that records were confidential and that they were not kept back that far.  Accessing Retraction Watch (6) demonstrated that there has been a total of 120 papers retracted from Science since 1963. The reasons for the retractions are given as data errors, errors in methods, result errors, errors in conclusions, errors due to contaminated experiments, falsification/fabrication of data, irreproducible results, misconduct by the author, ethical violations by the author, investigation by a company, institution, or third-party.  Only three of these papers had anything to do with psychiatry and those papers were primarily about the neurobiology of the brain. Cahalan’s investigation suggests that several of the reasons for retraction have been met.

Apart from the details of the Science paper, Cahalan also does a character study of Rosenhan. We learned that his brother had bipolar disorder and did well on lithium. It was suggested that was why he became interested in psychology. He was described as bright and charismatic. He was clearly influenced by the work of anti-psychiatrists and assigned work to his students that “describe psychiatric hospitals as authoritarian, degrading, and illness maintaining among other terms”. (p 73).  The title of the book highlights Rosenhan’s characteristics as a raconteur who would occasionally pretend to be someone who he was not. His son described an incident in New York City where he introduced himself as a professor of engineering at Stanford in order to get a tour of an interesting construction site with his son. In another scene he is joking about the wig he wore to get into the psychiatric hospital.  Cahalan finds the admission photo showing that he is bald without a wig. The people who knew him the best – acknowledge the he was difficult to know and just like Rosenhan’s arguments about psychiatric diagnoses being context dependent – his personality was as well.   

Apart from academic books about the history of psychiatry – most books review sensational history and arguments that by their very nature diminish the field.  This book is intermediate in that tone with those arguments interspersed through the investigative journalism about Rosenhan. They touch on the familiar themes of biological reductionism as opposed to a clinical psychiatry where patients are actually listened to with no reference to how clinical psychiatrists really practice every day. Some psychiatrists end up being caricatured and some are acknowledged as being highly motivated and humanistic. I am probably far too invested in clinical psychiatry and the good I have seen done to tolerate a journalist’s approach to the field.  I give Cahalan credit for touching on the current situation that has resulted in severely rationed care and the transinstitutionalization of patients in jails.  The overall concept that psychiatrists have little to do with the systems of care that are controlled by businesses and governments is not emphasized even though it was recognized as a problem by two of the pseudopatients.  She also points out that the pseudopatient experiment is irrelevant to psychiatric practice today but her resounding theme throughout the book was that it was extremely relevant irrespective of what actually happened.  The book also gives Rosenhan too much credit for psychiatric criticism. Like many books of this nature – there is little to no evidence that psychiatrists might be their own best critics or that outrage might be a legitimate reaction to outrageous criticism rather than defensiveness.

 In conclusion The Great Pretender identifies very specific problems with the original Rosenhan paper that have been listed in the narrative and table in this report. He gained initial celebrity status from the study and signed a book contract. Even though he was given an advance on the book and wrote a manuscript he never produced a book.  The author suggests that may have been due to the fact that Robert Spitzer was aware of Rosenhan’s nonadherence to the research protocol during his admission. As Rosenhan withdrew from the pseudopatient limelight he also stated that none of his research should lead to the conclusion that psychiatric hospitals were unnecessary and that represented a complete turnaround form earlier statements.

The controversy, the original paper and the book could be the subject of seminars in the history or philosophical aspects of psychiatry. It touches on a number of themes primarily the ethics of research and how it should be conducted. It also touches on psychiatric criticism and may be useful in discussing how future generations of psychiatrists can prepare to deal with it. 

 

George Dawson, MD, DFAPA

 

References:

 

1: Susannah Cahalan.  The Great Pretender. Grand Central Publishing. New York, 2019. 382 p.

2: Rosenhan DL. On being sane in insane places. Science 1973 Jan 19;179(4070):250-258.

3: Sartorius N, Jablensky A, Shapiro R. Cross-cultural differences in the short-term prognosis of schizophrenic psychoses. Schizophr Bull. 1978;4(1):102113. doi:10.1093/schbul/4.1.102

4: Lando, H. A. (1976). On being sane in insane places: A supplemental report. Professional Psychology, 7(1), 47–52. https://doi.org/10.1037/0735-7028.7.1.47

5: David E. Rosenhan, Martin E.P. Seligman. Abnormal Psychology- 2nd Ed. WW Norton and Company, New York City, 1984, 1989; p 181-183.

