Less Is Less - A World of Difference Between Psychiatry and Cardiology

I read Lisa Rosenbaum's opinion piece in this week's New England Journal of Medicine (1). She discusses both sides of the rationing coin. On the one hand, we don't want to reduce resources to the point that people do not get necessary care. On the other hand there are forces including financial incentives and the inability of physicians to tolerate the diagnostic uncertainty of not performing the necessary tests that lead to both increased cost and in some cases unnecessary risk to the patient. She provides an example from her personal medical history on forgoing a recommended test with no associated adverse outcome. A lot of the article is written from her perspective as a cardiologist or cardiology fellow. I can recall, the think tank studies from the 1980s suggesting that coronary artery bypass surgery was overutilized. There are many studies that suggest that medical treatment of coronary artery disease provides similar outcomes. Today we hear the same arguments about the treatment of the atrial fibrillation epidemic and the equivalence of rate control versus rhythm control. The options are presented as a coin toss to many patients. But in both cases it is much more than that. Anytime population based averages of care are applied across large populations there will be a significant number of people who do worse than the norm and may have done better with the other option. My concern has always been, the implicit pressure by healthcare companies to make money by exerting pressure in the direction of the least expensive option right up to including no care at all.

Dr. Rosenbaum discusses the "less is more" movement and the Choosing Wisely campaigns to reduce unnecessary care. She discusses the early role of the Dartmouth Atlas in pointing out the lack of correlation between cost of care and outcomes - a notion that has been discredited (2) but it was the mantra of administrators for nearly two decades.  She concludes that these movements resulted in the idea that "less care is better care or that more care is harmful."  She reviews more recent data that higher spending is associated with better outcomes. She includes recent research on unnecessary admissions and how Medicare beneficiaries discharge from the emergency departments (ED) of hospitals with the lowest admission rates were 3.4 times as likely to die with a week than similar patients admitted to hospitals with higher admission rates - even though those same patients were healthier.

She discusses overdiagnosis in cardiology. Unlike psychiatry, cardiology has a considerable array of biochemical markers, electrophysiological studies, and imaging studies that are very useful in the diagnosis and management of their patients. She illustrates the trade offs involved in considering false positives for troponin and how liberalization of the cut-off values leads to better diagnosis and treatment rather than overdiagnosis. In the area where I currently practice, the entire landscape for diagnosing and treating suspected acute coronary syndrome (ACS) has changed significantly. Nobody tries to guess if chest pain has a cardiac origin or not.  Middle-aged patients are generally admitted and tested with troponin levels and an exercise stress test the following morning if the troponins are negative. If the stress test is negative they are sent home. In most acute care metropolitan hospitals there is ample intensive care and telemetry space to accommodate all of these admissions. The cost of that overnight admission to cardiology exceeds the cost of a week long admission to an inpatient psychiatric unit with a psychosis diagnosis.

What is the parallel process on psychiatry? A patient in crisis presenting to an ED of a metro hospital in crisis has no similar guarantee of cautious screening. In the majority of cases they will never see a psychiatrist. In most cases the assessment and screening is done by nonphysicians. In addition, diagnoses and syndromes are generally secondary in the discharge process. The only way that patient gets admitted is dangerousness to self or others. That could be due to an acute intoxication, an emotional overreaction, a mood disorder, a developmental disorder, a neurodegenerative disorder, or a psychosis. The only thing that counts is the dangerousness. There are no biochemical markers or imaging markers of dangerousness. There is significant disagreement in many cases among clinicians, patients, and their families. If a person is admitted either voluntarily or on a legal hold - in any case they will typically find themselves sitting on a psychiatric unit until somebody determines that they are no longer dangerous. Hopefully they will see a psychiatrist and other skilled professionals like trained psychiatric nurses, social workers, and occupational therapists - but there is no guarantee. The issue in an acute dangerousness based psychiatric hospitalization is not a question of overdiagnosis - but whether the patient will get the correct diagnosis and an adequate medical evaluation and discharge plan.  The driving force for that is rationing. The cost of an overnight stay on a cardiology unit with telemetry, blood tests, and an exercise stress test in the morning easily exceeds the payment for complex psychiatric care. I would say that complex psychiatric care is the equivalent to treating a person with a psychosis, extreme mania, or life threatening catatonia or depression. In general we are not worried about the issue of overdiagnosis. People flee psychiatric units if they are given the opportunity and they don't really care if they get diagnosed or not. Psychiatrists cannot present them with an array of options because there aren't any.

