The Florida Psychotherapeutic Medication Guidelines

This month's Journal of Clinical Psychiatry has a lead article about medication guidelines for adults with major depressive disorder.  Is is an apparent function of the Florida Medicaid Drug Therapy Management Program For Behavioral Health.  It is hard to imagine a title with more inappropriate terms for what psychiatrists do with medications.  At least until I read the title of the article: "Florida Best Practice Psychotherapeutic Medication Guidelines (FPG) for Adults with Major Depressive Disorder."  Here is a little insight into what I have difficulty with.  Treatment with medications is not psychotherapy.  Psychotherapy almost always needs to accompany medication treatment at one level of intensity or another.  But providing medication alone is not psychotherapy.  That is an important distinction because one of the common misconceptions is that a medication will solve common life problems like interpersonal problems at work or home and it will not.  The second issue is the idea of medication "management".  As one of my colleagues used to say: "Pharmacists manage medications we treat patients".  The term should also be anathema to any psychiatrist who was around when billing and coding guidelines were invented.  The term came to mean 10-15 minute appointment that reduced psychiatric treatment to a brief discussion of a medication.  They were two of the lowest reimbursement codes in the coding scheme and they handily allowed psychiatric treatment to be split off from the rest of medicine and reimbursed at a lower rate.  And finally the term behavioral health.  This is a long standing business term to indicate a managed care environment with business supervision rather than a mental health environment with psychiatric supervision.  All of these terms suggest that managed care companies and the government have more to do with these guidelines than psychiatrists.

Sure enough, looking at the partners for this project the majority are behavioral health organizations or managed care companies followed closely by government organizations, other associations, and three psychiatry departments out of 24 organizations.  The article itself describes the process as being the result of a multistakeholder Florida Expert Panel.  The stakeholder word always makes me cringe.  Whenever I have seen it in medicine and psychiatry nothing good has ever come of it.  There are only two stakeholders in medical treatment - the physicians and the patient.  I can stretch that to the family if they are still actively involved.  I don't want to see anybody else in the room.

The  authors detail their rationale for yet another guideline.  They state:

"Notwithstanding the public health priority of MDD, as well as increasing public, academic.  and policy attention given to MDD, misdiagnosis or delayed diagnosis and failure to incorporate appropriate measurement based care are significant modifiable deficiencies in current practice."

If only that were true.  In a state where there is widespread PHQ-9 screening. the screening tool suddenly becomes the diagnosis.  Measurement based care suddenly becomes the collection of meaningless cross sectional scores from clinics all over the state listing a diagnosis of MDD.  If only real life worked like intensive clinical trials out to prove a hypothesis.

They go on to list several other reason for their guideline.  They cite the American Psychiatric Association (APA) guideline as a "conflation" of empirical evidence and expert consensus - suggesting that nothing is sacred about expert consensus and that the patients seen by experts may not be the same as patients seen by other physicians.  They suggest that guidelines derived from pharmacological trials may be limited by suggesting that they may have limited generalizability due to trail designs and conditions that rule out certain conditions, but don't discuss other problems in experimental design.  They discuss limited long term follow up and measurement of functional capacity as a limiting factors.  Given that the authors don't really intend to correct any of these criticisms it is difficult to see that as a rationale for the new guideline.  Instead they say that their consensus process was their overarching principle in writing the FPG along with providing guidance (especially to primary care physicians) to provide safe and effective treatment for depression.

The authors use a hierarchical approach to tiers of treatment without using an algorithm.  Level 1 is initial treatment and Levels 2, 3, and 4 are basically used if the initial levels of treatment are ineffective or not tolerated.  There are few surprises for any psychiatrist who is used to treating depression, especially referrals from primary care physicians.  Given the stated concerns about the biasing effects of clinical trials sponsored by pharmaceutical companies for specific FDA indications, there were not many qualifiers about the addition of an "atypical antipsychotic approved for major depressive disorder (ie. aripriprazole, brexpiprazole)" at Level 2.  Level 2 is basically a failure of Level 1 antidepressant monotherapy.  In fairness switching to another antidepressant monotherapy at Level 2 is a suggested option.  The clear concern that the authors have about second generation antipsychotics in their scheme is metabolic rather than neurological side effects.  I have found a significant number of neurological side effects from aripiprazole including Parkinson's syndrome, akathisia. and tardive dyskinesia from these medications.  Nowhere in the paper are the diagnostic skills listed as important for the physicians.  In the emphasis about measurement based care there are no rating scales for drug induced neurological disorders.  The question of safer augmentation strategies are not discussed.

