Sensational Antidepressant Article from the New York Times

Take some quotes taken out of context, the suggestion that doctors know less about the problem than the New York Times does, and the suggestion that you may be "addicted to antidepressants" and what do you have - the latest article on antidepressants by the New York Times.  Although the New York Times has never been an impressive resource of psychiatric advice they continue to play one and the latest article  Many People Taking Antidepressants Discover They Cannot Quit is a great example.

The reader is presented with numbers that seem to make the case "Some 15.5 million Americans have been taking the medications for at least five years. The rate has almost doubled since 2010, and more than tripled since 2000." and "Nearly 25 million adults, like Ms. Toline, have been on antidepressants for at least two years, a 60 percent increase since 2010."  Guaranteed to shock the average reader, especially in a culture that systematically discriminates against the treatment of mental illness.

Adding just a little perspective those figures translates to 15.5M/254M = 6.1% and 25M/254M = 10% of the adult population in the US.  Looking at the most recent epidemiological estimates of depression in the US 1990 - 2003 shows one year prevalences of 3.4 - 10.3% of the adult population.  The lifetime prevalences from some of those studies 9.9-17.1%.  It seems that the claims of antidepressant utilization may be overblown relative to the epidemiology of depression and the number of people disabled by it.  The authors go on to quote a study on the overutilization of antidepressants on data obtained from the National Health and Nutrition Examination Survey (NHANES) study.  These same authors have quoted an increase of antidepressant use of 10.4%.  This same study estimated a lifetime prevalence of depression of 9.5%.

Depression alone is not the sole indication for antidepressants. Anxiety disorders is another FDA approved indication.  Anxiety disorders can add an additional 3% 1 year prevalence and 5-6% lifetime prevalence.  About 16.5% of the population has headaches and antidepressants are used to treat headaches.  Another 6.9-10% of the population have painful neuropathies that are also an indication for antidepressant treatment.  Over a hundred million Americans have chronic back pain another indication for a specific antidepressant.  The main reference points to a study (3) that suggests only about 7.5% of antidepressants are prescribed for nonpsychiatric conditions.  Only 65.3% of the prescriptions were for "mood disorders. A study looking at antidepressant drug prescribing in primary care settings in Quebec Canada (5) provides specific data and concludes that  29.4% of all antidepressant prescriptions were not for depression or anxiety but for insomnia, pain, migraine, menopause, attention-deficit/ hyperactivity disorder, and digestive system disorders. Those same authors go on in a subsequent paper to provide a detailed analysis of the off-label use of those antidepressants.

The number of antidepressant prescriptions is far less drastic when taken in that context.  I am not arguing that every person with an eligible condition should be on antidepressants.  I am definitely saying that given the large numbers of people who will potentially benefit - the number of antidepressant prescriptions is not as outrageous as portrayed in the article.

What follows is a brief descriptions of antidepressant discontinuation symptoms and the fact that the medical profession doesn't know what to do about it.  This is certainly not the case in any setting where I have practiced. Discontinuation symptoms are well know to occur with SSRI and SNRI medications.  I routinely describe them and their varying intensity as part of the informed consent procedure when I prescribe these medications. The reality is that 20% of people will stop taking antidepressants in the first month after getting a prescription. Many will just get the prescription and never start.  An additional 20-30% will stop in the next 3-4 months.  Stopping antidepressants without medical guidance is so common that I routinely ask patients if they have abruptly stopped at any point when I am making any changes in their medications.  The majority have stopped without getting any of the discontinuation symptoms.  I qualify that by the fact that I have not prescribed paroxetine in 30 years because I considered it to be a problematic medication and I have a very low threshold for stopping antidepressants if I don't believe they are tolerated.  Even in their referenced study (2) the authors state: "In one national study, for example, only about one-quarter of adults initiating antidepressants for new episodes of depression continued to take their medications for 90 days...".  Does that sound like it is a medication that is difficult to stop?

They don't stop there.  After making it seem like we are in the midst of an antidepressant epidemic and that people are unable to stop antidepressants they make an even more absurd argument - doctors are unable to help patients get off antidepressants.  Before I go into their details consider this.  I work at a facility where we routinely detox people off high doses of the most addictive drugs in the world.  If we are able to do that, why would a doctor not be able to figure out how to discontinue a non-addictive antidepressant?  This specific statement really had me rolling my eyes:

"Yet the medical profession has no good answer for people struggling to stop taking the drugs — no scientifically backed guidelines, no means to determine who’s at highest risk, no way to tailor appropriate strategies to individuals."

Do I really need a study to do something that I have been doing successfully for 30 years?  Tapering people off of medications is something that every physician has to do.  Successfully using antidepressants means being able to taper and discontinue one and start another or taper and discontinue one while starting another or starting another and eventually tapering and discontinuing the original antidepressant.  That is not innovation - that is standard psychiatric practice.

I can only hope that the quotes from family physicians that follow were totally out of context.  Statements about "parking people on these drugs for convenience sake." and that the "state of the science is absolutely inadequate" are ludicrous.  I would say if you have to park somebody on a psychiatric drug or have questions about how it is used - it is time to send that patient to see a psychiatrist.  Nobody should ever be "parked" on a drug.

These physicians seem to have lost sight of the fact that they do not have similar problems prescribing equal amounts of antihypertensive medications and leaving people on them indefinitely.  There is no rhetoric about "parking" somebody on an antihypertensive medication or a cholesterol lowering drug or a medication for diabetes.  The fact that depression is the leading cause of disability in the world seems to be ignored.  The fact that up to 15% of people with depression die by suicide is not mentioned.  The suggestion is that this disabling and potentially fatal condition should not be addressed as rigorously as other chronic illnesses.

In the midst of all of the confusion created in this article, the authors fail to point out the likely cause of increased antidepressant prescriptions but they quote one psychiatrist who comes close.  He points out that the increase in antidepressants is due to primary care physicians prescribing them after brief appointments and (probably) not being able to follow the patient up as closely as a psychiatrist.  This was one of the main findings in the paper by Mojtabi and Olfson (2).  The specific quote "...the increase in long-term use (of antidepressants) was most evident among patients treated by general medical providers."

What is really going on here?  This blog has repeatedly pointed out that mental health care and treatment by psychiatrists has been rationed for about 30 years.  The result of that rationing is that there are few reasonable resources to treat all kinds of mental illnesses.  With that end result, the argument is now being made that we really don't have to build the infrastructure back up - we just need to shift the burden to primary care clinics.  In order to make it more simple for them we can just screen people with a rating scale for depression (PHQ-9) or anxiety (GAD-7) and treat either symptoms with a medication.  That way we can not only ration psychiatrists, but we can also ration psychologists and social workers who could possibly treat many of these patients with psychotherapy alone and no medication. For that matter, we could treat a lot of these patients with computerized psychotherapy - but managed care organizations will not.  State governments and managed care organizations will screen people, make a diagnosis based on a rating scale, and put that person on an antidepressant medication as fast as possible.

That is a recipe for high volume and very low quality work.  A significant number of those patients will not benefit from a medication because they do not have a compatible diagnosis.  A significant number will not benefit from the medication because it is not correctly prescribed.  In order to compensate for that inadequacy, a model of collaborative care exists that provides a psychiatric consultant to the primary care clinic.  That psychiatrist never has to directly see the patient.  The collaborative care model depends on putting patients on antidepressants as soon as possible and even more classes of psychiatric medication.

