An Excursion into the Psychiatric News - Blurred Lines Between Business and Professional Organizations

Psychiatry Eclipsed

Before anyone says that this is me going off the rails again - consider one small factor.  For over 30 years I have been paying the American Psychiatric Association (APA) significant amounts of money in annual dues.  Last year it was about $935.  During some of those years, I thought it might be useful to also donate to their political action committee and I gave them significantly more money.  All the time, I was expecting something to reverse the inexorable deterioration in the practice environment  and the rationing of mental health services.  During that time, I witnessed first hand the deterioration of psychiatric services in the state of Minnesota to the point that there is now a mandate that county sheriffs have priority in admitting their mentally ill prisoners to state psychiatric hospitals.  The psychiatrists in the state have no say in who gets admitted to these facilities or the severely rationed number of inpatient beds in the state.  The reason for professional organizations as I understand them is to speak for and advance the profession, support its members and advocate policies that benefit the people that interact with the profession.  In the case of psychiatry that is the patients that we treat, their families, and the larger society.  All I have to do is pick up a copy of the Psychiatric News to doubt that these mandates are very relevant anymore.

I will say in advance that in my assessment the APA does a fair job in terms of education and professionalism.  I have criticized them in this area in the past for not keeping the treatment guidelines up to date and relevant.  Subsequent to that there was a new guideline published.  Access to the educational materials is not contained in the membership dues.  A subscription to Psychiatry Online or the CME Journal Focus are additional charges as are CME credits for reading articles in the American Journal of Psychiatry.  There is also a CD version of courses and presentations at the APA Annual Meeting that is available for a significant cost.  The educational and professional materials are definitely available and some of them are first rate - but they do come at a price.

My biggest problem with the APA has been the total lack of rigor in countering the deterioration of the practice environment and in many cases seeming to directly participate in initiatives that are counter to the interests of psychiatrists and their patients.  Thumbing through the September 16, 2016 edition of the Psychiatric News provides some ready examples.

On page 1, there is a story Everett Appointed head of New SAMHSA Office.  The story is all about APA President Elect Anita Everett, MD assuming a new position as chief medical officer at SAMHSA - the lead federal agency for mental health and substance use treatment.  A direct quote from Dr. Everett: "Having a psychiatrist as a member of the leadership team at SAMHSA will enable psychiatrists to join other mental health and public health professionals in guiding the federal component of the nation's behavioral health systems."  My emphasis on behavioral health.  As far as I am concerned SAMHSA is a pro-managed care government bureaucracy - like most of them.  Secondly, there are plenty of psychiatrists out there who have been chief medical officers for managed care companies and I would challenge anyone to tell me why they are necessary and what they have accomplished.  Managed care companies tell psychiatrists what to do.  They are not interested in a reasonable practice environment, reasonable inpatient settings of even professional standards.  They are interested in cheap, rationed care by overworked clinicians.  I don't doubt Dr. Everett's qualifications or good intentions.  I don't think I am going out on a limb too far to say that she is going to be severely restricted by the current bureaucracy with a strong managed care bias.  That is not good for psychiatrists and it certainly is not good for patients.

The other story on page 1 seems worse - Are Psychiatrists prepared for Health Care Reform?  Yes and No.   I really can't think of a more nauseating term in the medical literature than health care reform.  I have been hearing those hot little words for the entire length of my career.  I heard them from the Clintons back in the days when Hillary Clinton headed up the health care reform efforts during the first Clinton presidency.  Some students of the topic like to recall that for one reason or another the initiative worked on by Hillary Clinton was not successful.  I think that depends on the standard.  There certainly was no expected global program, but it did make managed care a household word and set managed care as the predominant bias in all further discussions of health care reform.  Like most history - people seem to have forgotten this and the Clinton administration (and all that followed) as having a strong managed care bias.  The article suggests that psychiatrists need to get on board with the collaborative care model - another managed care rationing technique.  In the span of 3 decades psychiatry has gone from protesting managed care rationing (especially because it affects us and our patients the most) to suggesting you really have to get on board with this.  The usual buzzwords like further workforce development and merit-based payment reforms are evident.  When professional standards are abandoned what is merit-based payment reform? In all likelihood it has to do with rationing techniques rather than quality medical care.  Paragraph after paragraph in this article read like a managed care playbook.  Maybe the only way to see through all of this pro management rhetoric is to have actually worked in one of these systems of care.  Try working in one with a manager who is reimbursed to extract the maximum amount of productivity while not providing resources to physicians in the system.  In that case I believe the management buzz word is creativity.  In a rationed environment there is often an audacious statement about creativity as a solution rather than additional personnel.  Most reasonable people would be shocked at what constitutes merit-based payment or the hold back procedures before you can get to that level.  Just another in a long line of meaningless cliches flowing from health care reform.