With regard to the issue of weight gain as a medication side effect, a strategy listed is "select medications that have a low relative risk of weight gain and metabolic syndrome".  A couple of related issues come up including the fact that a significant number of patients walk into the clinic with high BMI, but they are there for the treatment of depression.  Should the diagnosis of obesity and/or metabolic syndrome be made and managed along with the depression?  What about the patients who gain significant weight on either aripiprazole or brexpiprazole?  They definitely exist. What about clinicians who have developed successful strategies for using atypical antipsychotics with minimal to no weight gain?

There are also the very common problems of insomnia associated with depression that does not resolve with antidepressant therapy and significant anxiety with or without panic attacks.  Major depression with psychotic features and major depression with mixed features were discussed as important variants and special interventions not commonly used in primary care were included like electroconvulsive therapy (ECT) or transcranial magnetic stimulation (TMS).  It was acknowledged that lack of patient acceptance and availability of these treatments might result in using various medication combinations that may be less effective.  Vagal nerve stimulation was recommended as a level 4 treatment and I have serious reservations about that being effective for anyone.  

All in all the FPG is what I would expect from a collection of stakeholders, some of whom were listed as representatives of managed care companies.  Rather than have these stakeholders rehash strategies that have been around for 20 years, there was an opportunity to design a comprehensive system of care for patients with depression and there is no evidence that has happened.  There is a reason why people don't go in to psychiatry and some of those reasons don't bode well for the assumption that everyone in the system will now be doing comprehensive assessments like psychiatrists.  A system of mental health care designed by stakeholders could possibly develop state- of-the-art resources for neuromodulation (TMS, ECT, deep brain stimulation), sleep studies, monitoring the cognitive effects of depression and antidepressants, detoxification and addiction treatment, and reasonable inpatient and residential resources.  That same system would have designed in timely assessments of difficult problems like MDD with psychosis by psychiatrists.  Adequate numbers of psychotherapists or pilot programs looking at computerized cognitive behavior therapy for sleep, depression, and anxiety would be more useful that one or two crisis oriented sessions with no specific orientation.  A blanket statement about the utility of evidence-based psychotherapies without adequate numbers of therapists to carry it out is not helpful in any way.

We need system redesign by stakeholders, not stakeholders making more guidelines while pretending that they know something about quality.
    



George Dawson, MD, DFAPA

Synopsis:

If certain stakeholders in a system, have:

-all of the money
-all of the power
-sophisticated electronic health records that are set up more for administrative than clinical purposes.

They may have an obligation to design the system to optimize care rather than telling the people delivering the care what they can do in a poorly integrated system of rationed resources by applying strategies that are already well known.  

References:

1: McIntyre RS, Suppes T, Tandon R, Ostacher MJ,  . Florida Best Practice Psychotherapeutic Medication Guidelines for Adults With Major Depressive Disorder. J Clin Psychiatry. 2017 Jul;78(6): 703-713.

2: Ostacher MJ, Tandon R, Suppes T. Florida Best Practice Psychotherapeutic Medication Guidelines for Adults With Bipolar Disorder: A Novel, Practical, Patient-Centered Guide for Clinicians. J Clin Psychiatry. 2016 Jul;77(7):920-6. doi: 10.4088/JCP.15cs09841. PubMed PMID: 26580001.

3: Gartlehner G, Gaynes BN, Amick HR, Asher GN, Morgan LC, Coker-Schwimmer E, et al. Comparative Benefits and Harms of Antidepressant, Psychological, Complementary, and Exercise Treatments for Major Depression: An Evidence Report for a Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016;164:331-341. doi: 10.7326/M15-1813.