That is the real reason for increased antidepressant prescriptions and people taking them.  It is not because nobody knows how to prescribe them or stop them.  It is not because they are "addictive". It is because there is a lack of quality in the approach to diagnosing and treating depression in primary care settings and that is a direct result of federal and state governments and managed care organizations.


To be perfectly clear I will add a series of rules that will not question the current business and political rationing of mental health resources but will address the problem of antidepressant over prescribing and antidepressant discontinuation:

1.  Stop screening everyone in primary care clinics with rating scales - there is no evidence at a public health level that this approach is effective and it clearly exposes too many people to antidepressants and other medications.  I am actually more concerned about the addition of atypical antipsychotics to antidepressants for augmentation purposes when nobody is certain of the diagnosis or reason for an apparent lack of response and nobody knows how to diagnose the side effects of these medications.

2.  Provide any prospective antidepressant candidate with detailed information on antidepressant discontinuation syndrome - including the worse possible symptoms. While you are at it give them another sheet on serotonin syndrome as another complication of antidepressants.  It is called informed consent.  I encourage the New York Times not to write another article about serotonin syndrome.

3.  Triage depressed and anxious patients with therapists rather than rating scales - brief, focused counseling, CBTi for insomnia, and computerized psychotherapy all have demonstrated efficacy in addressing crisis situations and adjustment reactions that do not require medical treatment.

4.  Refer the difficult cases of discontinuation symptoms to psychiatrists who are used to treating it.

5.  Don't prescribe paroxetine or immediate release venlafaxine - both medications are well know to cause discontinuation symptoms and they are no longer necessary.

6.  Every physician who starts an antidepressant needs to have a plan to discontinue it - the idea that a patient needs to be on a medication "for the rest of their life" in a primary care setting is unrealistic.  If that determination is to be made - it should be made by an expert in maintenance antidepressant medications and not in a primary care clinic.

7.  Every patient should be encouraged to ask to see an expert if either their medication prescribing or treatment of depression is not satisfactory.  The standard for treating depression is complete remission of symptoms - not taking an antidepressant.  If you are still depressed - tell the primary care clinic that you want to see an expert.

In an ideal world, people with severe depression would be seen in specialty clinics for mood disorders, by psychiatric experts who could address every aspect of what they need.  That used to happen not so long ago.  It still happens in every other field of medicine.

But quality care like that is no longer an option if you have depression.


George Dawson, MD, DFAPA

References:

1: Carey B, Gebeloff R. Many People Taking Antidepressants Discover They Cannot Quit. New York Times April 7, 2018.

2: Mojtabai R, Olfson M. National trends in long-term use of antidepressant medications: results from the U.S. National Health and Nutrition Examination Survey. J Clin Psychiatry. 2014 Feb;75(2):169-77. doi: 10.4088/JCP.13m08443. PubMed PMID: 24345349.

3: Mark TL. For what diagnoses are psychotropic medications being prescribed?: a nationally representative survey of physicians. CNS Drugs. 2010 Apr;24(4):319-26. doi: 10.2165/11533120-000000000-00000. PubMed PMID: 20297856.

4: van Hecke O, Austin SK, Khan RA, Smith BH, Torrance N. Neuropathic pain in the general population: a systematic review of epidemiological studies. Pain. 2014 Apr;155(4):654-62. doi: 10.1016/j.pain.2013.11.013. Epub 2013 Nov 26. Review. Erratum in: Pain. 2014 Sep;155(9):1907. PubMed PMID: 24291734.

5: Wong J, Motulsky A, Eguale T, Buckeridge DL, Abrahamowicz M, Tamblyn R.Treatment Indications for Antidepressants Prescribed in Primary Care in Quebec, Canada, 2006-2015. JAMA. 2016 May 24-31;315(20):2230-2. doi: 10.1001/jama.2016.3445. PubMed PMID: 27218634.

6: Wong J, Motulsky A, Abrahamowicz M, Eguale T, Buckeridge DL, Tamblyn R.Off-label indications for antidepressants in primary care: descriptive study of prescriptions from an indication based electronic prescribing system. BMJ. 2017 Feb 21;356:j603. doi: 10.1136/bmj.j603. PubMed PMID: 28228380.

Psychosis Idealized

I thought I would provide a counterpoint to the New York Times editorial entitled "Medicating A Prophet" written by Psychiatrist Irene Hurford (1).  The opinion piece is available free online and I encourage anyone interested in the topic to read the article rather than accepting my summary here as adequate.  I will say from the outset that I am not a stranger to any of the issues that Dr. Hurford discusses either clinically or personally.  The bulk of my career was spent treating people with severe mental illnesses and addictions.  Once you have worked in that setting, it is clear that many people who are severely ill need involuntary treatment and that is one of the decision points that she addresses.

In her essay, Dr. Hurford describes an early call experience during her residency.  She was asked to assess a man in the emergency department (ED) who had been delusional for 30 years.  The delusions were religious and grandiose in nature.  He was a college graduate but was homeless living on the street in Philadelphia.  He also had AIDS and the complication Kaposi sarcoma.  His reason for being in the ED was "to preach".  Dr. Hurford encourages him to come in for voluntary treatment but he refuses.  At that point she ponders involuntary treatment but in the essay decides to discuss the patient's right to psychosis. Later we learn that she made the decision but has decided to analyze that decision in retrospect based on factors that she has encountered since.

One of those factors was the influence of a professional colleague who based on her own experience with psychosis and that colleague's mother's experience suggested that thoughts about living "in psychosis" and outside of psychosis need to be challenged.  She basically states that the problem may be within the beholder rather than the identified patient. Following that logic, it makes sense to show up in an ED to preach while ignoring serious health problems.  It also makes sense to make decisions about the person's "in psychosis" experience knowing so little about them.  In my experience, nobody in the ED calls the parents or family of a 50 year old street person, to get a clear picture of how the psychosis has truly affected him.  When I have treated these people on an inpatient unit and made those calls, I have never heard that the patient was well served by the psychosis.  Not a single time.  In many cases, family members were surprised to hear that person was still alive.

Dr. Hurford advances a number of other arguments that I call into question.  She uses a very loose definition of insight as a "failure to accept an alternative view of reality".  She turns this around to suggest that anyone who does not accept this premise (implicitly the treating physician) also lacks insight.  I don't think that you can practice psychiatry and not be comfortable with alternative realities.  I would suggest a more appropriate definition of insight as a decision-making process.  Can I accurately assess how I am doing in the world?  Am I making decisions in my best interest?  Are those decisions consistent with my ability to survive?  If I realize that I am not doing well can I get help?  Pretty basic decisions.  Not a question of lifestyle choices.  To have a lifestyle you have to live.  That is the kind of insight that I am used to dealing with.

Dr. Hurford discusses a case of a young patient with a psychotic disorder who stopped taking his medications and started using cannabis on  daily basis.  He dropped out of college and became progressively incoherent and then mute.  She is concerned about traumatizing the patient by "enforcing" treatment even though he cannot "eat, sleep, and talk."  I don't follow the logic that some treatment intervention - even basic detoxification from cannabis is somehow more traumatic than not eating, sleeping, or being able to communicate.  How is that a preferred alternative existence?