As you might imagine I was a little tense and clammy as I went on to page 2.  There I was an editorial piece by APA President Maria A. Oquendo, MD.  It was title Why 'Physician Heal Thyself' Does Not Work.  I was mildly optimistic that she might come to the same conclusion that I have about physician burnout - it is not a disease it is just bad management.  Dr. Oquendo began  with a description of the recent suicides of a psychiatric resident and a medical student.  She presents the epidemiology of physician suicide and suicidal ideation.  She points out for example that suicide is the second leading cause of death for physicians between the ages of 24 and 35.  She discusses the stigma of a psychiatric diagnosis and the gap between problems and who gets treated.  Her solution is self identification of depression and excessive alcohol use.  There seem to be other factors that are operative.  She quotes a six fold jump in PHQ-9 scores during internship - using that as a metric for depression.  I can't help but think how physicians and trainees are more isolated now than ever.  No matter what the setting we had great teams when I was an intern and resident.  We took care of one another and we had attending physicians who cared.  I addressed some of that in my previous burnout article.  Nobody discusses what it is like to train in a managed care and rationed environment today compared with medical care as usual in the past.  During my last stint in a hospital I did not see well developed teams anywhere.  Most of the senior physicians who did a lot of the teaching and tended to view themselves as affiliated with residents had been replaced by hospitalists.  Entire teaching services had been replaced.  Non-medical management has left many medical institutions very arid places with few personnel and limited collegiality.  That is exactly the wrong environment for depressed and stressed physicians.   Training programs everywhere can help residents by making sure they build collegiality and that team factor in all of their rotations.  They need to provide highly motivated faculty who have the interests of trainees in mind as a priority.  The teams I am referring to here are teams of physicians, not teams that contain administrative staff telling physicians what to do.

The article most directly related to managed care hegemony was "Medical Necessity in Psychiatry: Whose Definition Is It Anyway? by Daniel Knoepflmacher, MD.  The title is of course purely rhetorical.  Like many things in medicine today medical necessity has nothing to do with medicine.  It is a pure business definition designed to give the appearance of legitimacy to what is a pure business driven decision.  The decisions are made by people with no appreciation of human biology or its complexity.  They are people who seem to think that a lot of meaningless business metrics somehow apply to the practice of medicine.  At the worst (and most probable) they are simply rationing to make a profit.  I would call them nerds but I really don't think that they are that smart.

In the article, Dr. Knoepflmacher makes that point.  There is not even a standard business definition of medical necessity.  Companies can basically say and do whatever they want.  He traces the history of the term and how various groups define it today.  Interestingly one of the largest managed care companies states that it is for payment purposes only.  He points out the overemphasis on acute or crisis care rather than professional guidelines or standards.  I would argue that in psychiatry, managed care companies do a very poor job of addressing acute care by using only a dangerousness metric.  The term cost effectiveness is incorporated into some of the definitions in the 1960s.  The acclaimed Mental Health Parity and Addiction Equity Act of 2008 lacks any definition of medical necessity or a more useful definition of medical appropriateness.  That may explain why this legislation has had negligible impact.  Dr. Knoepflmacher's thesis can be best summarized in the sentence:

"Without universal medical necessity criteria for mental health care, clinicians and their patients are saddled with a concept highly susceptible to abuse by insurers."

I would take it a step further.  The abuse has been institutionalized at this point.  Clinicians find themselves abused at every fork in the road.  Any time a psychiatrist refills a medication for a colleague or because the treatment setting has changed they are subjected to abusive prior authorization processes that are in place purely to harass physicians into giving up and patients to the point that they are paying out of pocket instead of using the insurance they have paid for.   In that case Congress is directly responsible for erecting two multibillion dollar industries and inserting them between the physician and their patient.  I would also propose a much better limit than arbitrary medical necessity criteria.  It should be apparent that any managed care company can get around legislation and rules that they lobbied to pass.  I propose that physicians recommend a course of treatment to patients and that they are totally removed from the payment process.  No more wasting time with insurance company employee-reviewers.  No more conflict of interest in favor of big business.  The physician recommends treatment.  The insurance company tells the patient if they will pay for it.  Other than civil action by the patient, the only oversight should be a panel of physicians carefully screened for conflict of interest at the state level to mediate disputes (sorry no insurance industry insiders).

Highlighting these four articles creates a portrait of what is wrong with the APA.  Like other professional organizations it has clearly bought into the pro-management zeitgeist that is generally sold by American businesses and government.  The general idea is that there are business managers that know more about what you do and can tell you what to do - irrespective of your professional training and experience.  That idea is a mile wide and an inch deep.  Anyone with middle school analytic skills should have come to the same conclusion as Dr. Knoepflmacher - about 20 years ago.  His article is there now as a necessary reminder that there is a much better way to do things.  Instead of affiliating with these outrageous business practices - they should be actively resisted at every level.  That should include the practice and training environments.  There is nothing worse for physicians and patients than wringing the humanity out of medical practice.

And there is nobody better at doing that than current healthcare business managers.


George Dawson, MD, DFAPA



Attributions:  The graphic is all me.  It is supposed to represent a progressive overlap by government and business interests with the profession.  There are psychiatrists that work in the overlap areas and some who work just in the black and gray zones.  The field is still plodding along as though it is an autonomous profession.  