4: Qaseem A, Barry MJ, Kansagara D, for the Clinical Guidelines Committee of the American College of Physicians. Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients With Major Depressive Disorder: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016;164:350-359. doi: 10.7326/M15-2570.

Billboard - Stigma or Not?

I don't know how I missed the controversy but the APA has vigorously criticized a billboard that sends a message about inadequate access to mental health services and inadequate gun control.  I found out about it only through the APA listserv yesterday.  The Psychiatric News alert can be viewed here.  The billboard can be seen on major news services like NBC here.   If anyone can spare a photo of this billboard please e-mail to me and I will post it in the body of this essay.  The message basically states "Over 40 million Americans with mental illness - some can access care - all can access guns."  It is signed by Kenneth Cole.  He has a history of activist billboards and Twitter posts and is no stranger to controversy.  He has also discussed raising his brand's profile through the social responsibility messages.  In this case some APA members were outraged at what they perceived to be a stigmatizing message.

My perspective is that the message on the billboard is accurate. There is nothing to be gained by suggesting that Mr. Cole is trying to state that most people with mental illness are dangerous.  But there is the issue of whether a professional organization should be commenting on what they perceive as a controversial billboard in the first place, especially when it may be used to promote a brand name.  In this era of social media and the current trend for public shaming, I would suggest that scoring points in that landscape is the last thing any professional organization should be doing.

The fact is that most acute care psychiatrists are making these kinds of assessments every day in the United States and multiple times a day.  The vast majority of people designated to have a mental illness on this billboard do not need to see psychiatrists.  Acknowledging the fact that psychiatrists are actively engaged in violence prevention and that a small but significant number of people with mental illness are violent and aggressive and that it is a treatable problem is a very important message.  The potential benefits include:

1. Less stigma for people who are violent and aggressive as a result of severe mental illness.  The current bias is to see this behavior was willful and punish them based on a moralistic approach to mental illness.  That is until the violent and aggressive person is a family member trying to harm other family members.  At that point, there is no myth of mental illness and all of the talk about how the mentally ill are not aggressive is meaningless.

2. Clearly define the problem and develop centers of excellence for treating this problem.  In every metro area in the U.S. there are a handful of acute care psychiatric units and even fewer who accept violent and aggressive patients.  All of the violent and aggressive patients are typically brought to one or two hospitals that are set up to address the problem.  Those hospitals have protocols in place to treat the problem and many of them do a lot of civil commitments.  There is no funding source that is adequate to provide the level of treatment for these patients who must be hospitalized until they are no longer dangerous.  They also require more intensive staffing patterns by staff who must have a much higher level of training than in less intensive situations.

3. A denial of the potential for violence and aggression is inconsistent with the recently released Practice Guidelines for the Psychiatric Evaluation of Adults, Third Edition.  That document has explicit commentary about the psychiatrist’s role in addressing aggression.  There are 41 references to aggression in the body of the paper including 13 bullet points on the Assessment of Risk For Aggressive Behavior (p 23).  There are thirteen references to firearms.

In my opinion, the assessment of violence and aggression that is typically done in crisis situations by psychiatrists is more extensive than what is captured in the guideline. As an example there is no discussion of transference or countertransference issues and how they affect the treatment team and their approach to the safe treatment of violent and aggressive patients.

4. A more clearly defined role among advocacy organizations is a better role for professionals. The political use of the term “stigma” is at times all encompassing and it obscures the real source of the problem. For example, stigma is not the reason why there are no services available for psychiatric care.  Managed care companies and the governments that subsidize them and sanctify their business tactics are the reason there are no services.  The APA has been talking about stigma for years and it has done absolutely nothing to increase services or stop the rationing.  The highly acclaimed parity legislation initiated by Senators Paul Wellstone and Pete Domenici has done nothing to break the chokehold on mental health by businesses and governments.  There is new legislation in the works to “enhance” the original parity legislation because it has no teeth and has not made a difference. Businesses do what they want with the blessing of state and federal governments.

