Johnny Cash On Doctors And Chronic Pain

Driving home on a Friday night, as usual I am listening to public radio.  This time I happened to catch an interview with the late Johnny Cash.  Many people are not familiar with how much pain he endured over the course of his life, especially toward the end.  His problems with drug addiction are better known and that combination of chronic pain and drug addiction is a dangerous one.   I found a photo of Cash on Flickr that was taken by a photographer who encountered him when he had significant pain and I am currently trying to get permission to post that photo at the top of this essay.  The years of pain and illness appear to have taken a toll in this portrait and he looks weary.  I heard him commenting in a radio interview on the PBS series Blank on Blank.  After and introduction that describes him as having severe constant pain in his left jaw and the statement that he cannot take pain medications, the interviewer Barney Hoskins suggests that he is brave and Cash replies (1):

Johnny Cash: "No. I’m not very brave because for five years I didn’t try to take the pain.  I fought it.  I had a total of 34 surgical procedures on my left jaw.  Every doctor I’ve been to knows what to do next, too.  To relieve me of pain, I don’t believe any of them.  I’m handling it.  It’s my pain.  I’m not being brave either.  I’m not brave at all after what I’ve been through, I just know how to handle it."

That is hard fought wisdom when it comes to dealing with chronic pain.  In the previous few lines Cash had explained why he could not take pain medications.  He described it being like an alcoholic not being able to drink alcohol.  His pain started when his jaw fractured during a dental procedure and never healed appropriately.  In Hilburn's biography (2), Merle Haggard is quoted as saying that Cash was at a chronic 8/10 level, using the typical 10 point pain scale for the last 8 years of his life.  It is difficult to imagine how hard it might be to try to sing with chronic jaw pain.

Managing chronic pain in a person with a significant addiction problem is one of the most challenging areas of medicine.   For the past 15 years, the USA has been in the midst of an epidemic of opioid painkiller use and accidental overdose deaths.  This has been largely due to the effects of the politicalization of pain and pain medications starting with initiatives to prescribe more opioid pain medications for chronic pain and for acute indications that previously may not have resulted in that kind of a prescription.  From what I can tell, the liberalization of opioid prescribing came about initially as the result of initiatives from the Joint Commission (JCAHO), the Veteran's Administration, and the American Pain Society.  The initiatives can be viewed on this timeline. 

The treatment of chronic pain is also viewed as a treatment that involves multiple modalities.  It can certainly involve the use of various forms of pain medication, but physical therapy and psychological therapies are also mainstays of treatment.  I have consulted in many situations where patients have had multiple surgical interventions for pain that have not been effective.  I have never seen a person with 34 surgical procedures for the same pain.   From a purely medical perspective, the treatment can involve opioid medications, but also gabapentin, pregabalin, and various antidepressants.  Chronic pain is frequently associated with insomnia, anxiety, and depression and additional medical or psychological interventions for these problems is useful.  Many people have strong biases about opioid medications and consider them to be the ultimate treatment for pain.  Double blind, placebo controlled studies show that for neuropathic pain, the relief is moderate and generally equivalent to non-opioids.  Unfortunately for many, that fact is not known until after the person has become addicted to the opioid.

The surgical approach to pain is gradually changing over time.  I did a lot of neurosurgery during medical school rotations and in those days, there was a definite prosurgical approach to back and neck pain.  Imaging studies were more primitive with a predominance of CT versus MRI imaging of the spine.  I observed a lot of laminectomies and posterolateral fusions, using bone graft from a rib or iliac crest.  I was also in the clinic and saw large numbers of patients coming back over time for chronic opioid prescriptions for continued pain that failed to clear up with the operative procedure.  Our standard prescription in those days was Darvocet N-100s,  a fairly low potency opioid analgesic that also contained acetaminophen.  It was voluntarily withdrawn from the market by the manufacturer in 2010 after this labeling revision by the FDA in 2009 highlighting the risk of overdose, cardiac conduction abnormalities and fatal arrhythmias.  In the course of psychiatric practice, I pay close attention to spinal problems.  Spinal injuries are surprisingly common.  Degenerative disease of the spine is also common and there is very little focus on spinal health and the prevention of these problems.  In the people I have seen over the years, good prognosis spinal surgery in terms of pain relief generally involves a well defined lesion and neurological deficit in addition to the acute pain.  Chronic unchanged pain is still an outcome after repeated surgery.  At that point the question becomes, is there any medication that will reduce the level of pain.   Some people will do well with chronic opioids, but the problem is that patients with addiction generally do worse and exposing more and more people to opioids is increasing the number of people with addictions.  SAMHSA suggests the algorithmic approach in Exhibit 3-1 (3) above.  The problem is that there is no good data for relapse, failure, or success rates after trying an opioid for chronic pain in a person with an addiction.  My experience suggests that relapse rates are very high and success rates are very low, but I am seeing a population with a very high rate of addictions
         

In the absence of any markers of opioid addiction liability or reliable interview approaches a conservative approach is required and an extremely cautious approach is required if the patient has a known addiction problem.  The comment on doctors by Johnny Cash is one that is best not forgotten.  One of the reasons that opioids are prescribed in the first place is that pain is chronic and refractory to usual treatments.  In some cases, years of trying multiple opioids and going through residential drug treatment centers has resulted in the perpetuation of chronic addiction and chronic pain.  The algorithm above suggests the appropriate course of action for patients with that problem.  They need to be tapered off the pain medication and typically maintain the medication is necessary.  In many cases there is a significant amount of pain relief and improved function by tapering and discontinuing the opioids.  In some cases, the ability to function improves because the addiction fades away even though the pain is no better.