APA Misses On The Opioid Crisis - Several Times

The above infographic is courtesy of the CDC (see attribution for the direct link).  To those of us involved in treating addictions talking with many people who are addicted to opioids, getting them to see the problem, and helping them prevent accidental overdoses and death is an everyday occurrence.  The prescription opioid problem is widespread and has been a reality for the last 15 years even though it seems to have hit the news in about the last 5.  That probably coincides with heroin use starting to escalate.  The driving force for that has been economics.  Heroin is generally available in most areas for about a quarter the cost of diverted prescription painkillers.  In the past 5 years I have probably given about 50 lectures on the topic to physicians and graduate students and been actively involved in the clinical care of individuals with heroin addiction only or heroin addiction in addition to a number of other addictions.

When I got a post from the American Psychiatric Association (APA) on my Facebook feed last week it piqued my interest.  Part of what I teach is how failed policy is the root cause of the opioid epidemic and what physicians can do on an individual basis to correct the problem.  I was very interested to see what the APA had to say at a policy level.  Reading through the document that is really a blog post from the Medical Director the answer is "not much".  It appears that the APA has joined a Task Force of other professional organizations that includes that other great laggard the AMA.  They will be working to identify "best practices" and implementing them as soon as possible. Using Prescription Drug Monitoring Programs (PDMPs) is encouraged.  There will also be the focus on stigma.  Dr Levin states: "The APA maintains that substance use disorder is a medical condition that can be successfully treated, and we are actively advocating on behalf of the patients who are too often stigmatized by their community and disenfranchised by insurance carriers who fail to comply with mental health parity laws."

While there is no doubt that most people are biased against people with mental illness and addictions as well as their psychiatrists - I don't think that stigma has any traction in terms of increasing access to care or more importantly access to quality care.  I could argue that the APA support for the collaborative care initiative colludes with stigma-like biases.  That takes the form of "you don't have to see a psychiatrist - take this checklist instead."  I won't get into that today, only to say that I wonder how many people with heroin or opioid addiction are being seen in primary care clinics and being treated for anxiety, insomnia, or depression?  From what I see the numbers are significant.  But it is hard to fault primary care doctors because unless they are the prescribers of opioids, they may not realize that their patient has a problem with them.  There is also the issue of institutional stigma versus public stigma.  Public stigma or the type of stigma that everyday people have is more elastic and it usually depends on their experience with the problem.  If you live in a family where a member has a severe mental illness or addiction - you know that these problems are real, life-threatening, and you are ready to let people know that.  Institutional stigma is the type of stigma that governments and businesses can have, especially health care businesses.  They might grudgingly admit that there is some kind of problem largely because there is such a large secondary impact on medical and surgical services.  In some trauma centers over half of all admissions are primarily due to drug and alcohol problems.  At the same time,  institutional stigma is impervious to change.  It is codified in some texts on healthcare management and as noted in the APA blog post - not even amenable to change when new federal parity laws are implemented.  In terms of managing health care systems there is nothing like having a certain groups of disorders to shift resources away from in a pinch.  Mental illnesses and substance use disorders are that group.  The other considerations would include:

1.  Irrational policy initiatives:  There is no doubt that several policy initiatives to liberalize opioid prescribing were responsible for the start of this epidemic in or around the year 2000.  Making pain the "fifth vital sign", encouraging the use of opioids for chronic non-cancer pain, treating minor conditions with opioids, and a widespread policy initiative that encourage more aggressive treatment of pain even though specific measures were not know are among these initiatives.  I use the word irrational here to mean speculative initiatives that were not based on science.

2.  A serious misunderstanding of the current problem:  When all else fails blame physicians.  That is a highly effective political strategy that worked to consolidate control of the health care system under business and government.  To many of the politicians involved it flowed directly from their negative campaigning experiences.  In this case, the opioid problem is being framed at some level as a problem of inappropriate prescribing by physicians.  Some physicians are being subjected to criminal prosecution for deaths and complications that have resulted from opioid prescribing.  There are no references to the policy changes that occurred in the late 1990's that led to this change in physician prescribing behavior - the loss of gate keep functions in particular.

3.  A misunderstanding of the epidemiology of the problem: The upper decile of opioid prescribers (total number of prescriptions) account for 50-60% of all opioid prescriptions.  These prescribers are almost all family physicians, internal medicine specialists, and mid-level prescribers.  Available databases allow for rapid identification and intervention with these prescribers and that is where resources should be focused and not on all physicians across the board.  A mechanism for feedback on an individual physician's or physician extender's ranking in terms of their prescription of controlled substances is needed as well as individual access to that information.

4.  A serious misunderstanding for the overprescribing problem in general exists: As I have previously pointed out, opioids are one small group of medications that are overprescribed in the US.  Practically everyone who wants this problem to go away sees it as a cognitive problem or knowledge deficit.  If the physician involved just knew more they would not prescribe pain medications this way.  In fact, it is a much more complicated interpersonal, social and intrapsychic problem for physicians.  Until there is a widespread acknowledgement of this - all of the CME courses in the world on appropriate opioid prescribing will not change a thing.