5. In some cases advocacy organizations are at odds with clinical psychiatrists who are treating patients with severe mental illness and aggression.  One of the positions taken by at least one of these organizations is that psychiatrists could be easily replaced by “prescribers” in state hospitals where aggressive patients are sent.  The government in that case took the position that an administrator with no clinical experience could come into a state hospital setting and develop a program to treat patients with mental illness and violence and aggression.  That plan failed.

These are a few of the problems associated with denying the correlation between severe mental illness and violence and aggression in a subset of patients with severe mental illness. The reality is that there are thousands of psychiatrists that face these problems every day. Their goal is to keep people safe and prevent violence. Acknowledging what they do on a daily basis, supporting that work and the importance of that work to patients, families and the community is a step in the right direction.

Suggesting that it is too stigmatizing to discuss that issue is not a step in the right direction.




George Dawson, MD, DFAPA



Supplementary 1:    I contacted Kenneth Cole (the company) through the web site and asked them to send me an image of their billboard for use in this post.  I included a link to the post so the specifics could be read as well as the entire blog.  I was advised that although they appreciate my interest, the image was proprietary and therefore they could not send it to me.  I don't know if they are claiming that about every image or just the one I wanted them to send me.  It made me wonder if they are aware of how widespread the image is used on the Internet.

Supplementary 2:   I was graciously sent a photo of this billboard by a resident New Yorker.  I contacted Kenneth Cole again and was told again that I could not even use an independent photograph of their billboard for this post.  I really doubt that any place else displaying these billboard photos has gotten permission from them, but I am just a guy writing a blog and can't afford to get into it with them.  So there you have it.  Go to any one of the other hundreds of places on the Internet that have posted this picture to view it.

    

The New APA Practice Guideline

I got a link to the new American Psychiatric Association (APA) Practice guideline today in my Facebook feed.  It was entitled Practice Guidelines for the Psychiatric Evaluation of Adults.  It is an updated version of a previous guideline by the same name.  I have pointed out on this blog that the APA seems to have all but abandoned the production of these guidelines with the exception of some extensive work for CMS to determine whether or not administrative guidelines about billing and coding were adequate.   When I complained to APA officials about the fact that they were not producing any new or updated guidelines I was told two things.  The first was to wait for this current guideline.  The second was that guideline production and updating did not seem to be a wise use of limited resources.  My interpretation of that remark was that it was defeatist and probably related to the fact that everyone is currently producing guidelines.  I guess that nobody at the APA recognizes the need to set limits on pro-business and pro-government guidelines that actively discriminate against psychiatrists and their patients.  Apart from a single APA President, that seems to have been the conventional wisdom that they have been using for the past 30 years.

I read the entire relevant section of the Guideline and that involves the first 52 of 170 pages.  The last section includes references, abstracts and methodology like bar graphs showing how many experts agreed that a certain type of assessment needed to be done in an initial assessment.  The introductory release explained that the guideline was based on an Institute of Medicine (IOM) publication entitled Clinical Practice Guidelines We Can Trust.   I have not been impressed with some of the work done by the IOM in the past and after reading three of their previous books wonder if it makes sense to read a fourth.  There are additional references on the methodology in the introductory sections of the document.  The release describes the guideline as modular so that each of the nine different modules can be updated regularly and separately.   That is a good idea that will hopefully add timeliness to the process.  One of the goals is to have the guideline widely disseminated.  Apparently anyone can download the document and read it.  There are the usual legal qualifiers pointing out the limitations of a broad document like this one and why it cannot be considered a standard of care.  I did not see the most obvious reason mentioned and that is that this concept is a legal one used for the determination of medical malpractice and that it really has no application in medicine.  Guidelines are referenced in Gutheil and Appelbaum's text:  "Third, another source of information about standards of care is the growing number of practice guidelines.........  It must be remembered, however, that even well-designed guidelines  do not necessarily address all possible approaches to a clinical issue." (1).  So the guideline disclaimer is clearly debatable in court.