At that point she digresses to a very brief overview of the usual comments about mental illness being only peripherally associated with violence and the lack of evidence that forced treatment led to fewer hospitalizations, arrests, or a better quality of life.  She cites a meta-analysis of three randomized-controlled studies of more than 700 people.  There are a lot of reasons why meta-analyses are not superior to the actual trial data.  There are also a lot of reasons why truly clinical samples with these problems cannot be ethically randomized or included in the studies.  There are also reasons why I would expect the entry points into these studies to be highly variable as well as the treatment resources that are involved.  In Minnesota, we have 87 counties and the rule is that there are 87 interpretations of the commitment act for involuntary treatment.  There are two corollaries operating here.  The first is that the courts will be very liberal in terms of dropping commitments until something bad happens.  At that point the pendulum swings back in the direction of more frequent commitment.  The second is that only the wealthiest counties in the state can afford to provide adequate resources to treat the severely mentally ill.  Even then there is no assurance that the counties that can afford it will actually provide the care.  Some currently function like managed care companies and ration the care.  They can end up rationing care and commitments in order to save the county money.  The lack of evidence that forced care does anything may be more of an indictment of the lack of quality or consistency in delivering care and interpreting the law  and rationing care more than anything.  I have personally treated many times the number of people with forced treatment than in the meta-analysis and there is no doubt that the outcomes were better than with no treatment.

The outcome variables cited by Dr. Hurford are also dreadfully lacking compared with what can be seen routinely in clinical settings.  They include very adverse outcomes in encounters with the police including getting shot, dying from a treatable illness, suicide, loss of relationships with spouses and children, loss of a job and income, and acute loss of life due to poor insight and judgment.  In Minnesota, all that takes is going outside in the winter time without adequate protective clothing and you are dead or in the Burn Unit with frostbite.
     
Right now we are in the midst of a sweeping cultural change that idealizes psychosis and suggests that hallucinogens and cannabis are therapeutic drugs.  That will put the next generation or two of people with psychoses, mood disorders, and substance use disorders at risk for chronicity and every possible negative outcome.  A point that should not be lost on anyone is how no care for psychosis is "cost-effective" care when the total impact on the patient is ignored.  My point in writing this rebuttal is really advice for the people in these generations.  Ask any psychiatrist treating you or your family member where they stand on this issue.  

Especially if you value psychotic symptoms a lot less than your psychiatrist does.



George Dawson, MD, DFAPA





References:

1.  Irene Hurford.  Medicating A Prophet.  New York Times.  October 1, 2016.

The NY Times Opinion On Congress and the Opioid Epidemic

The NY Times came out with an opinion piece of the opioid epidemic on May 16 (1).  In their opinion it was a good thing that Congress had finally decided to "get involved."  They emphasize the need to fund treatment and prevention programs.  But wait a minute, didn't Congress already approve the The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).  That act was supposed to provide equal treatment for mental disorders and addictive disorders.  Here it is a few years later and we are supposed to be still trying to fund treatment despite a specific piece of legislation was was already supposed to provide funding?  In fact, this same editorial board came out with a very rosy assessment of the MHPAEA three years ago and they were wrong back then as well.  In that link, I posted reasons why the parity act would fail and of course - it did.  That failure is the only reason the editorial board is now calling for funding for treatment and prevention programs,  I criticized their original post because they lacked anyone with medical expertise on their panel and they did not seem to know how health care works or why Congressional intervention does not work. It looks like the same mistake has been repeated.  At some point we need to recognize that the opinions and legislation about health care aren't worth the paper they are printed on.  At least from the perspective of the prospective patient or the physicians who are trying to treat them.

This piece does reflect a dim grasp of the health care system in this country that is set up by Congress in the first place.  Some of the suggestions made me want to laugh out loud.

"The federal government can make the biggest difference by expanding high-quality treatment programs. States, which have more sway over doctors and hospitals, need to do more on the prevention side by placing limits on opioid prescriptions. States can encourage doctors to order alternative pain treatments, like physical therapy, and require insurers to cover those services." (1)

This seems to assume that the federal government is somehow interested in quality while they are setting up managed care organizations that really have nothing to do with quality.  Everything is set up to be cost-effective (translation = cheap).  There is nothing cheaper in the way of mental health care and treatment for addictions than refusing to fund it and that is a routine occurrence in spite of the MHPAEA, the bill that was supposed to put the care of mental illnesses and addictions on par with other medical conditions.  The second error in this paragraph is the idea of a bureaucrat somewhere placing limits on opioid prescriptions.  That will immediately alienate the majority of the physician workforce that currently prescribes opioids appropriately and of course the patients of these physicians.  And finally the idea that alternate treatments will be covered misses the cultural contributions to the opioid epidemic and the fact that Congress doesn't seem to be able to mandate insurance companies to do much of anything.  If they can't mandate equal coverage for mental illness and addiction, why would physical therapy be any different?

On the question of how much legislation must be written and how much money appropriated, the money figures quoted range from $600 million to $1.1 billion to address the treatment needs of 435,000 regular heroin users, 1.9 million people who are regular prescription opioid users, and 4.3 million people engaged in non-medical use of prescription painkillers each month.  Considering only the prescription of buprenorphine for medication assisted treatment of opioid use disorder and the $1.1 billion dollar figure, at about $1,000/month for buprenorphine, that figure would result in the treatment of 92,000 individuals and that is not including the cost of medical evaluation and administration of the drug.  That is less than a quarter of the heroin users and less than 10% of the painkiller users.  It also does not fund any of the additional treatment services including addiction counseling and a continuum of sober support and housing.

In situations like this, seeming to address the problem by political one upmanship is always tempting.  A Governor is quoted in the article giving her opinion that the cause of the current epidemic is the prescribing practices of physicians.  I am sure that many legislators take the same concrete approach to problems but this is a much more nuanced problem.  Technically speaking - all physicians leave medical school knowing how to prescribe opioids.  Not all of them are good at managing the relationship with the patient or telling patients what they might not want to hear.  The commonest errors I see in prescribing addictive drugs to people has nothing to do with technical expertise of the physician.  It has to do with the idea that the patient is in distress and that it is the physician's job to do something about it.  Many of these physicians have a difficult time balancing the decision to prescribe an addictive drug versus the potential harm of addiction or the harm of not treating a pain syndrome that does not respond well to opioids.  Many of these same physicians lack an understanding of addiction and the fact that it is possible to continue to take an addictive medication even though it is providing no symptomatic relief from pain.   The third problem is the patient's lack of insight.  There a lot of biases when it comes to addiction and assigning responsibility.  There are numerous arguments about whether addiction is a disease or not and these are generally arguments about who is responsible for the addiction and its treatment.  I don't think that there is any doubt that a person who is addicted to opioids will behave in a predictable manner to keep the addiction going.  They will not tell their physicians that they have an addiction and in some cases try to get extensions on prescriptions, escalate the dose of a prescription, get more opioids from non-medical sources (dealers or acquaintances) or use the opioid for a reason that it was not intended - usually insomnia, anxiety, or depression.  How do legislators address this complex problem?  Basically by blaming physicians and passing legislation that doesn't make any sense.