5.  There is a widespread cultural problem:  Opioid hoarding in medicine cabinets across the country, neighbors sharing opioids and neighbors and family members discussing what is the best (translation best = most euphorigenic) is a major problem in the US.  Many politicians have agreed that America's "insatiable appetite for illegal drugs" fuels the international drug trafficking problem.  It also fuels the opioid epidemic.  There are very few initiatives focusing on cultural change.

6.  Misunderstanding the problems inherent in prescribing addictive drugs:  Most physicians are not aware of the unconscious and conscious elements that are activated in susceptible individuals when they take addictive drugs.  There are widespread misconceptions in this area that lead to the prescription of addictive drugs during active addiction,  not assessing the risk of prescribing addictive drugs to a person in recovery, and failing to assess some of the indirect signs of addiction in patients who deny that they have a problem with addiction.  There is also a belief among many physicians that if their goal is to help people that well intended prescribing will not lead to problems in the future.  

These are 6 areas that the APA could be focused on.  I don't think that you will see that analysis anywhere else.  I expect that "best practices" will fall disproportionately on the average physician and be a waste of time on their time and energy.  But it does fall back on the time honored political strategy of taking the heat off of the people who really failed and pretending it is a physician based problem.


George Dawson, MD, DFAPA


Attribution:

The infographic is from the CDC at this URL:  http://www.cdc.gov/vitalsigns/heroin/infographic.html#use

The CDC has done great work in this area and their site should be closely monitored for new data relevant to the problem.

How Should APA Guidelines Work?

The guidelines of the American Psychiatric Association (APA) are an interesting story in how guidelines are important if used correctly by professional organizations.  The whole idea behind a profession is that the practitioners in that area have special expertise and that the expertise is standardized to some degree.  Standardization is useful in the case of physicians to assure the safety of the practitioners and so that people have some idea of what to expect in terms of safe and effective care.  Over a decade ago the APA began producing guidelines for practice in various areas of the field.  I thought it was an exciting development.  The guidelines were initially sent along with the monthly copy of the Journal of the American Psychiatric Association.  All of the guidelines are available publicly on this web site, but hardly anyone knows about them.  I make this statement because one of the many red herrings that the critics of psychiatry use is that psychiatry has no standards of care.  They seem quite shocked to find that these guidelines exist and address their complaints directly.  

I was asked to critique one of the existing guidelines and suggest how these guidelines could be used more effectively.   In looking at the guidelines web site, it is apparent that some of the guidelines have not been updated in quite a while.  Publication dates range from 2000 - 2010.  Given the pace of clinical research 5 years might be somewhat acceptable, but 10 - 15 is probably not.  Another issue that the APA needs to grapple with is the diagnostic manual versus treatment approaches.  There is widespread confusion about whether or not the DSM-5 is a guidebook for treatment as opposed to a guidebook for diagnoses.  The APA actually two approaches to treatment guidance - the guidelines themselves and a text entitled Treatment of Psychiatric Disorders (TPD).  TPD is currently in its 4th edition and it has gone from a series of two volume detailed text to a more basic single volume text.  That text was published in 2007.  Some of the chapters in the previous editions provide some of the most detailed information on the pathophysiology and treatment of certain disorders that could be found anywhere.  At that level of analysis, the APA has gone from providing outstanding information on the pathophysiology and treatment of psychiatric disorders to a relative vacuum over the past 10 years.

For the purpose of a more detailed analysis I will consider the Practice Guidelines on Substance Use Disorders and the associated Quick Reference Guide and Guideline Watch - a 2007 update of the original 2006 guideline.  I looked at the Guideline Watch first because it should reflect the latest literature reviews and treatment guidelines.  The document reviews medication assisted treatment of tobacco and alcohol use disorders with varenicline, naltrexone and acamprosate.  The document was a good summary of the literature at the time but it needs a serious update.  Since then there have been more extensive studies of the genetics, combination therapies, re-analysis of existing studies and side effects of naltrexone, acamprosate, and varenicline including use in specific psychiatric populations.  In at least one case, the current literature supports a course of action that is exactly the opposite of what is recommended in this document.  That course of action is: " Given its high potency and partial agonist activity at central nicotinic acetylcholine receptors, varenicline should not be combined with alternate nicotine replacement therapies."  An inspection of the references for varenicline notes that additional research has been done in this area and should be discussed.      

The Quick Reference Guide contains extensive tables from the original guideline so I will go directly to that document.  At first glance it looks like a significant document more than 200 pages long.  But about 177 of the 276 pages of the document are relevant text.   The rest are references and polls of various expert groups on what they consider necessary for a guideline.  Looking at the Table of Contents, the first thing that is apparent is that only a subset of substance use disorders is being considered.  Although it is likely that nicotine, alcohol, marijuana, cocaine and opioids represent the majority of abused substances psychiatrists treating addiction see a broader array of compounds being abused.  The full gamut of abused compounds should probably be addressed in the guideline whether or not there is a consensus about treatment methods or not.  The safety of users and treatment setting considerations will still need to be considered as well as the need for further assessments.  A good example would be Hallucinogen Persisting Perceptual Disorder and what might be the best assessment and treatment.  If the guidelines are supposed to apply to clinical practice then patterns encountered in clinical practice need to be addressed.  If the APA does not address them - governments and managed care companies will, most frequently to the detriment of patients.