As I read through the guidelines several things jumped out at me.

1.  It was not clear that this guideline was written for psychiatrists -  Some may say that this is implicit, but I am bothered by the fact that in the first 52 pages the word "clinician" pops up 34 times and the word "psychiatrist" pops up 17 times.  What would prevent any clinician from claiming that they have done everything listed in this document and therefore their evaluation is the equivalent of a psychiatrist's evaluation.  This is more than a guild or political issue as I will elaborate below.

2.  It was not clear what type of expertise was necessary to use the guideline - I suppose this is a minor variation of the first point, but technical expertise to me has always been a critical issue.  The guideline gets around this by saying it is not a "comprehensive" document.  I would not consider the recognition of acute medical and neurological problems or even chronic ones to be beyond the scope of a psychiatric evaluation.  I would not consider an abbreviated list of these conditions to necessarily render this a comprehensive document and it would certainly have more clinical value than a tedious list of all of the survey results.  The document also discusses tests in terms of the optimal ordering of tests and also specific kinds of tests.  What about who interprets those tests?  As a very basic example, I would go back to the days of the oral board exam in psychiatry and frequent questions about the use of lithium.  Board examiners were interested in what tests needed to be ordered to initiate and follow lithium maintenance therapy.  The goal of that exercise was to certify a safe practitioner of psychiatry.  In today's world, there is a much larger number of tests, interpretations and plans based on those tests.  This is a critical line of demarcation in some practice settings that seek to limit the medical role of psychiatrists.

It is apparent that the APA wants this guideline to be widely disseminated.  A related concern is that they may have not learned much from the wide dissemination of the DSMs over the years.  Although there is a partial financial incentive with DSM releases, the APA may be oblivious to the downside of everyone having a copy of this manual.  The pre-DSM-5 release rhetoric illustrates that a lot of critics had a very poor understanding of what the DSM-5 was and how it would be used.  Wide dissemination of a vaguely written practice guideline may have the same effect.  There is a common bias than anyone with a social brain who can speculate about the motivations and goals of others can do what psychiatrists do.  There are endless examples of various writers speculating about which public figure may have Asperger's or narcissistic personality disorder.  The sentiment in some circles seems to be: "If I have a copy of the DSM - I can diagnose people."  What is to prevent a similar co-opting of the Practice Guideline?

3.  There is nothing really surprising in the document - The assessment techniques are either obvious things that psychiatrists and psychiatric trainees do on a regular basis.   There are so many qualifiers that many approaches can be taken.  For example, the issue of coming back to an initial point to clarify the diagnosis if it could not be appropriately done in the initial interview was mentioned several times.  That is useful in cases when a patient is embarrassed or defensive about a particular aspect of their history.  In this regard, the document represents both content and process variables of the interview.  

4.  Tip of the cap to evidence based medicine - even when it is not needed - A common refrain throughout the guideline was:  The strength of research evidence supporting X is low, where X is the guideline of interest.  I summarized the guidelines and statements in the table below.  The numerical and letter designations can be translated as follows.  The numeral 1 is a recommendation.  The numeral 2 is a suggestion.  The letters A, B, and C are degrees of evidence reflecting high moderate or low degrees of evidence respectively.  The table basically reads as a recommendation or a suggestion backed by low degrees of evidence.

Using research evidence as a criteria for standard clinical methods is taking evidence based medicine to its absurd conclusion.   I am not talking about refinements in the way the history and physical has been done over the years, but the basic idea that a physician has to make a diagnosis and come up with a treatment plan.  Is there really any question that there are currently thousands of clinical trials that document positive treatment effects based on inclusion criteria that include a standard evaluation of the patient and the recognition of certain medical exclusion criteria?  The Guideline includes an explanation about why it is unethical to do certain double blind placebo controlled trials such as the study of suicide and aggression.  It does not comment on the important clinical question: "When does the anecdotal become statistical?"  To illustrate, if I am currently an inpatient psychiatrist and 100% of the patients I see are admitted for suicidal/aggressive ideation/behavior and my post discharge complication rate is very low (1 incident of suicidal or aggressive behavior every 500 discharges) - what is the likelihood that I am no more effective than placebo?  Do I really need a clinical trial to prove that I am doing something?  Are there any statisticians out there willing to speculate on that problem?    