6: Retraction Watch: Retractions from Science.  Accessed on May 22, 2020: http://retractiondatabase.org/RetractionSearch.aspx#?jou%3dScience


Supplementary:

The review was written for Philosophy Special Interest Group of the Royal College of Psychiatrists September 2020 newsletter and it can be found starting on page 8.

 

 

 

 

Saturday, September 19, 2020

Covid-19 Up Close and Personal

 On September 4, I started to feel typical symptoms of a flu-like illness. I have been a student of flu-like illnesses for at least the past 15 years. Some may say that I am obsessed with flu-like illnesses. By definition these illnesses start out as acute upper respiratory infections but also lead to systemic symptoms like malaise, weakness, and muscle pains or myalgias. In some cases, the symptoms can build to a disabling intensity. About five years ago I developed a flu-like illness after returning from Alaska that led to an exacerbation of asthma. I had not taken any asthma medications for 20 years but have been on those medications ever since. Researching that area suggested that flu-like illness was probably a rhinovirus. Some researchers think that rhinovirus is one of the main precipitants of asthma. Rhinovirus also happens to be a common circulating respiratory virus along with about 20 others that cause respiratory infections every year.  There are several non-COVID-19 coronaviruses in this group.

There were definite early signs even before the first respiratory symptoms. I have a fairly set exercise routine that I do every week and I noticed that my baseline heart rate (54 bpm) and blood pressure (105-110 mm Hg systolic) were increased and my exercise capacity was decreased by about 40%. That occurred about 48 hours before the onset of symptoms. As the symptoms increased my first thought was that I needed to get tested for coronavirus. That took an additional four days. It wasn’t from a lack of trying, but more a lack of resources going into the weekend. That delay highlights a significant weakness in the American healthcare system. I self-quarantined during that time but there are a lot of people who would need to see the test result before they could.  I did get positive test on day seven, I canceled the rest of the day at work and have been home recovering ever since.

The overall course of the illness has been very similar to a moderate case of influenza with the exception that I did not get a fever. It measured every day in the normal range. I also did not get shortness of breath.  Having the risk factors of asthma and old age, I was fairly anxious about any shortness of breath as a symptom. My symptoms are basically as graphed with a few exceptions of what I would refer to as atypical symptoms. The first one would be feeling flushed or like the skin temperature is elevated. That has been a fairly consistent feature that I have not seen mentioned anywhere. My skin was always cool to the touch and not moist. Another atypical symptom is laryngitis.  I have observed that in several COVID-19 patients in the media.  It can be fairly limiting if you have to talk all day at work like I do. The third atypical symptom was viscous mucus in the nose and throat. It was not abundant but difficult to clear and never reached the volumes typically seen in bronchitis.

One of the questions that I have been asked is: “How does a guy as careful as you end up catching COVID-19?”  It turns out that is an excellent question. As noted elsewhere on this blog I have essentially self-quarantined at home since the end of March or the start of the pandemic. I have had limited contact with people. I do not go into stores, supermarkets, coffee shops, or any public space. I pick up groceries ordered online and then collect them from a site where a masked attendant loads them into the back of my SUV.  All of my clinical work, continuing education, and professional meetings are done online.  I prepared a timeline of all contacts in or around my home for the previous 19 days (click to enlarge).  


From the summary, of the 18 total contacts I had direct contact with 6, only 4 of them about 6 days prior to the onset of symptoms.  All 4 of those contacts were wearing masks and none have tested positive for COVID-19.  My wife had contact with the other 12 and 9 of them were socially distanced or masked.  Only the electrician and three of the appliance repair/installers were not but they were socially distanced.  In addition, we made an effort to air out the house when they were there and after the left.  There was a total of 5 tradesmen in the house. They were all there for an average of about 1 hour.  I greeted one of them at a distance of about 12 feet and he was not wearing a mask. According to a recent hierarchy of transmission risk, I had no high-risk contacts for transmission (3).