The guideline uses the following conventions for the treatment recommendations.  They are conventions frequently see in professional guidelines:

[I] Recommended with substantial clinical confidence.
[II] Recommended with moderate clinical confidence.
[III] May be recommended on the basis of individual circumstances.

The introductory section does not suggest who the guidelines are written for.   This is a critical aspect of the document.  There is an implication that it is for psychiatrists based on the statement about a comprehensive psychiatric evaluation but I think that needs to be more explicit.  It is not uncommon for managed care companies to send letters that deny care to psychiatrists.  The letter often contains a list of guidelines that an insurance company reviewer used to deny the care.  The APA needs to be explicit that these guidelines are intended for use by the psychiatrist who has personally assessed and is treating the patient and not by an insurance company employee or contractor who is sitting in an office reading through paperwork.  Somewhere along the line professional organizations seem to have lost track of the concept that only direct assessment and treatment of the patient was considered the correct way to do things.  Putting it in all guidelines is a critical first step.

The next thing I would change in terms of guidelines is breaking out the treatment setting recommendations into separate sections in table form.  For example the Hospitalization guidelines are copied into the Supplementary section of this post.  They are all very appropriate and I doubt that there are any reasonable clinicians that would have a problem with them.   The problem is that these services are rationed to the point that it is difficult for any reasonable clinician to implement them.  By that I mean that a psychiatrist cannot get a patient meeting these criteria into an inpatient detox or treatment setting based on these criteria.  As an example, consider the patient who says they are drinking 1 liter to 1.75 liters of vodka per day for 6 months.  They describe uncomplicated symptoms of alcohol withdrawal (shakes, sweats, hangover symptoms and drinking in the morning to suppress these symptoms).  I think the person in this vignette meets criteria 2 for hospitalization and detox at least.  A significant number of patients presenting to emergency departments with this pattern of findings are not hospitalized.  Many are sent out with a supply of benzodiazepines to detoxify themselves.  Many are sent to county detox facilities where there is no medical coverage or so-called social detoxification settings.  None of these non-hospitalization options are realistic approaches to the problem.  Giving a person with an alcohol use disorder a bottle of benzodiazepines for home detox ignores the uncontrolled use and cross addiction aspects of the primary disorder.  It is highly likely that person will ingest the benzodiazepines all at once or use them to treat the morning withdrawal symptoms of the disorder.  Social detoxification is an equally suboptimal approach.  It depends on probabilities.  It is more likely that the person transferred to that setting will leave due to the adverse environment and go back to drinking or undergo withdrawal and not experience delirium tremens or withdrawal seizures.  Over the past 30 years, the managed care industry has refused to consider admissions in practically all of these situations often whether there was psychiatric comorbidity or not resulting in the rationing of care at the initial assessment in the Emergency Department.  There must be an awareness that clinical guidelines don't operate in a vacuum.  Having a guideline in place that nobody can use is not the best approach to providing quality care.   Managed care companies can deny inpatient care on practically any of the 7 inpatient criteria simply by saying that they do not exist.    

On the treatment side there are inconsistencies noted in the recommendations and editing problems.  For example, there are 49 references to "12-step" and 2 references to 12 steps.  One of the first statement one encounters is:  "The efficacy of treatment is related to the amount of psychosocial treatment received. The 12-step programs, hypnosis, and inpatient therapy have not been proven effective."  That characterization of 12-step recovery is inconsistent with just about every other reference in the document.  Where it is suggested it is footnoted with a "I" designation or "substantial clinical confidence."

Rather than critique other sections based on data that was not available at the time that this guideline was posted, I thought I would end with a comment on the process and general philosophy of professional guidelines.  Right at the top of this guideline is a section entitled "Statement of Intent".  The crux of that argument is contained in the paragraph (p. 5):

 "The American Psychiatric Association (APA) Practice Guidelines are not intended to be construed
or to serve as a standard of medical care. Standards of medical care are determined on
the basis of all clinical data available for an individual patient and are subject to change as scientific
knowledge and technology advance and practice patterns evolve. These parameters of
practice should be considered guidelines only. Adherence to them will not ensure a successful
outcome for every individual, nor should they be interpreted as including all proper methods
of care or excluding other acceptable methods of care aimed at the same results........"

I don't really agree with that approach.  The concerns about saying that these are standards of care is a medico-legal one and I have rarely found that to be a sufficient basis to practice medicine.  An example would be litigation against a psychiatrist for not following the stated standards of care in a malpractice suit.  This may seem protective of psychiatrists for varying practice styles but it also has the more insidious effect of basically allowing any standard of care to apply.  A walk down the street to a different hospital results in an admission for medical detoxification when the first hospital discharges the patient with a prescription of lorazepam and a promise to follow up with their primary care MD.  The resulting business incentive practice creep results in a complete lack of detoxification and a lack of any standards of medical care.  The default standard is whatever businesses decide to pay for.  My observation is that results in an unacceptable level of medical care.  And further:

"The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment
options available....." 