5.  The information aspects of the evaluation - this critical aspect of the evaluation has not been studied in the field and the lack of these studies leads to a number of vagaries in the guideline.  It should be possible to illustrate the range of information exchange across a number of interviews and the optimal amount of information exchange in terms of diagnostic yield and enhancing the diagnostic and therapeutic aspects of the interview.   It is a way to advance the technical aspects of the field without deference to neuroscience.  Psychiatry has been stuck in essentially the same interview technology since the 1940s with no significant advances.  Looking at the information exchange that occurs in the interview is a long standing omission and it is probably the best way to advance this central part of clinical practice.

6.  A well deserved shot at the electronic health record  - After about two decades of hearing nothing but praise for the EHR and how it will revolutionize the practice of medicine and "save" us all hundreds of billions of dollars, its shortcomings are so obvious and so severe that even the APA gets it.  From page 44 of the Guideline:

"With the increasing use of electronic record systems, the structured but fragmented information that is common in electronic record notes can increase cognitive workload and reduce the quality of communication among those caring for the patient..."

That is a diplomatic way of saying that if you follow the suggestions for collateral information in the Guideline and are unfortunate enough to get either a printout or have direct access to an EHR, you might spend hours reading through hundreds of pages only to discover that the document has no discharge date, that it contains minimal information or that (in the case of lab testing) you can't determine the dates that any of the testing was done.  You will probably also encounter an EHR template approach to documentation that provides a series of "yes-no" responses where real information is traditionally used.  The current EHR is a plague on those specialists who require high quality information and plenty of it.  It should be apparent from the general requirements of this guideline that psychiatry is at the top of the list.

7.  Inconsistencies are present in many places - One of the better examples is several qualifier paragraphs that point out how descriptions may be necessarily vague and how to negotiate that in the assessment itself.  There are terms having to do with time as well as clinical descriptions.  The guideline says that it does not encourage stereotypical questions to complete the assessment, but at the same time suggests "quantitative measures" like standard checklists.  I cringe when I see that term because it was a term that was included in the Joint Commissions 2000 statement on pain assessment and treatment and we all know how that turned out.  To an old chemist, asking a person where they are on a ten point scale that rates pain or depression or anxiety is far from a quantitative measurement.  At some point, psychiatrists and physicians lost sight of the fact that certain organ systems (the brain in particular) by its very structure,  precludes quantitative analysis - and that is a good thing.  The authors of this guideline should at least attempt to explain how an obviously subjective and flexible evaluation can eventually lead to rigid "quality" measures that are also being used as if they are quantitative.  At some point, some professional organization needs to point out that most if not all of these measures are fabrications of the business community and government and they have little to do with medicine or science.  If the APA can say that about all of the points in their guideline, why can't they point out that the same "quantitative measures" are used in collaborative care and they mean the same thing.

8.  The serious dimension of the diagnosis - There are a lot of reasons why patients and families tend not to take a psychiatric diagnosis as serious as they should.  It took me a number of years in clinical practice before I realized that any informed consent discussion I have with a person should include whether or not that diagnosis is life threatening to them.  In some cases like talking with a survivor of a near lethal suicide attempt it is obvious.  In other cases like a major psychiatric disorder and a number of close calls due to a substance use disorder, it is less obvious.  I will tell a person that the condition they have is life-threatening and the treatment plan and their part in the overall treatment needs to take that into account.  There may be an associated discussion of voluntary and involuntary treatment as well as a clarification of my position in the patient's treatment and the associated rationale.  I think it is critical that this assessment is made and carefully documented for continuity of care purposes.