When I saw the term overmedicalizing in Dr. Rosenbaum's title - I wondered if she was aware of its Szaszian origins? Szasz was apparently so enthralled by a form of psychiatric treatment that was totally subjective and more akin to a literary critique that he suggested society has an interest in using psychiatry as a way to exert social control over certain subgroups.   The logical conclusion is that mental illness is not a disease and calling something an illness is strictly a power play.  For some reason society and its unholy alliance with psychiatrists is seeking to exert power over a subset of society for unclear reasons. I doubt that Dr. Rosenbaum is using the Szaszian definition. She is probably referring to any number of situations where non-disease is treated as disease.

There are many problems with Szasz - not the least of which is how he would end up treating any number of severe mental conditions. More modern authors on what is and is not a disease seem confused about the imprecise definition, especially in the absence of gross pathology. There is no family member affected by schizophrenia, bipolar disorder, depression, alcoholism, or addiction that doubts for a moment that these are diseases. They generally don't doubt that psychiatrists, at least until very recently were the physicians most interested in treating these problems.

Dr. Rosenbaum's theme does not seem to apply to psychiatric practice. There are no expensive tests to overutilize. Stays on inpatient units are capped by ridiculously short lengths of stay that do not reflect the severity of illness.  Even then - admissions to psychiatric units are generally under the control of emergency physicians.  This is part of the oversimplication, that she referred to. That oversimplification characterized all inpatient stays by diagnosis related groups (DRGs) and suggested that all inpatient stays could be kept to a certain number of days or cost. Nothing else was necessary. This led to three outcomes that led to very subpar care. The first outcome was the deterioration of inpatient services. Rationing does not maximize state of the art care and practically all inpatient units are essentially observation services waiting for people to become less dangerous. Dialogue with patients on acute care units is essentially focused on that issue. Addressing the psychiatric disorder is a consideration only as it applies to dangerousness.  I have had many utilization reviewers tell me that they would no longer pay for the treatment of extremely ill people because they did not seem to be dangerous. 

The second outcome was splitting off addiction treatment. At some point, a large number of detox admissions were directed to psychiatry because medicine units no longer did detoxiification. Then at some point to capitalize on the DRG payments, psychiatric units not longer did detox. patients with addiction were sent from the ED to a county detox unit. The only time they came back is if they experienced seizures or delirium tremens.  The overall rationale is saving the insurance companies money.  They don't cover people at county detox units.

 The third outcome is that patients with severe psychiatric disorders are sent to jail rather than inpatient units. This has resulted in county jails becoming the largest psychiatric hospitals in the United States at a time when psychiatric beds per capita here are among the lowest in the world according to OECD data. All of these changes are associated with a tremendous lack of quality and would be a national embarrassment - if they were not viewed as cost effective by the businesses and governments in charge. The American Psychiatric Association and other district branches still incorporate the cost effective rhetoric when in fact, psychiatry left cost effective in the rear view mirror thirty years ago.

Psychiatrists don't have expensive procedures to order.  In psychiatry less is less (or no) time seeing a psychiatrist.  Less is no time being treated in a medically supervised and therapeutic inpatient or detox unit when you need it.  Less is no psychotherapy that might work for you.  Less is no case management services.  Less is no public health nursing.  Less is not taking the best medication because a pharmaceutical benefit manager says you will have to pay full price for it.  Less in no available child psychiatrist when they are needed.  Less is not getting your blood pressure checked in a public clinic because there are no blood pressure cuffs.

Less in psychiatry is obviously far less than any other speciality.

That brings me to the last concept in the article illusions of value. There is no greater illusion of value than current psychiatric care and that is not because of psychiatrists. To give a clear example, I am an excellent diagnostician - both medical and psychiatric illnesses. I can figure out what is wrong with people and come up with a plan to address all of those issues. I can't do it in a 15 minute appointment. I can't do it if I have to type up all of my encounters like a stenographer or waste my time supporting horrible electronic health record software. In the case of people with severe problems, I can't do it without staff people who can get the patient to the appointment to see me and make sure that the person follows up with all of my recommendations. Without all of that infrastructure on the outpatient side, I will end up seeing about 60% of the people who are scheduled and the average person coming back will tell me they are taking their prescribed medication half of the time. Almost all of that supporting infrastructure has been eliminated in the past 30 years and managed care organizations have set up psychiatric services based on the prescription of a medication. Even if you have a severe problem. Show up 3 or 4 times a year, have the psychiatrist ask you a few questions, and get enough refills until the next appointment.