I agree with the statement but let's face it,  the judgment of the psychiatrist frequently has very little to do with the judgment of the psychiatrist or what options are ultimately considered in the working alliance with the patient.  Practically all inpatient and residential care these days is dictated by managed care companies and insurance companies irrespective of what a psychiatrist would recommend or a patient would accept.  These are standards of care that are forced on psychiatrists and patients rather than the prospective quality based standards.

Stepping back from that fact medical standards play a peripheral role to what businesses want and that unacceptable standard has been present to one degree to another for the past 30 years, I don't think a new approach in guidelines is too much to ask for.  I don't think it is too much to ask that APA guidelines be up to date, internally consistent, inclusive, actually apply as a standard of care as opposed to using business standards as the default, and be used to advocate for the best possible treatment settings for psychiatrists and their patients.  There are a number of specific methods that can be used and I will discuss them when the draft version of the latest  Practice Guidelines for the Psychiatric Evaluation of Adults comes out this year.


George Dawson, MD, DFAPA


References:

Work Group On Substance Use Disorder.  Practice Guideline For TheTreatment of Patients WithSubstance Use Disorders,  Second Edition.  American Psychiatric Association.  This practice guideline was approved in December 2005 and published in August 2006.


Supplementary 1:   These are the hospitalization guidelines from the APA Substance Use Disorders Guideline.

"Hospitalization is appropriate for patients who 

1) have a substance overdose who cannot be safely treated in an outpatient or emergency department setting

2) are at risk for severe or medically complicated withdrawal syndromes (e.g., history of delirium tremens, documented history of very heavy alcohol use and high tolerance); 

3) have co-occurring general medical conditions that make ambulatory detoxification unsafe; 

4) have a documented history of not engaging in or benefiting from treatment in a less intensive setting (e.g., residential, outpatient); 

5) have a level of psychiatric comorbidity that would markedly impair their ability to participate in, adhere to, or benefit from treatment or have a co-occurring disorder that by itself would require hospital level care (e.g., depression with suicidal thoughts, acute psychosis); 

6) manifest substance use or other behaviors that constitute an acute danger to themselves or others; 

or 

7) have not responded to or were unable to adhere to less intensive treatment efforts and have a substance use disorder(s) that endangers others or poses an ongoing threat to their physical and mental health [I]."      (p.  11).

Nice Survey - Wrong Conclusion

There is a survey study of ease of getting and appointment with a psychiatrist in this month's Psychiatric Services.  The researchers called psychiatrists offices in three major cities in order to get an appointment.  They wanted to assess the degree of difficulty and whether or not payer source would be a factor.  Of the total calls only about 25% resulted in an appointment.  The reasons are listed in two tables in the article that is available on line.   Interestingly  there was no big difference  between private pay payer sources and insurance or Medicare in terms of getting appointments.  Given the movement of psychiatrists out of employee systems and Medicare based systems that was surprising and suggests to me a possible sampling flaw in the study or an artifact of the low return rate.  The flaw could be that the researchers looked at a Blue Cross Blue Shield (BCBS) web site and called lists of in-network providers in Boston, Houston, and Chicago.  The authors in this case do a reasonable job analyzing their limited data.  In their discussion of possible solutions they fall short of possible solutions.

In this case a key assumption is that the inability to set up appointments with psychiatrists implies there is limited access and this in turn means a shortage of psychiatrists.  We are hearing this argument at a time when managed care organizations like BCBS are basically saying that patients can receive psychiatric care in a primary care clinic.   In fact, BCBS was one of the early adopters of the PHQ-9 based Diamond project, where PHQ-9 scores formed the basis of a depression diagnosis in primary care clinics and the focus was optimizing antidepressant prescriptions based on those scores.  Where does an appointment to see a psychiatrist fit in that type of care?  Does collaborative care mean collaboration with a psychiatrist for every 500 or 1,000 or 10,000 primary care patients with an elevated PHQ-9 score?  Are patients in systems of mass care likely to seek psychiatric consultation?  In many algorithms of similar integrated care, some systems are set up to avoid psychiatrists completely, including the psychiatrist who is doing the psychopharmacological consultation.   How would such a system of care bias patients against psychiatrists and would psychiatrists be more dependent on other referral sources? And most importantly, wouldn't we expect limited access to a group of psychiatrists designated as in-network providers for a managed care company?  This is after all what managed care companies do.  They provide disincentives for physicians to see patients.  Managed care is a rationing mechanism.  It does not surprise me at all that physicians operating in that environment are difficult to see.

The authors propose that there are a number of ways to get medical students interested in psychiatry and that this would potentially solve the problem.  I don't know how that would work if there are already psychiatrists out there who are either working too hard or not interested in seeing new patients or referrals.  There was also the issue of psychiatrists being listed with incorrect phone numbers in over 10% of the cases.  It would also be interesting to note if the psychiatrist contacted agreed that he or she was actually in the network of care being described.  Many psychiatrists have told me they were in networks or panels that they had never agreed to participate in.