These are a few of my initial comments.  The new treatment guidelines is far from perfect but it is a start to get the APA back on track again to establish reasonable guidelines written by psychiatrists about the practice of psychiatry.  The introductory material suggests that the method will be to modify the various sections, but what is needed is another section or probably a new guideline on treatment planning and how that interfaces with the Evaluation Guideline.   

George Dawson, MD, DFAPA

1:  APA Work Group on Psychiatric Evaluation.  The American Psychiatric Association practice guidelines for the psychiatric evaluation of adults — Third edition.  American Psychiatric Association, 2015.

2:  Thomas G. Gutheil,  Paul S. Appelbaum.  Clinical Handbook of Psychiatry and the Law,  3rd Edition.  Lippincott, Williams, and Wilkens, Philadelphia, 2000. p. 299.      

What Can The APA Learn From UpToDate?

By way of introduction UpToDate is a highly successful online internal medicine text.  It has associated features such as handouts for patients on medications, procedures, and medical conditions.  It also has an online drug interaction feature that allows a limited set of preferences on the part of the physician.  CME credits are available for reading online.  The text covers a broad range of diseases and conditions.  I have asked them for more specific data on the extent of their coverage and total number of pages, but they refused to give it to me citing that it was proprietary information.  I noticed that they currently say that they have 77,000 pages updated by 5100 physicians.

I have been a subscriber to this service for a number of years and the subscription rate is currently about $500/year.  To illustrate how important that number is I need to compare UpToDate to what it replaced.  Ever since graduation from medical school I purchased a new internal medicine textbook about every 4 - 5 years.  I was also a 20+ year subscriber the the Medical Clinics of North America.  I considered it all a part of keeping up on general medicine while practicing psychiatry.  The cost of a typical medicine text like the last one I purchased Textbook of Internal Medicine (William N. Kelley, MD, ed) was somewhere in the $200+ range.  Searching Amazon it looks like my text is out of print by the two comprehensive texts are available for $224 (Harrison's) and $151 (Goldman-Cecil).  Doing the math shows that for $200 you can get a serviceable text that might last you for 5 years (it goes without saying that you always have to do additional reading) and at the end of the day - you still have text in your hand and a valuable reference.  That same 5 year period as a subscriber to UpToDate will provide you with online access of updated data and at the end of that time unless you renew - it is all gone.  Granted it is handy to have this available online if you are working in a hospital setting on different units and the CME feature is very nice - but the cost is about $2500 or twelve and a half times as much as a text every 5 years.

The premium cost in UpToDate relative to a medicine text probably has many things driving it.  The advent of the hospitalist in combination with the electronic health record are probably two of the most significant factors.  If you have internists working 10 hour days 7 days on and 7 days off across large hospitals suddenly there is not time to go to libraries and do research.  All of the information needs to be available as they are essentially word processing documents in the EHR at computer terminals.  In case you haven't tried it, it is also much easier to electronically search a textbook than to heft its considerable weight and keeping flipping flimsy pages back and forth from the index.  Many large groups now provide UpToDate online to their hospitalists and medical specialists in order to keep them working right at those word processing terminals.  These same hospitalists consulting on my inpatient psychiatric unit introduced me to UpToDate when it first came out.

How does all of this this apply to the currently dated and I am guessing infrequently used American Psychiatric Association (APA) Practice Guidelines?  Just looking at the dates of these guidelines shows that applying my approach to internal medicine by purchasing a new text every 4 or 5 years, would have left me more up to date with a psychiatry text than the current APA Practice Guidelines.  What about content in UpToDate?  There are 13 chapters on the major psychiatric disorders that psychiatrists treat.  There are several subheadings under the major headings.  For example, under the heading Anxiety Disorders there are chapters on acute procedure anxiety, acute stress disorder, agoraphobia, combat operational stress,  comorbid anxiety and depression, co-occurring substance use disorder and anxiety, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, and social anxiety disorder.  There are separate chapters on the pharmacotherapy and psychotherapy of these disorders including fairly esoteric approaches to treatment like deep brain stimulation for obsessive-compulsive disorder.   The sections are all detailed and frequently updated.  Not only that but the recommendations section is essentially written as treatment guidelines.  As an example from that section (1):

"We recommend that patients with obsessive-compulsive disorder (OCD) be treated with cognitive-behavioral therapy (CBT), a selective serotonin reuptake inhibitor (SSRI) medication, or both (Grade 1A)."