It is important to remember that this epidemic did not start in a vacuum.  There was an activist movement among some professional societies and regulatory bodies to treat pain more aggressively.  Looking at past  New York Times editorials, some of this was recorded and in at least one case, the opinion came down on the side of aggressive pain treatment.   Congress and the media seems to have come full circle on the issue of opioids and is ready to head back in the other direction.  The news can be a powerful source of influence in encouraging people to use public health measures to stop this epidemic.  That can be as basic an idea as not hoarding leftover opioid painkillers and discarding them.

Hoping that Congress will solve the problem, when they were supposed to 7 and 22 years ago, does not seem like the best idea.  If they went back to sleep - nobody would notice the difference.


George Dawson, MD, DFAPA



1:  The Editorial Board.  Congress Wakes Up To The Opioid Epidemic.  New York Times May 16. 2016.

2:  The Editorial Board.  Making the Pain Go Away.  New York Times.  March 4, 1994:

"The new guidelines, issued in detail for physicians and in brief for patients, call for treating pain early and aggressively, starting with the simplest options, like aspirin and acetaminophen, and progressing through mild opiates to more potent drugs like morphine."

And....

"But there are scant data from scientific studies to document whether or not marijuana is as effective as or better than other anti-nausea drugs. The same outdated attitudes that inhibit the use of narcotics for pain relief should not be allowed to suppress clinical investigations into the therapeutic uses of pot."

Reductionism Is Not A Dirty Word...

A recent opinion piece in the New York Times, by George Makari, MD has me shaking my head.  The thesis was that a recent headline grabbing story (what's wrong with that criteria?) on the effects of comprehensive treatment of psychosis as opposed to treatment as usual surprised many and highlighted the problem with reductionism.  He bemoans the fact that the reaction to the story was one of surprise.  He doesn't specify who was surprised.  I certainly was not surprised.  I attended recent meeting and somebody in the audience asked Daniel Weinberger if he was surprised.  His response: "They spent $15 million dollars showing that good treatment is better than bad treatment."    He certainly was not surprised.  I have not heard about Eric Kandel's response, but based on his 1979 paper on plasticity and what happens in psychotherapy - I doubt that he would be surprised.  The exact population of who might be surprised by these findings seems poorly defined at this point in time but I doubt that it included any psychiatrists.

Speaking for myself, I will elaborate on why I was not be surprised.  At one point, I was the Medical Director of a community support program of a group of about 100 outpatients in the State of Wisconsin.  According to the state statutes, access to the program depended on diagnosis and degree of psychiatric disability.  You could only apply if you had a diagnosis of Bipolar Disorder, Major Depression, Schizophrenia,  or Borderline Personality Disorder had significant associated disability or were at high risk for hospitalization.  The clinical goal of the program was to reduce hospitalizations, maintain independent living, and facilitate employment.  The program was staffed by a psychologist, 2 social workers, three nurses and me.  When I arrived, one of the early dynamics was to frame problems in terms of medication needs.  That translated to increasing the dose of a medication (typically an antidepressant or antipsychotic) in crisis situations or other emotional crises.  The patients in the program had chronic problems and symptoms that did not necessarily respond to medication.  One of my first steps was to start to discuss problems and solutions with the patients.  I met with all of the patients and did supportive psychotherapy when possible.  We had team meetings every morning and problem solved around the needs of the patients in the community, how to solve any crises, and how to approach people in ways other than medications.  I tracked the total dose of antipsychotic medication and days of hospitalization as outcome measures.  At the end of three years, the days in hospital had gone down from about 14 days per person to less than 1, and the total dose of antipsychotic medication had gone down a total of 600 mg chlorpromazine equivalents.

My point is obviously that comprehensive care of patients with severe problems results in improved outcomes.  In this case lower doses of medications were used and the patients spent less time in the hospital and more time at home.  My orientation and ability to implement such a program was not an accident.  I was trained by Len Stein, MD at the University of Wisconsin.  Dr. Stein was a pioneer in the area defined as community psychiatry.  He was motivated by realizing that once people were in large state hospitals - it was very easy to warehouse them in overcrowded conditions.  Nobody seems to recognize it but overcrowding and suboptimal conditions were the state hospital equivalent of managed care rationing.  Once your state hospital is on the spreadsheet of a state bean counter with no accountability to patients or their families rationing and fewer and fewer resources are the order of the day.   In a community psychiatry seminar, Dr. Stein projected a slide of a gymnasium-sized room populated by male patients with hundreds of cots aligned edge to edge.  There was no room to walk between the cots.  That was his motivation for moving people out of these state facilities and into their own housing.  When I trained, there were three programs with independent living and quality of life as the primary goals and the staff involved in the programs was very good at it.  My effort just extended that skill set.  Contrary to the "surprising" results of the quoted study - I did the same thing back in 1986!

If it is true that we have known for 30 years that comprehensive care for psychiatric disorders trumps "treatment as usual" what is all of the rhetoric about?  Dr. Makari seems to want to make this into a mind-brain argument.  In other words, the biopsychosocial approach and the uncertain effect it has on the mind as opposed to a brain based approach that looks at specific mechanisms of action and seems to be focused on psychopharmacology.  He points out for example that the highlighted study would possible not qualify for current NIMH funding unless it looked at specific brain mechanisms.  He throws around the word "reductionism".  Anytime reductionistic or reductionism is used rhetorically in the same sentence with psychiatry it is pejorative.  My old psychoanalytic teacher would refer to anyone who talked about brain biology as a "dial twister".  The implication is that the reductionists are somewhat simple minded largely because they cannot accept the uncertainty of dealing with an organ that has poorly defined inputs and outputs.  Kind of a double whammy of rhetoric - you are a unsophisticated reductionist and you really can't see the big picture.  Are things really that simple?  Are these arguments accurate?  Are there problems with equating reductionism with "bad".

Of course there are major problems.  The first is the statement that inherent to the proposition that mental illness is a brain disease is "the implication that psychological and social events somehow are not also brain events."  This is a serious misreading of the definition of plasticity or experience dependent changes in the brain.  When I give my neurobiology of the brain lectures. I use Kandel's original New England Journal of Medicine article that discusses brain changes in a patient and a therapist conducting psychotherapy and how those changes are associated with brain plasticity.  I give further examples - weightlifting,  playing the violin, and how the typical stream of consciousness is profoundly altered by drug addiction.  There is no neuroscientist or biological psychiatrist I know who would suggest that psychological and social events are not brain events and there are numerous experimental paradigms that look specifically at how these events occur in the brains of animals.

The second aspect of Dr. Makari's argument has to do with reductionism.  His specific comment is:

"With luck, studies like Dr. Kane’s, which undermine these suppositions, will help move us away from such narrow thinking and embolden the substantial community within psychiatry that has never accepted such reductionism."

