WIll Integrity Save Psychiatry?

The answer is - it  depends on how it is applied.

In the last two days, I have seen the integrity argument pulled out.  Allen Frances is still using his bully pulpit on the Huffington Post, where it seems that anything critical of psychiatry is readily posted.  In this case, he used the text of a blogger and the timeline created by this blogger to illustrate how there was no disclosure of a conflict of interest by a group of researchers, one of whom was the chair of the DSM-5 Task Force.  The APA investigated this and acknowledged the non-disclosure of the conflict of interest.  Apparently the acknowledgement in the form of an apology from the research group and the investigation by the APA is not enough for these critics.  The blogger Dr. Nardo suggests that an "outside panel" be appointed to review his findings and the original materials again.  I cannot think of how an "outside panel" could be convened.  I have never really seen an objective analysis by an outside panel and wonder who might be selected.  And yes I am suggesting that any outside panel would naturally have a significant conflict of interest.  There appear to be many critics of psychiatry and only weak defenders.

He refers to a post by an anonymous web professional Neuroskeptic who summarized the state of things in his post as there being "no smoking gun."  He also concludes that the idea of a psychiatric critics benefiting from book sales with the same theme suggests "by which logic, every author in history has had a financial conflict of interest in their own ideas." As a student of conflict of interest that IS a logical conclusion, especially when I see links to two of Dr. Frances' books listed right below the Huffington Post article.  It is also an obvious fact that people routinely deny that applies to all human endeavors.  If I am heavily invested in any subject my "ideas" can be counted upon to be fairly subjective and consistent with my self interest whether that is academic or financial.  That is why I have read thousands of articles in Science, Nature, and medical journals in the past three decades and very few have panned out.  At a larger level it is why Ioannides could declare that most published research is false.  It is why you can count on seeing significant side effects from practically every medication approved by the FDA as safe and effective.  So yes, I am afraid that same standard applies to the critics as well as the people doing the heavy lifting and trying to prove something in the first place.  I would even take it a step further and suggest that the same transparency rules should be applied.  How much money can you make as a critic of psychiatry or the DSM?  My guess is plenty.

Both Dr. Frances and Dr. Nardo seem to be suggesting that all of the conflict of interest issues of academic psychiatrists and the way the APA handles them is sending psychiatry to hell in a handbasket.  This is a historically incorrect view of the dismantling of psychiatry in the United States.  Every day people in this country are getting inadequate psychiatric care.  It has nothing to do with the ethical behavior of academic psychiatrists.  It has a lot to do with the fact that the APA is not a very politically savvy organization and there are massive conflicts of interest interfering with the delivery of psychiatric care.  Here are a few scenarios:

1.  A depressed or psychotic but nonfunctional person is discharged from the emergency department because of a lack of "acute dangerousness" criteria.  The family is outraged but they are told: "Look there is nothing we can do because he/she is not imminently dangerous to themselves.  Upon further investigation the state has a "gravely disabled" criterion in the commitment statutes but it is practically never used.  They find that local hospitals and courts never use that criteria because the patients admitted are too difficult to treat and place.

2.  A person with acute alcohol and benzodiazepine withdrawal is sent home from the ER with a bottle of lorazepam and advised how to detoxify themselves.  They go home and take the entire bottle to get high.

3.  A person with alcoholism and depression is admitted for suicidal behavior.  She was intoxicated, depressed and staring at a handgun.  The next day the attending physician is contacted by a psychiatrist/utilization reviewer from the insurance company who has concluded the patient is no longer suicidal and they can be discharged.  He will no longer authorize payment for inpatient treatment. 

4.  A pharmacy benefit manager refused to refill a 2 week prescription by a patient's psychiatrist.  They have the pharmacist faxes a form to the psychiatrists office saying that they will only accept a 3 month prescription.  The psychiatrist takes time to explain first to the pharmacists and then 2 different people at the PBM (total time 30 minutes) the rationale for not giving a large supply of medication to a chronically suicidal patient.  The PBM refuses to change their position.

5.  A managed care company refuses to cover psychotherapy provided by a psychiatrist.  The psychiatrist explains that he is an expert in this type of therapy and the patient has been referred to him by the patient's primary psychiatrist.  The managed care company authorizes 3 "crisis sessions".  

6.  A person completes a PHQ-9 scale in their primary care clinic and they score an 18.  They see their primary care physician and say they would like to see a therapist.  They are told to take an antidepressant and to come back in two weeks to fill out another PHQ-9.  Total time of the visit is 5 minutes.

7.  A person is seen in their primary care clinic and in 20 minutes is told by their nonpsychiatric physician that they have bipolar disorder.  They are prescribed quetiapine, citalopram, and divalproex.  Within several days they are too sedated to function at work.