As I have previously stated, I don't think it is a question of recruiting more people in to psychiatry.  That approach ignores the state of crisis that the field is in right now.  That crisis involves the government and managed care companies dictating what psychiatric care is.  It also involves the American Board of Medical Specialties dictating what they think psychiatrists need to do for ongoing professional education.  It involves professional organizations - both the American Psychiatric Association (APA) and the American Medical Association (AMA) abandoning their member practitioners for what appears to be short term political gain.  The first thing lost to the politicians and businessmen  has been the practice environment.  Being a physician is more and more like being an assembly line worker.  Physicians are accountable to managers with no medical knowledge and no professional standards.  All of these developments have clearly demoralized physicians.

Taking a look at one of the suggestions, an interesting one was the suggestion that exposure to psychodynamic therapy increases medical student choice of psychiatry as a speciality field.  There are a few problems with that theory that are consistent with the deterioration of the practice environment.  It is certainly unlikely that any trained psychiatrist would make their expected productivity numbers for employees by doing psychodynamic psychotherapy.  It is currently practiced strictly in private settings or as supplementary activity once the productivity expectations are met in other endeavors.  Some psychiatrists have a psychotherapy practice "on the side" of their main employment.  It is highly unlikely that hospital or clinic environments are psychodynamically informed settings anymore or that residents learn how to manage those problems.  Many of those environments are a set up for split treatment.  Using psychodynamic psychiatry to sell residency to medical students seems like an informed consent issue to me.   Sure we will train you in it and supervise you doing the therapy but good luck practicing it in the real world.  I could put together a program that medical students would flock to, but they would never be able to use what they learned in a dumbed down practice environment.

You cannot have a profession that allows itself to be defined by hack politicians and businessmen with their own for-profit agenda.  Unless organized medicine and psychiatry focuses on that basic element, everything else is rearranging chairs on the deck of the Titanic.  Successfully rationing care does not mean there is a shortage of doctors.  It may mean the doctors just find the cost of doing business with a particular insurance company so high that they would prefer to see fewer or no patients from that payer.

It is absolutely mind blowing to me that nobody else can see that.


George Dawson, MD, DFAPA

Ref:

Monica Malowney, Sarah Keltz, Daniel Fischer, J. Wesley Boyd; Availability of Outpatient Care From Psychiatrists: A Simulated-Patient Study in Three U.S. Cities. Psychiatric Services. 2014 Oct (early online release).

The Lancet has it about 40% right

The Critical Psychiatry blog listed a brief editorial in the Lancet commenting on the current state of affairs in psychiatry. The commentary describes psychiatry's current "identity crisis" as an international problem and cites recent comments by the American Psychiatric Association and the Royal College of Psychiatrists suggesting that psychiatry is not "scientific" enough, that it does not have a central role in medicine, that the image of psychiatry with other professionals is negative, and that the therapeutic interventions are weak. The conclusory statement is: “But more fundamental still, it is time for the specialty to stop devaluing itself because of its chequered history of mental asylums and pseudo-science, and to realign itself as a key biomedical specialty at the heart of mental health.”

The Lancet has it right in concluding that psychiatry has a long history of self-flagellation that continues right up until present times. The Lancet is also correct in concluding that the image of psychiatry is negative, and that was well-documented in the journal Psychiatric Treatment showing that press coverage for psychiatry is four times as negative as any other specialty. The remarks about the science of psychiatry, the lack of a central role in medicine, and weak therapeutic interventions miss the mark entirely. In fact, I think the only way an editor can lump all of those negatives together is the uncritical acceptance that all of the negatives about psychiatry must be true.

What the critics of psychiatry can never explain away is the fact that psychiatric treatment is effective. I have personally gone to work every day for over 20 years confident that I have been doing far more good than harm. When you are doing the same work for a span of decades rather than the time it takes someone to do a clinical trial and you are personally responsible to your patient and their family you need to realize that you are effective. If I did not think I was effective and doing a reasonable job for people I would have quit a long time ago.  I also work with hundreds of competent psychiatrists in my home state where being competent is the rule not the exception.

My personal sense of effectiveness is built on decades of watching people suffer. That happened before I was a psychiatrist. Many of those people were my own family members and neighbors with severe problems who did not have access to psychiatrists. They were treated by generalists and the treatment did not go well. In many cases it was worse than no treatment at all. When I was growing up, it was also a fairly common practice for counties to sequester people with mental illness at subpar facilities that were designed for containment.  In some cases that meant that people were placed in facilities that were also tuberculosis sanatoriums or “poor farms” for the indigent.  I think that many of us in the mental health field got into it to compensate for the deficiencies of the past.  Much of that “chequered” past has nothing to do with psychiatry at all.

Although the Lancet associates psychiatry with asylums it leaves out the fact that psychiatry invented the paradigm to care for people with severe mental illnesses in the community. That was the direct product of psychiatrists and their collaborators realizing that state-funded institutional care was completely inadequate. Psychiatry moved people out of asylums on a massive scale and helps them stay out.  At this time many of these programs have been in place for over 30 years.  These same programs are actively working on the health problems of the people that they serve.