The suppositions in this case are that mental illness is a brain disease and that social or psychological events have no brain representation.  The argument is based on that false premise.  But further the use of the term "reductionism" is instructive here as previously noted.  By definition reductionism applies to many proposed etiologies of psychiatric disorders.  Those etiologies can be studied at a molecular level or at a higher level.  Schaffer (2) says that a model is reductive if it "employs standard biochemical and molecular entities to account for psychiatric symptoms and disorders".  Non-reductive models discuss "causal connections at higher levels of aggregation."  He illustrates these definitions by looking at Kendler's non-reductive account of major depression.  Kendler has used path analysis to look at clinical variables relevant to psychiatric disorders and although I do not have access to the one used in the book, here is a typical example.  The model looks at life stages, familial factors and psychological factors and all are higher levels of aggregation than molecular mechanisms.  At the reductive side of things he examines Harrison and Weinberger's proposed genetic susceptibility genes for schizophrenia.  At the time the book was written the author limited the discussion to 5 genes.  He also looked at the continuum of psychiatric genetic models ranging from basic and advanced genetic epidemiology being non-reductive, gene finding partially reductive, and molecular genetics fully reductive.  It seems perfectly logical to me that the study of brain biology proceeds in the same way that the biology of all living organisms proceeds.  The difference is that we are studying an infinitely more plastic organ with significant computational power.  There is clearly a lot of phenotypic heterogeneity that is unexplained in psychiatric diagnostic categories.  It is highly unlikely that refining diagnostic descriptors or applying clinical methods will lead to any significant change in the diagnostic or treatment process.  I don't understand the reluctance to go after more specific mechanisms or treatments.

The idea that a molecular or clinical focus in psychiatry is the problem with psychiatric services is also misleading.  As I hoped to point out by my mental health center example, psychiatrists know all about comprehensive care but they are rarely able to provide it.  They have known about how to provide it for decades.  State asylums became overcrowded and not therapeutic due to the financial management of the system by state governments.  The bean counters have moved out of the asylum and they are now integrated at every level in the health care system.  They all have a very strong bias against the comprehensive treatment of mental illness.  They insist that patients with severe psychiatric problems do not get comprehensive evaluations, that they are discharged before they have been adequately treated, and that any associated addictions are poorly treated.  They do not have the same biases against people hospitalized for medical or surgical illnesses.  They have in effect, moved the poorly run, overcrowded asylum model into the general health care system.  Any comprehensive care for severe mental disorders in such a system is an advertising phenomenon rather than reality.

The reductionism argument is good for New York Times opinion pieces.  It may sell a few more papers or get a few more clicks online.  Unfortunately it perpetuates an old pattern of blaming people and psychiatrists in particular for the shortcomings of a non-system of mental health care in this country that is set up to favor large health care businesses.  You can blame psychiatrists all you want for that - but until people realize that the real problems are the product of business and politics - and not the scientific interests of psychiatrists - nothing will change.


George Dawson, MD, DFAPA

References:

1.   George Makari.  Psychiatry’s Mind-Brain Problem.  New York Times.  November 11, 2015.

2.  Scaffner KF.  Etiological Models in Psychiatry - Reductive and Nonreductive Approaches in  Philosophical Issues in Psychiatry.  Kenneth Kendler, Josef Parnas (Eds), The Johns Hopkins University Press, Baltimore, 2008:  pp 48-98.

Attribution:

Image is Microscope 1 by Bill3t Hughes on Flickr.  Reposted as noncommercial via Creative Commons License on 11/14/2015.  The original work is not modified.

Bipartisan Agreement on Treating Mental Illness - Believe It when You See It

The New York Times has an incredibly naive article on how legislators may be split on gun control but both parties support better care for people with mental illnesses. The article alludes to a bipartisan plan that would "prevent killers .....from slipping through the cracks."  The next paragraph says that the plan: "would lead to some of the most significant advancements in years in treating mental illness and address a problem that people on both sides of the issue agree is a root cause of gun rampages."

That would be groundbreaking news if it were true, but let's be realistic.  The history of funding treatment for addictions and mental illnesses in this country has been a downhill spiral for at least 30 years and there are no real signs that will changed.    Congress has essentially been at the root of the problem.  Congress after all is responsible for the disproportionately poor level of funding for the treatment of mental illness.  Congress basically invented the managed care and pharmacy benefit manager industry that has increased the rationing of psychiatric services that has led to the current deterioration.  Rather than focus of providing quality in the services that federal, state, and local governments typically provide (like community mental health centers, case management, civil commitment, protective services, and crisis intervention) they have adopted the managed care model of rationing services.

The only relative bright spot in mental health legislation was a parity law spearheaded by Senators Wellstone and Domenici.  The actual boilerplate is one thing and there was always a question about managed care would react to the parity law and if they could continue their successful rationing techniques.  Events in the past week suggest that they are as evidenced by the New York State Psychiatric Association and the Connecticut Psychiatric Society joining in a class action lawsuit against United Health Care and Anthem Health Plans for violations of the Mental Health Parity and Addiction Equity Act (MHPAEA).  The interesting aspect of the alleged "violations" is that they are standard rationing tactics that have been used by this industry for decades.

There are surprisingly few details of "improved mental health care" provided in this article.  There are many legislative tricks to make it seem like something has happened when it really has not.  The mental health issue seems like a safe haven for legislators who don't really want to address the gun issue.  I have posted some of the rhetoric on the issue here and some of it is fairly grim.  The President's initiative in the article involves over $100 million for screening.  There is no good evidence that screening adds much more than getting people on medications as fast as possible - probably too many people.

A related issue with Congressional lawmaking is that they rarely seem to consult anyone with expertise.  Many consider themselves to be experts in something even though they have never trained or worked in the field.  The people with the most significant access are business lobbyists and in many cases they are writing the laws or at least very satisfied with what is happening.  The focus is generally on improving the wealth of the folks with the lobbyists.  That is unfortunate because there are numerous ways to improve the provision of psychiatric services for severe mental illness without giving away more money to managed care companies.  The idea that "the most significant advancements in years in treating mental illness" will come out of Congress and business lobbyists sets my teeth on edge.


George Dawson, MD, DFAPA

Jeremy W. Peters.  In Gun Debate No Rift On Care for the Mentally Ill.  New York Times April 12, 2013.

More PPACA News

More news on the Affordable Care Act (ACA) in the New York Times today. I certainly want to applaud the New York Times for including another article that is fairly positive in terms of content regarding psychiatry and mental illness. On the other hand it is probably not a realistic appraisal of the impact the ACA will have on increasing the quality and availability of mental health services in the United States.

As I posted a couple of days ago the predominant business paradigm in healthcare is the main obstacle to reform, not the laws regulating healthcare or the payment mechanism. As long as the health care system is run by people who have no expertise and are making essentially business decisions we can expect the ongoing triple whammy of more health care inflation, poorer healthcare quality, and a lack of innovation.

This opinion piece is interesting because it includes a comment about what was supposed to be the great leveler of the healthcare landscape - the Mental Health Parity and Addiction Equity Act of 2008.  Similar opinion pieces were written about this law as soon as it came out in 2008. It was a cause for celebration among psychiatrists and advocacy groups. And then slowly over time it became clear that reality did not match the enthusiasm, even by a long shot.

The same process is occurring as I write this about the ACA.  Through a process of being favored by politicians and regulation, managed care companies have always been able to use purely subjective guidelines often under the rubric of "medical necessity" to deny care to people with mental illness or addictions.  There is absolutely no reason to expect that will not continue to happen.

Let me be clear about the types of problems I am referring to.  I am referring to people with significant disability due to major mood disorders, psychotic disorders, and addictions who have life-threatening problems and no real access to solutions other than spending a few days in a hospital ward that is poorly equipped to help them and the hope that they can make it to a 10 or 15 minute equally meaningless outpatient appointment anywhere from one to four weeks down the road. These people frequently have associated medical problems and no resources like a stable income or housing.