Their definition of  Grade 1A Recommendation is:

"A Grade 1A recommendation is a strong recommendation, and applies to most patients in most circumstances without reservation. Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present."

This is the general outline of the psychiatric disorders section in UpToDate.  From the sections I have read their literature review and section updates are all within the last 1-2 months and some of the sections are written by top experts in the field.  The detail is well above what an internist or family physician would need but I would not say it is less than what most psychiatrists need.  It gives practical advice on what is known about the treatment of psychiatric disorders and it is condensed down to about 4 - 12 bullet points at the end of each section.  Solid recommendations are made on management where possible and the recommendation is also graded as to whether or not there is good research to back it up.

What is the importance of these developments for psychiatrists, organized psychiatry, and medicine in general?  I think there are a number of important points.  First, psychiatry is represented in a text that is read by internists and family physicians to a greater extent and in more detail than ever in the past.  This is good for several reasons.  It provides some guidance to primary care physicians in considering the treatment of patients with complicated psychiatric problems at time when there may be fewer psychiatrists covering their patients.  It provides them with technical details that are needed to provide care.  It makes it easier for them to assume the care of patients who have be correctly diagnosed but can no longer be followed by a psychiatrist.  Overall it is good for the idea that psychiatry is a mainstream speciality in the field of medicine.  Second, it brings up the critical question of why the APA has a web page with the APA Practice Guidelines listed at all?  Most are hopelessly out of date.  They have little public visibility.  There have been some opinions that the time for practice guidelines by professional organizations are a thing of the past.  After all, managed care organizations and governments write the guidelines now don't they?  A secondary question is what is the purpose of a professional organization?  In my most read post on this blog, I suggest that it is to propose and disperse state-of-the-art treatments to its membership ("There is a responsibility to establish professional standards for patients referred to psychiatrists for the assessment and treatment....").  Certainly there was a recent opportunity.  An expensive effort bringing together top experts in all fields from around the world was done to compile the DSM-5.  The public was clearly confused about this project when the press and several critics equated the DSM-5 to treatment rather than diagnosis and misread the DSM-5 as being something more than it really is - a guidebook to the International Classification of Diseases.  I have seen experts from that collaboration speak at two conferences now and they happen to also be experts in the treatments of these conditions.  Would it have been wise to update the treatment guidelines in the manner of UpToDate rather than leaving the effort at the level of the DSM-5?  I think that it probably would have.

I brought this issue up recently and was told by people at decision making levels in the APA that they are rethinking the Practice Guidelines from a cost effectiveness standpoint.  My thinking on this is very clear.  If the APA does not want to represent the membership as a union dedicated to advancing the rights and interests of the members from that perspective then it really needs to present itself as a professional organization.  APA members certainly don't enjoy the benefits typically seen when businesses or unions lobby Congress.  If anything psychiatry and medicine has been in an unchecked downward spiral of overregulation and exploitation from businesses for about 30 years now.  The argument is typically made that we are a professional organization and focus on professional education and accountability.  Practice guidelines demonstrate that you have the expertise and wisdom to make that claim.  The APA can no longer say that.  There are more succinct treatment recommendations written by experts and more frequently updated in an online text that targets nonpsychiatrists.

I will be the first to suggest that  this is bad for the profession for a number of reasons and further evidence that the APA is doing very little to advance the profession and the plight of its members.  The current guidelines should be removed (at least the dated ones) and the organization needs to think about a streamlined process to construct new ones or get out of the practice guideline field.  



George Dawson, MD, DFAPA    

References:

1:  Simpson HB, Stein MB, Hermann R.  Pharmacotherapy for obsessive-compulsive disorder.  In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on February 21, 2015.)