The are just a few examples of thousands of people everyday who are receiving grossly inadequate care based on a specific ethical principle of physician behavior.  That is the physician makes an assessment and prescribes care in what he or she believes is the best interest of the patient.  That is the contract.  There is no insurance company or government bureaucrat involved.  There is no restricted access to mental health care or pretending that primary care physicians are psychiatrists.  There is no remote "assessment" by a physician employed by a managed care company that prioritizes the financial well being of that insurance company or pharmacy benefit manager over the patient.  In fact,  I do not understand how that is ethical behavior at all.

That is the basis of the decline of psychiatry in this country.  It has taken a proportionately larger hit than any other specialty.  It is documented in detail on this blog and in E. Fuller Torrey's recent book.  The adventures or misadventures of academic psychiatrists are relevant only insofar as the APA seems to use the President of the APA as a position that academics cycle in and out of.  The idea that "psychiatrists in the trenches" are poorly represented by such a system is accurate with two possible exceptions that I can think of.  Psychiatrists in the trenches are also poorly represented by criticism of academic psychiatrists and their conflict of interest agreements and personal employment contracts.  It does nothing to address the central problems of the specialty, provides no tools that front line psychiatrist can use against all of the real conflicts of interest they face on a day by day basis, and is generally demoralizing.  Before any critics suggest that I am supporting a "whitewash" - put yourself in the position of a psychiatrist who has just put in a 12 hour day taking care of 20 inpatients and putting up with passive aggressive and aggressive MCO and PBM reviewers who have been wasting your time and interfering with your care.  You go home to read the paper and suddenly there is a major story of how unethical psychiatrists are - based on the appearance of conflict of interest.  You try to remember that last time you saw a CME event that was sponsored by a pharmaceutical company.  Then you check your files to make sure you have enough CME credits for relicensure.  As an added piece of information that same psychiatrist doesn't really care about Section 3 in the DSM-5 or the issue of dimensional versus categorical diagnoses.  They have not blinked an eye with the release of DSM-5 and won't in the future.

That is how the psychiatrist in the trenches experiences this academic exercise in conflict of interest.  I say if you want to pull out an ethical argument and use that to help front line psychiatrists, it needs to be focused on the obvious targets in managed care and the government bureaucracies that support them.

You know - the real forces dismantling psychiatry (very effectively I might add) over the past three decades.

George Dawson, MD, DFAPA

kappa statistic rhetoric

This post was inspired by a post on the Neuroskeptic.  The impression I get from that blog is that the average reader thinks that psychiatrists are a bunch of chuckleheads who know very little and that is probably why they are so ignorant of science.  The Neuroskeptic himself seems to be slighlty more tolerant but like most bloggers he has to stir the pot.  The focus of this post was to take a look at kappa statistics given in the article by Freedman on DSM5 field trials and a graphic supplied by the boringoldman blog and conclude that DSM5 reliabilities were not good, they were not as good as DSM-IV, and thankfully psychiatrists could just ignore the DSM if they wanted to.

On the face of it all this seems like damning criticism.  Is there any defense from the neuroscientific opinion?  It turns out that there is and it comes from two sources.  The first is the common experience that most people have had who have any medical diagnosis in their lifetime.  Were you ever misdiagnosed?  Did you ever get a second opinion and find that the diagnoses by both doctors were so far apart that it was difficult to make a plan to address the problem?  I can give you one of many examples from my lifetime.  When I was a second year medical student I had several incidents of ankle pain.  I was assessed and ended up at an orthopedics clinic.   I had my ankle casted a couple of times, even though I had no history of trauma.  I finally woke up one night with excruciating left ankle pain and went to the emergency department.  I saw orthopedics again and they aspirated the joint.  They also asked my  wife to leave and asked me if I had possibly contracted gonorrhea somewhere.  I was given acetaminophen with codeine and discharged after about 8 hours.  A couple more weeks of pain and I finally got in to see one of the top experts in Rheumatology who finally made the diagnosis of gout.  At that point I had seen 4 or 5 other doctors and none of them had been able to correctly diagnose the cause of my ankle pain.  Calculating a kappa statistic for a comparison between the expert and the previous physicians would have resulted in a very low number.

But the story doesn't end there.  As anyone with gout knows, it has varied presentations including inflammation that often seems to extend outside of the joint.  During my residency training a few years later I had acute right wrist pain.  The internist I saw decided he needed to aspirate my wrist joint and ended up aspirating a piece of the wrist joint into the syringe.  No diagnosis despite this procedure.  I demanded treatment for gout and of course it worked.  Several recurrences of wrist pain have resulted in misdiagnoses of cellulitis.  Keep in mind that I am not testing these doctors.  I am presenting to them and telling them I have gout and I think my wrist pain is an acute gout attack.  They are saying: "Well gout doesn't usually affect the wrist. I think this is cellulitis."  I have walked out of clinics and thrown the prescription for antibiotic away as I walked out the door.  I finally just got a supply of the anti-inflammatory medication that I need and treat these episodes myself rather than risk misdiagnosis by a physician who does not know much about gout.