Johnny Cash got to the point where he could be tapered off the opioids and make it on his own.   That is a tough goal, but one that more people should strive for at least until there is a better solution to chronic pain and addiction.  He also reminds us of the role of physicians in this process.  My overall impression is that there are more physicians willing to draw the line and say: "I really don't think that another operation or medication is going to add much to what you have already tried." ..... but I don't think there is a lot of evidence to back up my opinion.      

George Dawson, MD, DFAPA

References:

1:  Barney Hoskins.  Johnny Cash on the Gospel.  Blank On Blank.  October 1996. 

2:  Robert Hilburn.  Johnny Cash - The Life.  Little, Brown, and Company.  New York. 2013. 

3:  Substance Abuse and Mental Health Services Administration.  Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders.  Treatment Improvement Protocol (TIP) Series 54.  HHS Publication No. (SMA) 12-4671.  Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011. (Figure 3-1 above is from page 34 of this manual).

Is SAMHSA a managed care company?

As I read through their flagship document:  Leading Change 2.0: Advancing the Behavioral Health of the Nation 2015-2018 that was what came to my mind especially when I read statements like this:

"Over the past year, SAMHSA leadership with staff to establish a set of internal business strategies that will ensure the effective and efficient management of the Strategic Initiatives. The resulting Internal Operating Strategies serve as the mechanism through which SAMHSA will optimize deployment of staff and other resources to support the Strategic Initiatives. These Internal Operating Strategies (IOS)—Business Operations, Data, Communications, Health Financing, Policy, Resource Investment and Staff Development—articulate SAMHSA’s effort to achieve excellence in operations and leverage internal strengths by increasing productivity, efficiency, accountability, communications, and synergy." 

Being employed at one time in a large managed care organization, I am used to seeing business speak like this.  I learned to cringe when I read it because any Strategic Initiative based on business speak rather than science or clinical expertise typically ends up being a nightmare.  That's just my experience, but any American who survived the last financial debacle has to be sensitized to words like "productivity, efficiency, accountability, communications, and synergy."   I have a previous post on the Orwellian nature of the word accountability in case  you missed it.  But you can substitute any of a number of words in this paragraph - like excellence.  We used to have a term in medicine called quality that actually meant something.  Excellence as used in the business community is a whole new ballgame.  The number of centers of excellence and top hospitals and clinics based on business measures can be astounding.  You can probably drive out in your community and see one of these banners wrapped around some facility right now. 

SAMHSA is supposed to be the federal government's lead agency for the treatment of mental illness and substance use disorders.  There has been some debate, but I think the political strategy of SAMHSA is very clear and that is to continue the rationing and managed care tactics that have been in place for the past 30 years and make them official government policy.  Lately they have been using tactics that I have seen from these companies over the past 10 years.  Here is what I am seeing so far.

Consumer slogans and concepts are identified that are easy (and free) to support.  Micky Nardo, MD posted their pamphlet on their working definition of Recovery .  This is their "primary goal" for the next year and it was supposedly built on among other things: "consultation with many stakeholders" .  The pamphlet goes on to the definition of recovery with no apparent rules for their all inclusive definition.  For example, does everyone in recovery need to have all of the elements of the definition?  Are there exceptions?  If someone is lacking an element would we say their are not in recovery?  Is this just a subjective and totally personal assessment?  Or is this a goal? If so, why is the lead agency for mental health and substance use promoting it and making it a primary goal?  Note the goal here is "behavioral health".  Behavioral health is the managed care version of mental health.    SAMHSA is therefore supporting the managed care view of the world.  That world view has rationed and otherwise decimated resources available for the treatment of mental illnesses.  Just a few observations on the 10 page pamphlet.

Social media is used for marketing purposes.  Well it is the 21st century and this is how everybody including government agencies gets noticed these days.  I got this cheery notification from SAMHSA in an e-mail this morning:

  Nothing like using a standard Internet marketing strategy to discuss a process that has no proven efficacy in treating mental illness.  This is the kind of marketing approach to medicine and mental illnesses that I have seen and expect to see from managed care companies.  It usually happens right before they decide they will financially penalize you for NOT practicing Wellness activities.  In a plan where I was enrolled each employee had to pick a Wellness activity and a counselor would call at intervals and decide if you were in fact compliant with your activity.  Noncompliance meant higher premiums.  In the business world wellness can cost you.