My wife on the other hand was in a couple of higher risk scenarios (but not much higher).  As an extrovert, she was also out talking with people every day and exercising with several of her health club friends at their homes. She did however test negative for COVID-19 on the exact same test that I took. There are various estimates that 20-40% of COVID-19 infections result in asymptomatic carriers. It may be possible that she was a carrier and subsequently cleared the virus so that no viral RNA was detected on the nasal swab.  We are both currently trying to get antibody testing to COVID-19. It will confirm that I have short term immunity and possibly that my wife was an asymptomatic carrier.

When I did find out that I tested positive, I self-quarantined in the house pending my wife’s test and have been quarantined ever since.  The health plan recommendation is to wait for day 14 and if asymptomatic at that point, the self-quarantine can end. My wife is using the same date to end her quarantine and remained asymptomatic.  We have the luxury of having a large enough house where we can occupy separate areas and have separate bathrooms that are exhausted to the outside of the house.  I also kept an electronic air filter with a UVC germicidal light at the entrance to my office and between us in any public areas.  Several questions arise from this experience including:

1.  Why were my symptoms so mild (relatively speaking)?

Considering the actual statistics of the pandemic in the United States – my outcome is not that surprising.  About 1 in 34 cases have died and that number increases to 1 in 13 in my age range and 1 in 5 in the next highest age decile.  At the time of this posting there have been 197,000 deaths and 6.7 million cases.  There is a lot of comparison with influenza, but at this time there should be no mistake that while influenza typically generates more cases and more hospitalizations – there has only been one year where influenza mortality exceeded current SARS-CoV-2 mortality and that was the pandemic of 1918. 

The second consideration are the physical parameters of the environment. Assuming that my wife is not an asymptomatic carrier, the only time I was at a distance of less than 4 meters I was wearing a mask and so were the people I was in proximity to.  The contact lasted less than 10 minutes. And not a lot was said. We know that masks, distancing, and dilution in outdoor air probably works be reducing the concentration of airborne viral particles.  With that reduced concentration, any inhaled inoculum will be less resulting in a less severe infection. The estimated number of viral particles necessary to precipitate a case of COVID-19 is about 280 particles. That is 2-3 orders of magnitude higher than more virulent and lethal viruses like smallpox.

A few other lifestyle considerations. I eat a high-protein, high fiber, high whole grain, and low fat/low sugar diet.  I try to maintain a healthy weight.  I drink a lot of fluids every day.  I have been doing that for at least 30 years on the advice of a rheumatologist in order to maximize uric acid secretion and decrease the risk of gout attacks (I am an undersecretor of uric acid and had my first gout attack in medical school). Anyone reading this should drink a lot of fluid only based on their physician’s advice.  The only relevant factor in this paragraph in surviving the virus is probably maintaining a healthy weight and a good diet.  I was able to maintain my usual fluid intake during the course of this illness.

I take Vitamin D every day because my levels are typically marginal.  I take famotidine daily to prevent anaphylactic reactions. I only take it because the original H-2 antagonist recommended by my allergist (ranitidine) was taken off the market because of contamination in the manufacturing process. There has been some suggestion that famotidine is useful in the prevention or treatment of COVID-19 and for a while it nearly disappeared off the generic market.  I am not aware of any randomized clinical trial (RCT) results of famotidine and it has been demonstrated to not have any direct antiviral effect in vitro.  There is current speculation that in combination with H-1 antagonists that it may reduce histamine associated cytokine effects (13). At this point I would not consider it to be too relevant.

Exercise is a big part of my life and has been for the past 30 years. I typically exercise vigorously for 90 to 120 minutes per day.  Recent research (11,12) suggests that people who exercise vigorously into old age have better acute adaptive immunity (T-cell response) due to a better thymic environment.  One of the purported mechanisms is IL-7 production by skeletal muscle.  IL-15 is also an exercise responsive interleukin that enhances T-cell survival.  The net effect of these changes in the older person who exercises vigorously has a greater input of thymocyte progenitor cells and an enhanced output of CD4 and CD8 cells that are recent thymic emigrants (RTE). Both of these cells populations are critical for the acute adaptive response to novel viruses.  If I had to speculate about the lifestyle factors that are important it would probably be the effects of exercise, diet, not smoking and no alcohol intake on immunity and pulmonary function.