The proponents of the ACA will tell you that these people will now be seen in integrated outpatient primary care clinics and the quality of their care will improve. The logical question is why have the resources to help them been denied for the past 20 years and what is the likelihood that dynamic will change with an additional 15 to 20 million people in the system?
Psychiatric illness on a par with all other medical disorders?  I don't think so.  Not as long as a faceless managed care bureaucrat with no accountability can throw you out on the street, deny a medication that you need for an "equivalent" medication, or tell you that the treatment for your problem involves an endless series of "medication checks" with a "prescriber". 

George Dawson, MD, DFAPA

Richard Friedman.  Good News for Mental Illness in Health Care Law.  New York Times July 9, 2012.

NYTimes on Involuntary Treatment

The New York Times somehow let an all too true story about the treatment of mental illness slip through today instead of one of their more typical speculative pieces.  It is a story of a family desperately trying to get their father and husband assistance after he develops acute bipolar disorder with psychotic symptoms.  It is a reasonable discussion of some of the issues behind deinstitutionalization, involuntary treatment, and the sad state of affairs that currently exists in trying to get treatment for those with severe mental illness. 

Probably the best quote in the article follows:

“The lack of resources has triggered a devolution of the standard,” says Robert Davison, executive director of the Mental Health Association of Essex County, a nonprofit group that connects patients to services in northern New Jersey. “Twenty years ago, ‘imminent danger’ meant what most people think it means. But now there’s this systemic push to divert people away from inpatient care, no matter how sick they are, because we know there’s no place to send them.”

I will refrain from the typical term applied to the situations whose definition is: "a particularly bad or critical state of affairs, arising from a number of negative or unpredictable factors".  The reason I will refrain is that it is not exactly accurate.  The entire debacle has been totally predictable.  It is the predictable result of applying managed care rationing techniques to the private and public mental health sector and denying care to those people with the most severe forms of mental illness.  When your only perspective is rationing care to make money - there are no standards.

So  what are the solutions?

They are fairly straightforward.  First off, there needs to be reasonable commitment standards with a more appropriate balance than "imminent dangerousnessness".  From the article it is clear that even that standard is interpreted widely.  There needs to be a three part standard for danger to self, danger to others, and gravely disabled and not able to care for oneself.  Some states accomplish the same goals by separating civil commitment from protective services/protective placement statutes.  The latter approach has the advantage of avoiding the use of commitment courts for issues that come up in the course of Alzheimer's disease and other dementias.

Secondly,  the statutes need to be uniformly interpreted.  My experience working with probate courts from a 3 county area illustrates that no two judges would make the same decision on a particular case.  In many counties, the social workers screening the cases had much different philosophies.  The only time that changed was when there was a bad outcome.  That outcome was typically a person released by the court who attempted or committed a homicide or suicide.   

Third, there needs to be recognition that state hospital beds are not the only solution.  The main reason that state hospital beds don't work is that there are no local resources.  Once a person is ready for discharge, there is no place to send them.  More and more people accumulate at the state hospital and nobody is discharged.  There needs to be housing resources and community teams to actively work with people to facilitate discharge and maintain them in the community.   Just building state hospital beds has the predictable outcome of building more state hospital beds.

Fourth, financial conflicts of interest must be eliminated.  They exist at multiple levels and are the predictable outcome of rationing techniques that originated in the managed care industry 30 years ago.  The basic premise of managed care is that a "medical necessity" standard can be developed that will be subjectively interpreted by the company in order to ration care and save the company money.  One of the major loopholes has been any person that needs involuntary treatment.  The managed care company can simply say this care is no longer "acute" or "medically necessary" and transfer the financial burden of care to the taxpayers.  Huge cost savings to the managed care company.  That doesn't happen if you need a heart transplant.

The financial conflicts of interest occur at every level in the system.  Another example is the interpretation that at an aggressive or self endangering event has to have occurred in order to meet the commitment standard.  The author here does a good job of providing examples.  What is not obvious is the financial conflict of interest that is present in these situations.  In almost all cases - the hearing occurs  at the county level and the judge presiding knows the county's financial status and access to resources.  That significantly biases decisions especially in the case of counties where there are limited resources.

The only solution to avoiding these pure conflicts of interest is to have the money follow the patient and have it in a dedicated fund.  It is too easy to move funds around that should be designated for the treatment of severe mental illness if they move in and out of a general fund.  

Fifth, there need to be better managers of the systems responsible for the care of patients with severe mental illnesses.  Managed care companies clearly do a very poor job.  On the other hand every state generally has a large Department of Human Services and second to education they are usually the largest budget in the state.   Despite significant constant and high demands they are generally managed like any other state agency.  If there is a revenue shortfall and everybody has a 6% across the board spending cut, DHS also has a 6% spending cut.  These departments usually employ cost  center accounting that is also a detriment to coming up with an adequate plan of care across treatment settings.  Finally it is also common these days in both managed care and state systems to see managers with no clinical experience attempting to hold clinicians accountable to subjective standards and implementing plans to change care delivery - even though they have no expertise.

These are a few changes that would make a world of difference for families and patients like those mentioned in the NYTimes article today.  I am not very hopeful that they can happen because it would also involve changing a culture that has been the most insidious aspect of managed care.  That culture is quite simply - bureaucrats and business people telling psychiatrists what to do and restricting the resources needed to provide adequate care.

George Dawson, MD, DFAPA

Jennen Interlandi.  When My Crazy Father Actually Lost His Mind.  NYTimes June 22, 2012. 

Why Allen Frances has it wrong

Allen Frances has been a public critic of the DSM process and as an expert he frequently gets his opinions out in the media.  Today he has an op-ed piece on the New York Times that is a more general version of a more detailed post on the Health Care blog.  His main contention is the stakeholder argument and that is that there are too many stakeholders both public and professional to allow the American Psychiatric Association to maintain its "monopoly" on psychiatric diagnosis.  I will attempt to deconstruct his argument.

He discusses the earlier DSM versions as revolutionizing the field and the associated neuroscience but then suggests that diagnostic proliferation has become a central problem and the only solution is political arbitration.  What about the issue of diagnostic proliferation?  The number of diagnostic entities per DSM are listed below:

DSM-I, 268 entities

DSM-II, 339 entities 

DSM-III, 322 entities

DSM IIIR, 312 entities

DSM-IV, 374 entities

DSM-V,  370 - 400 entities (depending on final form)

In terms of the total diagnostic entities, I have not seen any stories in the media pointing out that the total number of diagnoses may end being less than DSM-IV.  I have also not seen any discussion of major diagnoses where that is clearly true, such as the elimination of schizophrenia subtypes.   Other issues on diagnostic proliferation that are not discussed are the other required diagnostic system in medicine - the International Classification of Diseases 9th Revision or ICD-9.   The recent modification the ICD-10 has undergone a revision and the total number of diagnoses has increased from 14,000 to 68,000 diagnosis codes.  A fourfold increase.  The number of potential codes for a fractured kneecap has gone from 2 to 480 or more than the total potential codes in DSM5. 

I have also not seen any discussion of the role of psychiatrists in making a psychiatric diagnosis.  Psychiatric diagnosis does not depend on looking up a diagnosis in a catalog of symptoms.  It involves being trained in psychopathology and knowing the patterns of these illnesses.  The patterns of psychotic disorders and the other main diagnostic groupings have basically been unchanged across DSMs.  Psychiatrists make clinical diagnoses based on these major groupings and not the total number of diagnostic entities.