You could say this is all anecdotal.  I have more anecdotes about how I have been personally misdiagnosed and the anecdotes of an additional thousand people at this time.  I heard Ben Stein say: "At some point the anecdotal becomes the statistical" and this is a good example from medicine.  But what does the literature say about the reliability of diagnoses.  The diagnostic criteria for gout have been around longer than the DSM.  Another frequent criticism of psychiatric diagnosis is that there are no confirmatory tests for the diagnosis.  Numerous confirmatory tests for gout did not prevent misdiagnosis in my case.  

That brings us to the second line of defense - kappa values that are documented in the medical literature.  Let me preface that by saying that compared to psychiatry, there are literally a smattering of kappas from other specialties.  The following table is a sample from this literature search:
  

observation	kappa	reference
Scaphoid bone fractures diagnosed by radiologists	0.51	de Zwart AD, et al.  Interobserver variability among radiologists for diagnosis of scaphoid fractures by computed tomography. J Hand Surg Am. 2012 Nov;37(11
Reproducibility of serrated polyp diagnosis by pathologists	0.38-0.557	Ensari A, et al. Serrated polyps of the colon: how reproducible is their classification? Virchows Arch. 2012 Nov;461(5):495-504. doi: 10.1007/s00428-012-1319-7.
Detection of anomalous origin of coronary arteries by CT	0.65	Jappar IA, et al. Diagnosis of anomalous origin and course of coronary arteries using non-contrast cardiac CT scan and detection features. J Cardiovasc Comput Tomogr. 2012 Sep-Oct;6(5):335-45.
Skeletal muscle CT to idenitify various muscular dystrophies	Overall 0.27 but in some cases 0.51 and 0.59	ten Dam L, et al.  Reliability and accuracy of skeletal muscle imaging in limb-girdle muscular dystrophies. Neurology. 2012 Oct 16;79(16):1716-23.
Criteria standards to diagnose CHF	0.59-0.74	Collins SP, et al. A comparison of criterion standard methods to diagnose acute heart failure. Congest Heart Fail. 2012 Sep-Oct;18(5):262-71.
Spoke sign for otitis media	0.21 (residents) 0.24 (staff) 0.61 (ENT residents)	Sridhara SK, Brietzke SE. The "Spoke Sign": An Otoscopic Diagnostic Aid for Detecting Otitis Media With Effusion. Arch Otolaryngol Head Neck Surg. 2012 Oct 15:1-5.
Pediatric residents diagnosis of otitis media compared to ENT experts	0.3	Steinbach WJ, etal. Pediatric residents' clinical diagnostic accuracy of otitis media. Pediatrics. 2002 Jun;109(6):993-8.
Abnormal cardiac exam during sports screening	0.1 (cardiology fellows) 0 (fellows compared to staff)	O'Connor FG, et al. A pilot study of clinical agreement in cardiovascular preparticipation examinations: how good is the standard of care? Clin J Sport Med. 2005 May;15(3):177-9

What jumps out at you from the table?  The kappas from other specialties are widely variable and certainly no better than criticized values from psychiatry.  The fact that some of these kappas are based on interpretations of more uniform test data (radiology images or pathology specimens) seems to make little difference.

Low interobserver consensus seems to be the rule rather than the exception in medicine.  Psychiatry is the only specialty that openly admits this.  Misdiagnosis is a universal phenomenon and I would argue that it is a basic element in the process of medical diagnosis.  Some have referred to it as the "art" of medicine, but I prefer a more scientific explanation.   From a neurobiological standpoint there is certainly the phenomenon of significant variability between people.  Medicine from the outset has always presented itself to practitioners as a field where rational analysis produces a logical result.  With the degrees of freedom inherent in biological systems that degree of certainty is an illusion at best.   Pretending that psychiatry is less reliable than any other field is an equally problematic illusion, but I guess it makes for good rhetoric.

George Dawson, MD, DFAPA

Freedman R, Lewis DA, Michels R, Pine DS, Schultz SK, Tamminga CA, Gabbard GO, Gau SS, Javitt DC, Oquendo MA, Shrout PE, Vieta E, Yager J. The Initial Field
Trials of DSM-5: New Blooms and Old Thorns. Am J Psychiatry. 2013 Jan
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Yoshizawa CN, Le Marchand L. Re: "Misinterpretation and misuse of the kappa statistic". Am J Epidemiol. 1988 Nov;128(5):1179-81. PubMed PMID: 3189294.

Singh H, Giardina T, Meyer AD, Forjuoh SN, Reis MD, Thomas EJ. Types and Origins of Diagnostic Errors in Primary Care Settings.JAMA Intern Med. 2013;173(6):418-425. doi:10.1001/jamainternmed.2013.2777