The scientific basis of psychiatry has exploded in the past two decades.  The criticism of the “lack” of science in the field always astounds me.  The criticism often seems to flow from the lack of understanding of the process of science and how the scientific accomplishments within psychiatry are on par with other fields of science.  It also seems to ignore the fact that many prominent scientists like Kandel, Snyder and others are psychiatrists.

The idea that psychiatrists are ineffective seems to flow from the same biases.  Details about the effectiveness of primary care physicians are usually left out of that argument.  It is well known that 30-50% of complaints presenting to general medical and specialty outpatient clinics have no medical explanation even after extensive investigation. Other studies have shown that primary care physicians deliver error free care in uncomplicated situations 73% of the time and in complex situations 9% of the time.  It is really not possible for psychiatry to be worse than that and yet there are no movements critical of other specialities and those are specialities that generally have far more toxic treatments.

So we are left with an abundance of critics. The critics all have various motivations but one thing is clear and that is at least part of their agenda is not to recognize the fact that psychiatrists are currently effective,  care about their patients, and that their clinical practice really is not removed from the rest of medicine.  In order to recruit more psychiatrists, the best thing to do is expose students to psychiatrists working with patients and to follow those patients while they recover. It might be useful to expose them to the biases against psychiatry and why a lot of the criticism does not match reality.  The fundamental work for many psychiatrists is to stop devaluing themselves, but it also requires recognition that much of that devaluation occurs due to the uncritical internalization of criticism that is far from the reality of clinical practice.

George Dawson, MD, DFAPA

Psychiatrists work for patients - not for pharmaceutical companies

That should be obvious by anybody reading this post but it clearly is not. I have already established that there is a disproportionate amount of criticism of psychiatry in the popular media compared with any other medical specialty. The most common assumption of most of those critics is that psychiatrists are easily influenced by pharmaceutical companies or thought leaders who are working for pharmaceutical companies. There are many reasons why that assumption is incorrect but today I want to deal with a more implicit assumption that is that there is a drug that is indicated and effective for every medical condition.

In the field of psychiatry this marketing strategy for pharmaceuticals became prominent with the biological psychiatry movement in the 1980s. Biological psychiatrists studied neuropsychopharmacology and it followed that they wanted to apply their pharmaceuticals to treat human conditions. At the popular level initiatives like National Depression Screening Day were heavily underwritten by pharmaceutical companies and the implicit connection was that you could be screened and be treated with a medication that would take care of your depression.

From the perspective of a pharmaceutical company this is marketing genius. You are essentially packaging a disease cure in a pill and suggesting that anyone with a diagnosis who takes it will be cured. The other aspects of marketing genius include the idea that you can be "screened" or minimally assessed and take the cure. We now have the diagnosis, treatment, and cure neatly packaged in a patent protected pill that the patient must take.  The role of the physician is completely minimized because the pharmaceutical company is essentially saying we have all the expertise that you need. The physician's role is further compromised by the pharmaceutical benefit manager saying that they know more about which pill to prescribe for particular condition than the physician does. That is an incredible amount of leverage in the health care system and like most political dimensions in healthcare it is completely inaccurate.

The pharmaceutical company perspective is also entirely alien to the way that psychiatrists are trained about how to evaluate and treat depression.  Physicians in general are taught a lot about human interaction as early as the first year in medical school and that training intensifies during psychiatric residency. The competencies required to assess and treat depression are well described in the APA guidelines that are available online.  A review of the table of contents of this document illustrates the general competencies required to treat depression. Reading through the text of the psychopharmacology section is a good indication of the complexity of treating depression with medications especially attending to side effects and complications of treatment and decisions on when to start, stop, and modify treatment. Those sections also show that psychopharmacology is not the simple act that is portrayed in the media. It actually takes a lot of technical skill and experience.  There really is no simple screening procedure leading to a medication that is uniformly curative and safe for a specific person.

The marketing aspects of these medications often create the illusion that self-diagnosis or diagnosis by nonexperts is sufficient and possible. Some people end up going to the website of a pharmaceutical company and taking a very crude screening evaluation and concluding that they have bipolar disorder. In the past year, I was contacted by an employer who was concerned about the fact that her employee had seen a nonpsychiatrist and within 20 minutes was diagnosed with bipolar disorder and treated with a mood stabilizer, an antidepressant, and an antipsychotic medication. Her concern was that the employee in question could no longer function at work and there was no follow-up scheduled with the non-psychiatrist who had prescribed medication.  Managed care approaches screening patients in primary care settings increase the likelihood that these situations will occur.

The current anti-psychiatry industry prefers to have the public believe that psychiatrists and their professional organization are in active collusion with the pharmaceutical industry to prescribe the most expensive medications.  In the case of the approximately 30 antidepressants out there, most are generic and can be easily purchased out-of-pocket.  Only the myth that medications treat depression rather than psychiatrists keeps that line of rhetoric going.

George Dawson, MD

American Psychiatric Association.  Practice Guideline for the Treatment ofPatients With Major Depressive Disorder, Third Edition. 2010