Further evidence that the total number of diagnostic categories is unlikely to have any impact on the number of people diagnosed with mental illness in any given year comes from the distribution of diagnostic codes in an outpatient setting. For 2006-2007, there were approximately 58 million ambulatory care visits for mental disorders. 92% of those visits were for 10 major diagnostic categories that have not changed in recent DSM revisions. It is not likely that new diagnostic categories will significantly impact the remaining 8% or 4.8 million visits per year.

In a study more specific to psychiatry, the number of psychiatric ICD-10 codes used in Danish Psychiatric Central Registry.  The data  represented 1,260,097 diagnoses from 1,041,589 discharges of 653,754 patients from in- and outpatient treatment episodes.  Forty nine of the diagnostic codes accounted for 75% of all the diagnoses (Munk-Jørgensen, et al). 

The "medicalization of normality" is another argument.  The media routinely runs stories about the percentage of the population that is "mentally ill" based on DSM diagnoses.  One of the common stories is the estimate that as many as 50% of the population has a DSM diagnosis over the course of the year.  There is never a critical look at that statistic.  The first dimension is whether any percentage should be too high or too low.  For example, would anyone be surprised to learn that 100% of the population has a medical diagnosis in the previous year?  With a high prevalence of gastroenteritis and respiratory infections - probably not.  The second dimension speaks directly to the issue of threshold for an illness.  One of the key papers in this area shows that although the one year prevalence using DSM criteria may be high, limiting the diagnoses to severe disorders reduces the prevalence to 8%.

The use of high prevalence numbers for mental illness based on DSM diagnoses also ignores the extensive Epidemiological Catchment Area (ECA) work that estimated lifetime prevalence.  Readers are generally not told that the methods used include addictive disorders and neurological disorders that cause cognitive impairment.  Would anyone doubt that 32% of adults would report a psychiatric disorder that included an addiction or cognitive impairment at any point in their lifetime?

Similarly there has been the repeated criticism that psychiatrists were going to start treating grief like clinical depression.  I have never seen that approach anywhere in my career spanning psychopathology seminars, journal articles, and continuing education courses.  Any psychiatrist with a clue knows the difference between grief and depression and at some point they have probably been tested on that difference.  What psychiatrists know that is not public knowledge is that a small number of grieving people actually develop a depression that is indistinguishable from clinical depression and it may have to be treated that way.  Knowing the difference is part of psychiatric expertise and you really cannot write it down as sentences in a manual.  In fact, it is a grave  mistake to equate a manual of diagnostic criteria with the clinical expertise and methods of psychiatry.

Dr. Frances correctly points out that the other common media theory that DSM diagnoses are driven by the pharmaceutical industry is a myth.  He continues on to suggest that the public and other mental health professionals somehow have a stake in the DSM and that organized psychiatry has frozen them out.  He concludes: “Psychiatric diagnosis is too important to be left exclusively in the hands of psychiatrists.”  I don’t understand how the specialty who invented the technology, who is trained and tested on it, and who is focused on a comprehensive view of psychopathology that extends beyond it should somehow give way to political considerations.  As he points out – there are always political considerations – even in science.  I would suggest that there is no such thing as “independent scientific review” of anything that psychiatry does.  There are many ways to address issues of professional bias in terms of including a diagnosis or not.

The arguments against the DSM and psychiatric influence vary across the usual spectrum of there being no such thing as a psychiatric diagnosis to there are too many diagnoses to the fact that psychiatric diagnoses are nonspecific.  There is no practical way to incorporate that spectrum into a diagnostic manual that is designed for psychiatrists to make clinical diagnoses and do research.  The single most important fact that is left out of these debates is that psychiatrists are effective in treating serious mental illness and they are undoubtedly more effective now than they have been in the past.  That is the only reason we need a DSM and that is why it stays squarely in psychiatry.

George Dawson, MD, DFAPA  


Frances A.  Diagnosing the DSM.  New York Times May 11, 2012.

Frances A.  DSM5 begins its belated and necessary retreat.  Health Care Blog May 10, 2012.

Kessler RC, Avenevoli S, Costello J, Green JG, Gruber MJ, McLaughlin KA,

Petukhova M, Sampson NA, Zaslavsky AM, Merikangas KR. Severity of 12-month DSM-IV disorders in the national comorbidity survey replication adolescent supplement

Arch Gen Psychiatry. 2012 Apr;69(4):381-9.

Munk-Jørgensen P, Najarraq Lund M, Bertelsen A. Use of ICD-10 diagnoses in Danish psychiatric hospital-based services in 2001-2007. World Psychiatry. 2010 Oct;9(3):183-4.

Regier D, Kaelber CT.  The Epidemiological Catchment Area Program:  Studying the Prevalence and Incidence of Psychopathology. in  Textbook in Psychiatric Epidemiology eds.  Ming T Tsuang, Mauricio Tohen, and Gwnedolyn EP Zahner.  John Wiley and Sons, 1995. p141.

Schappert SM, Rechtsteiner EA. Ambulatory medical care utilization estimates for 2007. National Center for Health Statistics. Vital Health Stat 13(169). 2011. (see Table 7.)

NYTimes Tells You How to Rate Your Doctor

The New York Times has a feature (see first reference) that discusses why the number of Internet reviews of physicians is sparse and the quality is poor.  The main contention is that people are too intimidated to rank physicians. The author ignores the profit motive of all the sites as a potential conflict of interest and leaps to the conclusion that the AMA speaks for most physicians even though only about 29% of physicians are members of the AMA.  He also describes physicians as "untouchable" when in fact at least 20% of physicians can be expected to be sued for malpractice during their lifetime and malpractice lawsuits have resulted in entire specialties migrating from a particular state. That is hardly what I would describe as "untouchable".  He is openly critical of the president of the AMA suggesting that anonymous, undocumented, and unverified reviews are probably not the best source for a physician recommendation.  He quickly invalidates "disproportionately positive reviews" on some websites is the product of an "unquestioning mindset".

The worst part of the article is leaping ahead to the Medicare initiative and their physician report card. Nevermind the fact that the risk adjustment concern by the AMA is legitimate.  Nevermind the fact that there is really no valid way to compare physicians at this point in time.  Nevermind the fact that there are political interests at play in particular the managed-care industry and how they can potentially game the system in favor of their principles. The author basically is encouraging people to go full speed ahead.

The result of that experiment is fairly predictable. The only thing I am hoping is that Google will come up with a way to prioritize the relevant information about physicians such as where they really practice and how to get a hold of them instead of the pages and pages that you currently encounter when you are trying to find a physician.

The AMA doesn't give much better advice in their recent edition of the amednews.  In a piece entitled "Physician rating website reveals formula for good reviews", their first suggestion was to not have a patient waiiting for more than 15 minutes and no more than 10 minutes in the exam room.  I can't think of any practice where the physician has that kind of control over their schedule - even if they postpone all of the documentation and stay for several hours after the clinic closes to get it done.  The business experts observed:  "overall ratings were based on time in the waiting room and the exam room -- rather than perceived clinical quality".  Keep that in mind when you are looking at online ratings of physicians.

I would suggest an experiment of my own that I have conducted several times with a high degree of success.  Imagine that you have a serious medical condition that requires a high risk procedure and you want to find the best physician to help you.  Your search process will involve the Internet, but it does not involve looking at any of the ratings you find when you search on a physician's name.  What do you do?