Psychiatry is actually a paradigm that the rest of medicine should look to in terms of less is less. In her final sentence Rosenbaum describes "less is more" as an aphorism that is "better suited to telling coherent stories than to the complex decisions faced by doctors and patients." I could not agree more. My only qualifier would be that the administrators are always telling their coherent stories that make it seem like they know more than physicians know about medical practice. They do a great job of selling it and convincing people that a symptom checklist and an antidepressant prescription constitutes optimal care. 

That is the only way that the current abysmal psychiatric services offered by large health care corporations could get a pass.



George Dawson, MD, DFAPA







References:


1: Rosenbaum L. The Less-Is-More Crusade - Are We Overmedicalizing or Oversimplifying? N Engl J Med. 2017 Dec 14;377(24):2392-2397. doi: 10.1056/NEJMms1713248. PubMed PMID: 29236644.

2:  Sullivan K.  The rise and decline of the Dartmouth Atlas.  The Health Care Blog, September 25, 2016  http://thehealthcareblog.com/blog/2016/09/25/the-rise-and-decline-of-the-dartmouth-atlas/

NEJM Three Part Series - Severe Medical Illness In the Context of Severe Mental Illness

Lisa Rosenbaum, MD has written a three part series in the New England Journal of Medicine that should be read by non-psychiatric physicians, family members, patients, and policy makers.  It is focused squarely on providing medical care to patients with severe mental illness and all that involves.  It is really impossible for psychiatrists to avoid the issue.  At some point in your career you find yourself in a situation with a patient who has a severe medical problems and refuses to address it because of the way that their decision making process has been impacted by mental illness.  If you are an inpatient or ACT team psychiatrist - it is usually up to you to come up with a plan to address that problem,  Several of the scenarios she describes across this series are directly from those settings.  Like any other specialty, psychiatrists will all migrate toward a certain niche.  For many reasons being that person who has to confront mentally ill patients about the fact that they are seriously ill or dying is not a position that is in great demand.  But mostly it is because inpatient and ACT team positions are rationed and none of the payers or administrators want those psychiatrists to do what they are capable of.

This series is part of an overall increase in psychiatric topics that are discussed in the NEJM.  So far this year there have been three Case Records of the Massachusetts General Hospital and a review of the basic science of addiction and a number of other articles on addiction and mental health policy.  Although I have not attempted to quantify it, there does seem to be a general increase in the coverage of psychiatric topics that include reviews of diagnostic groups, basic science mechanisms, clinical trials, and articles of general interest from the field.  The search function of the web site allows for grouping according to specialty and there are generally 20-30 psychiatry references per year over the past 5 years.  Lisa Rosenbaum is a cardiologist and is a national correspondent for the NEJM and in that field has probably seen a number of cases of people with severe mental illnesses and cardiac problems.

In the first article in the series she discusses the issues of informed consent and coercion in treating patients with severe mental illness.  It is well known that this population is undertreated from the perspective of primary treatment that is focused on the mental illness.  She uses an estimate of 9.8 million people with severe mental illness and only 60% of those people receiving treatment.  She cites the systemic problems of a lack of bed capacity 11.7/100,000 currently compared with 337 per 100,000 in 1955.  The contrast is more striking if per capita health expenditures for health and the number of psychiatric care beds per 100,000 population are compared.  For OECD data per capita expenditures for healthcare rank the USA at the very top by far and the per capita number of psychiatric care beds near the bottom compared with other countries.  The article discusses how deinstitutionalization was supposed to be linked to more community resources and not less.  The underfunded systems is portrayed as somewhat of a mysterious problem rather than system-wide rationing of psychiatric services.  The author in this case ties the underfunding to problems that it can't fix namely severely ill patients not seeking treatment  and antipsychotic drug side effects.  The high discontinuation rates in the CATIE trial are cited as proof of this problem.  I think that underfunding due to rationing is the problem.  With adequate resources comprehensive care is possible when the focus is comprehensive care more than medication.