 2.  Why is there such heterogeneity in responses?

The host determinants of response are not well characterized at this point- other than the suggestion that previous exposure to common circulating coronaviruses could possibly lead to an enhanced antibody effect and either apparent asymptomatic carrier status or a less severe case as an adult.  Is it possible that the severe respiratory infection that I got in January was a coronavirus that was not SARS-CoV-2 and that it conferred some immunity?  This is one of the theories about why children are less affected by COVID-19 than adults – they tend to get more respiratory virus infections per year. Human coronaviruses and rhinoviruses are generally considered to cause up to 50% of common cold infections per year (10).  The Minnesota Influenza Incidence Surveillance Project, (MIISP) 3 of the 4 normally circulating human Coronaviruses – NL63, HKU1, and 229E (not OC43) since last September. Although these coronaviruses are now considered all part of the collection of common cold viruses they have been fairly recent discoveries with NL63 discovered in 2004 (7) and HKU1 discovered in 2005 (8).  The common coronaviruses have considerable RNA sequence homology with SARS-CoV-2 suggesting cross immunity can exist (9).  For example, pre-existing T-cell immunity in blood donors to SARS-CoV-2 is documented and is thought to be due to exposure to beta-coronaviruses that are in circulation (4).  But there is also evidence suggesting that pre-existing coronavirus immunity is not effective with SARS-CoV-2 (15).

One the genetic side, there are essentially no data at this point about genetic factors that favor successful recovery from the pandemic virus (click to enlarge).



 

3.  Given the exposures – is it possible that some other exposure (packaging, mail, aerosols from washing packing or mail) is more important than suggested by conventional wisdom?

Even though handwashing and washing of frequently touched surfaces is a top recommendation the current opinion is that transmission is unlikely from either groceries or mail based on studies that look at virus survival on different materials over time.  To me that is somewhat inconsistent with the hand washing advice.  The original theory was that a person could touch a contaminated surface, touch their face, and then end up with the infection through mucus membranes.  Groceries and the mail seem to be designated as infrequently touched surfaces relatively free from contamination.  An additional question for consideration is whether aerosols generated in washing the surfaces of groceries can transmit. SARS-CoV-2.  I use a UV sanitizer for mail and any objects the size of a large book or smaller. That method has limitations in terms of how accessible the surfaces of any contaminated object are.

One final critical consideration is the person you are in quarantine with. Do they share your goals and risk tolerance or not?  In my particular case, I am not risk tolerant at all if the risk is contracting a virus that has a 1 in 13 chance of killing me.  The prior probability of an adverse outcome is higher due to me having asthma, but the exact numbers are probably not known at this time. I would happily remain at home, not get a haircut (I have not), and just go out for groceries and necessary medical care.  My wife on the other hand is very social, and has maintained an active schedule with her friends and associates over the entire pandemic.  She spends her days exercising, socializing, and attending limited activities with friends.  She is distanced and wears a mask when necessary. Despite our ability to pick up groceries without having to enter a store she will spontaneously stop at these stores, put a mask on, and pick up a few items. This difference in approaches to the pandemic does create some tension.

Whether our different approaches produced predictable outcomes or not is up in the air at this point.  She was just approved for antibody testing and I still have to get approval at an appointment next week. All we know is that I was positive for SARS-CoV-2 on a PCR test and she was not. That leaves either airborne transmission, contaminated surfaces, or aerosols from washing contaminated services.

Getting through this does provide a sense of relief.  Even though immunity to this virus does not seem to be permanent at this point I am very grateful to have made it through these two weeks.  My boss sent me an email and asked what that sense of relief was like and I told him:

“It feels like I dodged a bullet.”

And it does…..