I will come back and answer that at a later date and discuss how that needs to be modified when you are looking for a psychiatrist.

George Dawson, MD

Ron Lieber.  The Web Is Awash in Reviews, but Not for Doctors area Here's Why. New York Times March 9, 2012

Pamela Louis Dolan.  Physician rating website reveals formula for good reviews.  amednews. Feb. 27, 2012

Why Do They Hate Us?

The title of this column weighed heavily on the minds of some Americans immediately after the terrorist attacks of 911. I was involved in some Internet forum political debates at the time that looked at this question.  The question itself implies a lack of self analysis and misunderstanding of rhetoric and political strategy. Those same basic concepts can be applied to an analysis of psychiatry and the common political and rhetorical strategies that are used against us.

At this point some readers may suggest that this is quite a tangent for me to take given the fact that psychiatry after all is part of the medical establishment and as such should have very little to complain about.  Four or five decades of complaints from anti-psychiatry cults and about two decades of complaints from competing professionals has done little to diminish the influence of psychiatry.  If that is really the case, why has psychiatry been disproportionately affected in terms of resources available to treat patients and why are psychiatrists blamed for that?  I suggest that the discrimination against psychiatrists and their patients occurs at every level as the direct result of an antipsychiatry bias.

I first came directly in contact with hatred of psychiatrists in an unexpected setting – an academic team rounding on medical surgical patients.  It consisted of an attending, a senior resident, two interns and two medical students.  When the attending learned I was going to do a psychiatric residency, it was an opportunity for ridicule.  Didn’t I realize that psychiatrists were lazy and did not know what they were doing?  Didn’t I know that nobody with a mental health problem should consult with a psychiatrist?  The special attention focused on me peaked when this attending challenged me on the correct diagnosis of acute abdominal pain.  The patient was middle aged, obese and had acute abdominal pain with nonspecific exam findings.  What was my diagnosis?  When I said “appendicitis” – the attending said I was wrong and gave all of the reasons why the diagnosis was cholecystitis.  Several hours post op we had the diagnosis of acute appendicitis.  I learned more about what some physicians think of their psychiatric colleagues than the diagnosis of the acute abdomen during that rotation.

I came across an illuminating piece in the British Journal entitled Advances in Psychiatric Treatment. The author Claire Bithell of the Science Media Center in London showed that psychiatry was less likely to be reported on in the popular press and when it was, received treatment that was four times as negative as other medical specialties.  In an associated piece based on meetings with journalists, academics, clinicians and journalists she found problems at all levels in terms of engaging the media and one of the conclusions was that experts need to engage with breaking news stories to get important messages across to the public.

  

It is easy to prove to yourself that the same problem with the press exists in the US.  It is as easy as going to the New York Times web site and doing a quick search on psychiatry.  The search returns the articles and several commentaries on how psychiatrists are turning to medication management rather than psychotherapy,  an article on how the man accused of the mass shooting at Fort Hood was a psychiatrist, Radovan Karadzic was a psychiatrist, and an article about Carl Jung.  One of the central articles “Talk Doesn’t Pay So Psychiatry Turns Instead To Drug Therapy” gives the specific detail: “A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session”.  But at that point the author incorrectly concludes that competition from other mental health providers is the reason that psychotherapy is so poorly reimbursed.  He should have just applied his earlier conclusion that the dominance of large hospital groups and corporations in combination with the government essentially fixes insurance reimbursement to whatever the payers want to pay.  They do not want to pay for psychotherapy despite the fact that it is clearly an evidence based therapy.

The origins of bias against psychiatry are varied and include the continued misunderstanding of what we do and what our training is, fear of mental illness, and in many cases the pursuit of political goals.  We have seen attacks on psychiatrists by politicians, Hollywood stars, other psychiatrists, and of course anyone who wants to write an antipsychiatry book.  It can be very subtle such  as recognizing that there is no practical way that psychiatric services can be provided and shutting them down.  In this case it is common to blame psychiatrists for the “lack of access” rather than inconsistent and unrealistic reimbursement by payers.   I was talking to a highly reimbursed proceduralist one day who said that she didn’t mind that some of their margin was used to pay for psychiatry because it seemed like a needed service.

 At times the sheer amount of noise out there about psychiatry is deafening.  I don’t think we are alone when it comes to negative publicity.  Teachers and law enforcement come to mind.  I do not think that there is any doubt that public perception is affected by what is often false information about psychiatry. 

Apart from what is purely propaganda,  most people have an innate tendency to see themselves as armchair psychologists.  Artificial intelligence philosophers came up with the term folk psychology to discuss this tendency and its benefits.  If you are a folk psychologist you might conclude that it is so easy that a psychiatrist has nothing to add, especially when you watch other folk psychologists on television all day long.  Some of the people who have hated us the most have had their theories rejected by organized psychiatry.

From an organizational standpoint,  how do we respond to the hate?  Although it would serve us well,  I doubt the public is very familiar with the philosophical criticisms of folk psychology any more than they know the difference between a psychiatrist and a psychotherapist.  What can we do when we are being smeared on a routine basis?  Ignoring the attacks is a strategy that the APA has used for years.  From a strategic perspective – it is effective to a point.  That point is where some of our detractors gain either political advantage or there are sudden and unexpected changes.  Before that happens we need to be much more aggressive.

Since my early days of involvement with the Minnesota Psychiatric Society,  we have always believed that getting our message out to the public was a critical first step.  I was the Public Affairs Director in the 1990s and coordinated several of the initial National Depression Screening Days.  Today the majority of depressed people I see have been treated for at least 10 years by family physicians and although they were reluctant to see a psychiatrist , they really had no idea that I was a medical specialist.  MPS recently tried to get a letter published by local media on the mass shooting phenomenon.  We co-authored the letter with two mental health public service organizations and it was rejected at a time when there was peak speculation about whether or not the alleged perpetrator was mentally ill and others  were identifying heroes and suggesting that we move on.   Depending only on a biased press is a recipe for continued failure.

We need to start by recognizing that we all have a common interest here and it is called the psychiatric profession.  That is true if you are employed by a health care organization, the government or self employed.  That is true if your job is primarily research, patient care, or administration.  That is true if you are a medical student who has just been accepted to psychiatric residency.  When we are under constant attack – a short term solution is to cut and run.  That will not work in the long run.  We are currently the standard bearers for the kind of care that is possible and apart from our colleagues in other countries we are often shouting alone in the woods.  It is very clear that state and national governments and their allies in the business world do not care about reasonable standards of psychiatric care and in many cases have codified that.  Other advocates are often left to play one side against the other on an artificial playing field of constrained resources.  Psychiatrists have a common interest in making a stand against unfair treatment by both the government and the health care industry.

The other issue is how to make that stand.  We currently have political strategies with politicians and other groups with similar interests.  Those groups are not interested in our standards and we need to take those arguments directly to the public.  We have to let them know what inpatient units and state hospitals are capable of doing.  We need to let them know what state of the art community psychiatry looks like.  We have to let them know that outpatient psychotherapy for depression is actually more than a session or two and coming back every month or two to see somebody about medications.  We have to speak out on every topic of mental health interest in the media and presenting it ourselves rather than expecting the media to pick it up.  That is our job in the near future.

That is also in part what this blog is all about.