The philosophy behind ignoring psychosis due to a psychiatric disorder compared with other physical illnesses is discussed.  The author points out that given the severe disability of these illnesses they cannot be ignored and that unlike other illnesses there are no major campaigns focused on prevention or treatment.  From there she transitions into the issue of intervention against the patient's wishes.  She discusses Stone's theory of paternalistic intervention if the affected person is likely to be grateful after they have been stabilized.  The flaw with that theory is that in many cases only a degree of psychiatric stabilization can be achieved.  In many cases it is likely that the person will have continued problems with insight and medical decision making and will continue to disagree with any suggested treatment.  She discusses the flaws with "dangerousness" as a component but does not take that discussion to its logical conclusion.  Dangerousness is of course not a psychiatric concept.  It is used by the courts as a basis for the initial stages of civil commitment and by managed care companies to decide if they will pay for psychiatric hospitalizations.  Any inpatient psychiatrist has found themselves talking with an insurance company reviewer - usually many states away who wants to know "where's the dangerousness?" and who is quick to deny payment for the treatment of a severely disabled person on that basis.  Dangerousness is probably the single word in the English language responsible for shutting down psychiatric care bed capacity and driving skilled psychiatrists away from the treatment of severe psychiatric disorders.

Rosenbaum makes the mistake of overemphasizing the importance of stigma.  She accepts as a given that stigma causes "countless harms" when the real harm is caused by systemic discrimination by the government and insurance companies.  The dangerousness concept as a justification for no treatment has done far more harm than the stigma of mental illness.  She also connects the attempt to counter stigma with illness minimization behaviors such as treating a person with a severe mental illness and impaired decision-making capacity as a competent decision maker.  Stigma is of course tied in with the recovery movement and policy that flows from the Substance Abuse and Mental Health Services Administration (SAMHSA).  Overmedicalization and disregard for civil liberties is cited as a need for this recovery based model.  That cannot be reconciled with the fact that for at least 40 years, all states have had civil commitment and guardianship/conservatorship laws in place that are in place to assure the civil liberties of anyone where there is a suggestion of coerced treatment.  When people "die with their rights on" they are generally dismissed by courts and end up dead as the result of untreated mental illness.  Only psychiatrists are generally bound by these laws and not other physicians and that part is left out.

The other significant group left out of course are the antipsychiatrists and their considerable allies whose raison d'etre is basically to bash psychiatrists and make them look bad.  That group frequently uses the term overmedicalization and pretends that there has not been decades of legislation to protect the civil rights of the mentally ill.  She is patronising in suggesting that "most psychiatrists" recognize "peer support, structured activities, psychotherapy, employment assistance, and case management" might be useful -  ignoring essentially a century of research by psychiatrists on these elements of treatment.  It also ignores the truth that every psychiatrist knows and that is - people recover and people with severe illnesses recover.  I don't need a recovery movement to tell me that.  I have people walking up to me on the street who I treated decades ago who tell me that they are married, they have children, and they are working.  Despite that severe shortcoming, I give her credit for pointing out how recovery proponents "twist data to advance their agenda".  There is currently a lot of twisted data out there.

She ends the first discussion with commentary on whether a living will for treatment of psychiatric disorders, innovations like a "one-time autonomy violation for forced treatment", or civil commitment as usual is the best approach to forced treatment of severe mental illness.  That assumes that some innovation is necessary and that it will be universally applied.  Both assumptions are incorrect.  It is possible these days to look at the editorial pages of any major medical journal and of course the non-medical media and read endless suggestions about how "the system" of medical care should be changed.  The reality is that there is a loose system of medical care and for psychiatric care the system is non existent except in the minds of antipsychiatrists.  As far as I can tell the only thing wrong with mental health law is that it is subjectively interpreted and that interpretation is clearly affected by the attitudes of attorneys and judges and the resources of the county that is financially responsible for treatment.  That skews undertreatment more severely to the counties with fewer resources.  There is nothing wrong with the law as it is written.  Civil rights are protected and the decision about rights is made by the legal system and not psychiatrists or physicians.

The second article in this series (2) is focused on the mortality gap between persons with mental illness and those without.  Unlike recent authors Rosenbaum points out that the problem was first identified by a psychiatrist in 1932, long before there were any effective treatments or treatments that allegedly cause medical complications.  She almost avoids the accusation of some recent extremists that psychiatrists and psychiatric treatment are responsible for this increased mortality rate but does bring that point up.  Nobody can argue that a lot of this mortality is based on pessimism in dealing with the mentally ill.  I can still recall the obsessing about the decision go to smoke-free inpatient psychiatric units.  One of the arguments is that it would lead to much more aggression among patients and toward staff.  The  other argument was that smoking was "all they had" and it should not be taken away from "them."  Both arguments were advanced by trained mental health staff and are extremely demeaning.  It is not surprising that patients with mental illness have lower rates of guideline recommended care or disease altering interventions.  I have contacted many primary care physicians who were surprised to hear that their patient was still alive.  I have also found myself in the position of treating people with sustained very high blood pressures or people who were actively bleeding because the patient was refusing treatment.  The only advice I got from consultants was to call them back when something bad happened and in some cases it did.