 

George Dawson, MD, DFAPA

 

References:

1:  Stephens DS, McElrath MJ. COVID-19 and the Path to Immunity. JAMA. Published online September 11, 2020. doi:10.1001/jama.2020.16656

2:  Gandhi M, Beyrer C, Goosby E. Masks Do More Than Protect Others During COVID-19: Reducing the Inoculum of SARS-CoV-2 to Protect the Wearer [published online ahead of print, 2020 Jul 31]. J Gen Intern Med. 2020;1-4. doi:10.1007/s11606-020-06067-8

3:  Jones Nicholas R, Qureshi Zeshan U, Temple Robert J, Larwood Jessica P J, Greenhalgh Trisha, Bourouiba Lydia et al. Two metres or one: what is the evidence for physical distancing in COVID-19? BMJ 2020; 370 :m3223 Link

4:  Stephens DS, McElrath MJ. COVID-19 and the Path to Immunity. JAMA. Published online September 11, 2020. doi:10.1001/jama.2020.16656 Link

5:  Fischer EP, Fischer MC, Grass D, Henrion I, Warren WS, Westman E. Low-cost measurement of face mask efficacy for filtering expelled droplets during speech. Sci Adv. 2020;6(36):eabd3083. Published 2020 Sep 2. doi:10.1126/sciadv.abd3083 Link

6:  Bar-On YM, Flamholz A, Phillips R, Milo R. SARS-CoV-2 (COVID-19) by the numbers. Elife. 2020 Apr 2;9:e57309. doi: 10.7554/eLife.57309. PMID: 32228860.

7:  Fouchier RA, Hartwig NG, Bestebroer TM, Niemeyer B, de Jong JC, Simon JH, Osterhaus AD. A previously undescribed coronavirus associated with respiratory disease in humans. Proc Natl Acad Sci U S A. 2004 Apr 20;101(16):6212-6. doi: 10.1073/pnas.0400762101. Epub 2004 Apr 8. PMID: 15073334; PMCID: PMC395948.

8:  Woo PC, Lau SK, Chu CM, Chan KH, Tsoi HW, Huang Y, Wong BH, Poon RW, Cai JJ, Luk WK, Poon LL, Wong SS, Guan Y, Peiris JS, Yuen KY. Characterization and complete genome sequence of a novel coronavirus, coronavirus HKU1, from patients with pneumonia. J Virol. 2005 Jan;79(2):884-95. doi: 10.1128/JVI.79.2.884-895.2005. PMID: 15613317; PMCID: PMC538593.

9:  Yaqinuddin A. Cross-immunity between respiratory coronaviruses may limit COVID-19 fatalities. Med Hypotheses. 2020 Jun 30;144:110049. doi: 10.1016/j.mehy.2020.110049. Epub ahead of print. PMID: 32758887; PMCID: PMC7326438.

10:  Greenberg SB. Update on Human Rhinovirus and Coronavirus Infections. Semin Respir Crit Care Med. 2016 Aug;37(4):555-71. doi: 10.1055/s-0036-1584797. Epub 2016 Aug 3. PMID: 27486736; PMCID: PMC7171723.

11:  Duggal NA, Pollock RD, Lazarus NR, Harridge S, Lord JM. Major features of immunesenescence, including reduced thymic output, are ameliorated by high levels of physical activity in adulthood. Aging Cell. 2018;17(2):e12750. doi:10.1111/acel.12750

12:  Lazarus NR, Lord JM, Harridge SDR. The relationships and interactions between age, exercise and physiological function. J Physiol. 2019;597(5):1299-1309. doi:10.1113/JP277071

13:  Hogan Ii RB, Hogan Iii RB, Cannon T, et al. Dual-histamine receptor blockade with cetirizine - famotidine reduces pulmonary symptoms in COVID-19 patients [published online ahead of print, 2020 Aug 29]. Pulm Pharmacol Ther. 2020;63:101942. doi:10.1016/j.pupt.2020.101942.

14:  Minnesota Influenza Incidence Surveillance Project,  (MIISP). Minnesota Department of Health.  Correspondence on circulating common coronaviruses in Minnesota.  Received on 9/19/2020. 

15:  Loos C, Atyeo C, Fischinger S, Burke J, Slein MD, Streeck H, Lauffenburger D, Ryan ET, Charles RC, Alter G. Evolution of Early SARS-CoV-2 and Cross-Coronavirus Immunity. mSphere. 2020 Sep 2;5(5):e00622-20. doi: 10.1128/mSphere.00622-20. PMID: 32878931; PMCID: PMC7471005. 



Supplementary 1:

My wife tested negative for SARS-CoV-2 IgG antibodies today (9/22/2020) in addition to the negative nasal swab PCR tests - making her an unlikely source of infection.


Supplementary 2:

COVID-19 follow-up: 

Saw my internist yesterday (9/25/2020). 

My course of the illness was "average" for all of the patients he has seen. He agreed that PCR false positives are not likely but false neg are. He declined Ab testing. I applied to the Red Cross convalescent plasma program.

       

Saturday, September 12, 2020

Existential Psychopharmacology And Much More

 

 


I offered an opinion on existential psychopharmacology recently and after completing those three tweets - decided that a more comprehensive look at this issue was in order. Psychiatrists have been debating the extent of what can be done in time-limited sessions for at least 25 years now. Those debates basically come down to what the government and businesses allow psychiatrists to do. About 25 years ago there was a billing and coding scheme that suggested that psychiatrists could do a few things including a comprehensive evaluation, follow-up visits, follow-up visits with psychotherapy, and family therapy.  Eventually the follow-up visits without psychotherapy are broken down into “medication management” visits and very brief medication management visits. If you happen to work as an employee that might mean you had to see four or five people an hour and do the necessary documentation and billing. There were bitter debates about whether that was a long enough period of time to see someone. Because these designations all trickled down from the government and the business world they had very little to do with whether or not a psychiatrist could provide services that they thought were needed in those time frames. There some articles about how psychiatrists are just focused on medications and “no longer did psychotherapy”. There were counter arguments by psychiatrists and community mental health centers saying that they could provide adequate services in those time frames for a lot of people. The politics escalated the point that psychiatrists were being stereotyped as specialists who are only interested in prescribing medications.

Any critical thinker could question the idea of “prescription only” psychiatry. Looking at a few common scenarios illustrates why that is not possible or defensible irrespective of the fact that psychiatrists are trained to provide comprehensive mental health services. A common example encountered in clinical practice is the crisis situation.  The psychiatrist is treating a patient who they have been seeing for any length of time who suddenly experiences a crisis in their life usually due to an overwhelming loss or stressor. The appointment is no longer focused on the long-term treatment and needs to refocus acutely on the crisis. The crisis generally affects the evaluation and treatment of the long-term problem and I have had many patients state that explicitly at the beginning of those appointments. Medications can be prescribed for crises but in general the best approach is psychotherapy.  Staying with a rigid approach to the original problem is not only ineffective but it harms the therapeutic alliance between the psychiatrist and the patient. That alliance is built on the patient knowing that they are being heard and understood by the psychiatrist. Ignoring a new crisis fails that test.

Another common example about why “prescription only” psychiatry fails is problems that need to be discussed rather than treated medically. These vary from comprehensive analyses of various medical problems and how they fit into the psychiatric formulation to stressors and social problems. In many cases the approach is educational.  Common examples there would include recommendations on sleep, diet, and exercise where they apply. But the examples include supportive psychotherapy for interpersonal conflicts, maladaptive problem-solving, and any clear sequence of behavior that the patient has questions about that can benefit from additional discussion.

It doesn’t take too much consideration to understand that psychiatrists need to talk with their patients in great depth in order to establish a treatment relationship that works.  That is not to say that there are suboptimal practices at either end.  I have certainly talked with people who told me that their last doctor always seemed poised over a prescription pad and would only talk about medications. There are some mass prescribing practices in primary care that depend on checklist descriptions of symptoms for a diagnosis and then that diagnosis for a well-defined list of prescriptions. There are also patients who tell me that they were seeing a psychiatrist who was psychotherapy focused and very reluctant to consider a medication.  Eventually they did get someone to prescribe a medication that worked and they decided to terminate with that psychiatrist for not presenting medication alternatives to them.  Psychiatric practice is all about a balanced presentation of the diagnostic formulation and ways to address it and that always includes a dialogue with the patient that communicated both information and understanding.

 

Case Example:

I am working in a large trauma center on weekend call and have seen a number of admissions to the acute care unit.  I get a call to the Coronary Care Unit about a recent admission who is tearful and depressed. She was admitted to rule out a myocardial infarction and that was done but the fellow is concerned about discharging her without treatment for depression.