The medical rather than psychiatric assessment of capacity to consent is discussed.  A study is presented that shows  that on a typical medical service 40% of patients lacked capacity to consent and the treatment team was aware of only 25% of those cases.  This implicit consent on medical and surgical services is widespread.  It is generally questioned only in the case of high risk procedures or if a patient illogically refuses routine care.  In hospitals with psychiatric consultation-liaison services - they are typically consulted with the question.   Rosenbaum suggests that in contested situations forced treatment results in brutal seclusion, restraint and forced medication.  That is an unlikely outcome in these situations.  Most people no matter how delusional agree to care if a judge orders it or they realize that just leaving is not an option.  The suggestion is made that more time and training for capacity to consent evaluations be considered.  That is not going to happen.  There is a reason that people avoid going into psychiatry.  Talking to patients and making these assessments is one of them.  And there is no way that hospitalists are ever going to have the time it takes to do this job in addition to their medical evaluations.  It is just another psychiatric resource rationed out of the system.

Rosenbaum concludes with a valentine to integrated care models.  She has access to some of the few internists who are adept are treating people with severe mental illness, including one internist who specializes in it.  The recent MGH Case Reports have discussed similar models.  The main model that was invented in 1974 by Len Stein, MD, Mary Anne Test, MSW and  others is never mentioned.  Since that time there are ACT teams that coordinate medical care for people with severe mental illnesses and help them stay healthy outside of hospitals.  As a psychiatrist trained in these community psychiatry interventions there was nothing about patient care in these three articles that was news to me.  There are plenty of psychiatrists trained in these interventions but very few settings to implement them.  That is because the rationed care approach has split psychiatric care off from managed care organizations and placed it under the purview of the state - usually as a way to justify shutting down state hospital bed capacity.   In states where the resource becomes state-run managed care poor outcomes can be expected to follow.  Since ACT treatment was originally focused on deinstitutionalization and quality of life it is easy to dismiss based on typical cost effectiveness arguments.  I can still remember Len Stein showing us the reason why ACT was invented.  It was a single slide showing a gymnasium sized room full of cots that were placed edge to edge.  The patients were all men wearing the same uniforms off to one side.  His question to the residents was whether it was better to help all of those men live independently or let them live in those state hospital conditions?  Unlike today - incarceration and homelessness were not acceptable options.      

The final article in the series suggests that inaction on the part of physicians in addressing the problem of medical illness in people with severe mental illness is a result of learned helplessness.  That refers to a well known animal model of depression where test animals are subjected to some insurmountable stressor and generally give up and stop trying.  That model alone provides an interesting disconnect between psychiatrists and the rest of medicine.  Since the days of German asylums, psychiatrists have wanted to talk to their severely ill patients - even before there were any effective treatments.  That drive is one of the most  compelling reasons for medical students to go into psychiatry in the first place.  I don't think that properly trained psychiatrists view these problems as hopeless situations, even though some of the inpatient units they work on are clearly repositories for problems that other physicians consider hopeless.

I have no problem at all talking with anyone who has a severe psychiatric problem, understanding them, and discussing treatment options for both their psychiatric and medical problems.  I have no problem understanding that the only reason I am the one offering help is a matter of genetics and good luck.

Any psychiatrist that I know can do that.      


George Dawson, MD, DFAPA



References:

1: Rosenbaum L. Liberty versus Need - Our Struggle to Care for People with Serious Mental Illness. N Engl J Med. 2016 Oct 13;375(15):1490-1495. PubMed PMID: 27732817.

2:  Rosenbaum L.  Closing the Mortality Gap - Mental Illness and Medical Care.  N Engl J Med. 2016 Oct 20; 375 (16): 1585- 1589.

3:  Rosenbaum L. Unlearning Our Helplessness - Coexisting Serious Mental and Medical Illness. N Engl J Med. 2016 Oct 27;375(17):1690-1694. PubMed PMID:27783917.