I interview the patient and she is definitely depressed and tearful. I learn that she has recently retired and is having some difficulty finding meaning in her life.  She was previously the CEO of a large company and her day was scheduled for years.  It was so scheduled that she needed an assistant and was in constant contact with her.  She has never seen a psychiatrist or psychotherapist before and never been treated for depression. She has two adult children and did not have postpartum depression associated with either pregnancy.  She is generally healthy and physically active.  Her husband has noticed that she is less interested in some of their mutual activities – tennis and travelling.

 A stereotypical approach to this problem of going down the diagnostic criteria for depression may not be the best one. When I am talking to a patient in this situation, I ask them to join me in a conference room for the interview and not in their CCU bed.  I introduce myself, explain why I was consulted and then ask the patient for their take on the situation.  The questions are always open-ended since I am interested in their unique experience of the problem. That is a technique I learned as a first year medical student and it was greatly expanded in psychiatry. Learning medicine involves trying to recognize certain patterns in what the patient is saying and then honing in for more specific details. Psychiatry is a little more complicated.  It involves recognizing the typical disease patterns (eg. stroke), the patterns specific to psychiatry (eg. aphasia versus formal thought disorder), and the best therapeutic way to talk with the patient (loss, role transition, problems associated with stroke, aphasia). The initial two elements of that pattern recognition are fairly straightforward but intense aspects of medical and psychiatric training. The third is not and it has been a topic that has been politicized over the years to the point that it has become confusing for both psychiatric residents and practicing psychiatrists.

The best way to conceptualize therapeutic discussions is to see it as an extension of interviewing and psychotherapy training. There is always plenty of hostility associated with the idea that psychiatrists might be doing psychotherapy with patients while they are discussing medications and medical treatment.  There should not be.  I have already illustrated in this post why it is impossible to function as a psychiatrist without psychotherapeutic discussions. The psychiatrists who I know who were highly regarded by patients approached all patient encounters this way.  They expected there was going to be a discussion with the patient that had nothing to do with their medications, but that was essential in some way to the patient’s wellbeing.  How exactly does that happen?

The basics start with those initial interviewing skills.  In psychiatry, an emphasis on empathy, boundaries, and therapeutic neutrality adds a lot to those skills.  Talking to hundreds of patients and discussing those experiences with supervisors adds even more.  I can recall for example, listening to a supervisor talk about how to directly express caring for the patient (“I am really concerned about your ability to take care of yourself”) and operationalizing that for the patient to assure their survival.  I recall seeing another one of my supervisors telling a patient who was sobbing uncontrollably to “snap out of it” (in a nice way) in order to proceed with identifying the patient’s problems. When I saw that happen it was shocking for a trainee, but watching the interview it was clear that was a necessary skill.

An additional level of skill building occurs with one-to-one psychotherapy with patients and the corresponding 1:1 supervision by staff clinicians. In my case, I was supervised based on direct observation, audio tapes, video tapes, and process notes – 3 ongoing cases/week for three years. Those supervisors were also a rich source of texts and papers on psychotherapy technique. As I was starting psychotherapy training I read texts by Grinker, Arieti, Sullivan, Yalom, Beck, Klerman and Weismann, Basch, Werman, Dewald and others.  I attended an APA seminar by Kernberg and read his research.  I attended an APA seminar by David Burns and read his book.  I read the competing approach by Kohut and read the “Two Analyses of Mr. Z” and several other papers.  I was exposed to Lorna Smith Benjamin’s Structural Analysis of Social Behavior (SASB) and Viederman’s  psychodynamic life narrative.  I remember thinking of Viederman’s paradigm as I interviewed a young patient and realizing that she was describing neuropsychiatric symptoms consistent with complex partial seizures and having to change the paradigm and refocus the interview.  The ability to do that is all part of the complexity of psychiatric treatment.

Getting back to my clinical example, we discussed the patient’s transition into retirement as being the most significant factor that eventually led to more depression, panic attacks, and admission to a coronary care unit.  With that as a major focus of the interview the cardiologist’s questions about acute suicide risk, transfer to a psychiatry unit and medical treatment could all be addressed. The recommended treatment was psychotherapy rather than a medication.  The Cardiology fellow was still making rounds when I finished.  I talked with her about the existential aspects of the patient’s crisis.  Luckily the fellow was a creative writing and philosophy major and knew where I was coming from. The discharge proceeded without a hitch and the patient was clearly improved when she left.

What I am describing is essentially a supportive psychotherapy approach.  I notice the themes that various psychotherapies were designed to address and test them out with the assistance of the patient.  Do they seem to be relevant to the patient or not? Most importantly what can be said in that context that will be the most useful to the patient? That can vary from education about the therapy and the theory, to a clarification tying various events and reactions together, to an interpretation based on the developmental history discussed over the course of the interview.  Once that has been done and documented in an initial assessment it continues to evolve over the course of treatment and sometimes beyond.  I have had people come back years later to discuss additional developments – all in the 30-minute interview.  When you have 30 minutes to provide comprehensive psychiatric treatment – it can be done.   

For the person interested in existential psychopharmacology, Ghamei, Glick and Ellison have written about it as a “humanistic approach to the med check” (1).  In this article the authors emphasize the need for human connectedness and how it is necessary for psychopharmacology.  It basically emphasizes recognition of the individual and personalized treatment rather than seeing people as cross sections of symptoms.  I could not agree with the authors more and have outlined common areas of discussion that I try to cover in psychiatric visits. They discuss pejoratives of the 15 minute “med check” that focus almost exclusively on target symptoms and medications for this target symptoms.  I agree that it is suboptimal care but I also cannot forget where it came from.  It is a product of the government and the health care business community. Historically, there is no psychiatrist who stood out for saying: “From now on let’s see all of our patients for 10-15 minutes and pretend that only changing their medications is effective psychiatric care”.  There were definitely business administrators who said: “If you want to get paid, we want you to see this clinic full of patients every 15 minutes.”  Purely medication-based treatment is not really psychiatric treatment and it continues today as collaborative care. In some of the original collaborative care models – the unique experience of the patient is completely ignored.  All patients complete the same rating forms for anxiety and depression and decisions are made on that basis.  The patient’s conscious experience is collapsed into an aggregate number and a rating on the subscale of suicidal thinking. The models are at the opposite end of the spectrum from personalized care and are heavily promoted by managed care companies and governments who consider some of these aggregate measures to be “quality measures”.  I attended a meeting two years ago, where people were trying to use tens of thousands of these rating scale reports to develop an artificial intelligence approach to predicting suicide for these numbers. Human consciousness is not that simple.  

I know that many will see a 30 minutes appointment with a psychiatrist as a luxury or “too much expense”. In fact, it is a starting point. Once treatment proceeds, every aspect of treatment including frequency and intensity can be discussed in sessions.  One of the most well-liked psychiatrists (by his patients) that I have known, had several large clinics where he typically saw most people for 20 minutes, but 30 minutes when he needed to. Over the years he knew the several hundred people in these clinics very well and his patients did very well.

This method is the outline of what I do in clinic every day, what I did on acute care inpatient units for 22 years, and what I did in a community mental health center for the first three years of my career.  One of the reasons for writing this blog is not to suggest that I am the standard to measure everyone else by.  I write this blog because I know that almost every psychiatrist including my supervisors and professors and my colleagues practice this way. 

I just figured out a way to describe it.


George Dawson, MD, DFAPA

 

References:

1:  Ghaemi SN, Glick ID, Ellison JM. A Commentary on Existential Psychopharmacologic Clinical Practice: Advocating a Humanistic Approach to the "Med Check". J Clin Psychiatry. 2018;79(4):18ac12177. Published 2018 Apr 24. doi:10.4088/JCP.18ac12177 (free full text)

 

Addendum 1:

I was tempted to come up with a catchy name to encompass my approach to medical treatment and psychotherapy. I can see why the authors like the term existential.   

Addendum 2:

I don’t want to give the impression that my psychotherapy education ended in residency.  It is an ongoing process and I am always open to new techniques to help my patients.  The same way I study the medical conditions of my patients and make sure I completely understand the potential complications for psychiatric care.

Addendum 3:

I hope to come up with an additional post of the supportive psychotherapy techniques that I have found useful over the years and how I see that field evolving.