Since SAMHSA is really not a managed care company, why are they using their marketing and political strategies?  The most likely explanation is the unparalleled success of managed care against physicians and other traditional health care organizations.  SAMHSA seems to have surprisingly little expertise in treating significant mental illnesses.  That puts them on par with most managed care companies in the US who if they are honest will flat out tell you that their job is to extract as much money as possible from subscribers who believe that they signed up for some kind of mental health or substance use benefit and send it somewhere else.  That theme is repeated time and time again in corporate America and nobody would fault an American corporation with than attitude.  With a government agency, especially the lead agency there should be a much higher standard than a corporate one.  What is the evidence for my statement?

Let me focus on a section that I lecture on at least a dozen times a year and have more than a passing familiarity with and that is the excessive use of opioids and the current opioid epidemic.  It is a subsection of one of the strategic initiatives for 2015-2018:

The administrators here take the incredibly naive (or cynical) view that what they say will somehow be done.  It is eerily similar to the original statements without proof or scientific backing that were made at the start of the opioid epidemic.  In those administrative guidelines the most compelling feature was that physicians were not doing a good job treating pain and therefore they had to be educated about it.  These guidelines were written by nobody less than the Joint Commission.  Now SAMHSA in their infinite wisdom  is deciding that physicians need more education about this.  Administrators like to play the education card.  They don't seem to understand that this problem, specifically the problem of overprescribing has little to do with education and more about how physicians are being manipulated to provide services that somebody who does not have a clear picture of medical care wants.  Let's remember the SAMHSA track record here.  From the FDA web site, the FDA claims that in 2009 it launched an initiative with SAMHSA "to help ensure the safe use of the opioid methadone."  From that press release (my emphasis added in the underlined section):

"The methadone safety campaign materials provide simple instructions on how to use the medication correctly to either manage pain or treat drug addiction," said H. Westley Clark, M.D., J.D., M.P.H., C.A.S., F.A.S.A.M., Director of SAMHSA’s Center for Substance Abuse Treatment. "Our goal for this training is to support the safe use of methadone by all patients and prescribing healthcare professionals."

The operative term is "all patients and prescribing health care professionals."  In other words SAMHSA was seeing this as an educational deficit.  The detailed program is still available online.  If only the health care professionals could be educated enough by an administrative body that knows more than they do, the epidemic of methadone related deaths from overdose would stop.  The problem occurred when the CDC looked at the epidemiology of single and multiple drug deaths involving opioids and found that the methadone related deaths occurred at much higher rates in both categories than other opioids.  Their recommendation stands in contrast to the SAMHSA educational initiative. From that document - my emphasis added in the underlined section:

• Between 1999 and 2009, the rate of fatal overdoses involving methadone increased more than fivefold as its prescribed use for treatment of pain increased.
• Methadone is involved in approximately one in three opioid-related overdose deaths. Its pharmacology makes it more difficult to use safely for pain than other opioid pain relievers.
• Methadone is being prescribed inappropriately for acute injuries and on a long-term basis for common causes of chronic pain (e.g., back pain), for which opioid pain relievers are of unproven benefit.
• Insurance formularies should not list methadone as a preferred drug for the treatment of chronic noncancer pain. Methadone should be reserved for use in selected circumstances (e.g., for cancer pain or palliative care), by prescribers with substantial experience in its use.

The CDC does not believe that the problem with the disproportionate deaths from methadone is an educational deficit.  They believe it is a problem inherent in the drug, clinical setting, and experience of the physician.  It should definitely not be prescribed by all physicians, even if those physicians are educated.   SAMHSA apparently still believes in the educational deficit.  As I have posted the associated regulatory problems includes the FDA and their continued approval of high dose opioid products against the advice of their scientific committees, and their plan to educate physicians to safely prescribe these products.  I am using this example to illustrate that SAMHSA's approach, educate the masses and they will accept wellness and their health will improve by practicing wellness is a pipe dream of extraordinary dimensions.  It does not work on a focal issue, why would it work on a population wide basis?

Paul Summergrad's take on the politicalization of wellness/recovery versus psychiatry/medicine was a very accurate statement.  Americans in general are intolerant of probability statements.  Blog discussions are a particularly intolerant environment.  I do not agree with his support of integrated or so-called collaborative care.  It is no surprise that SAMHSA supports and has a leadership role in this managed care strategy.  He stops short of pointing out that SAMHSA has nothing to offer patients with severe mental illnesses.  

Besides being basically a pro-business strategy, the SAMHSA initiative also takes the grandiose approach that there are no psychiatrists out there (I will let other mental health clinicians speak for themselves) who want to see the people they treat recover and lead meaningful and satisfying lives.  They make it  seem like their simple business objectives will be better at this goal than personalized treatment provided by a psychiatrist.   That may provide a rallying point for the detractors of psychiatry, especially when the APA chooses not to counter the insult, but it is not a concept based in reality.  There is nothing more important in the practice of medicine than how a patient does under a physician's care. 

I think it is time for SAMHSA to put up or shut up.  Even though they have probably stacked some of the outcome statistics in their favor ahead of time and some of the outcome measures are as vague as managed care company measures of excellence (both proven business strategies), let's see what happens.  And let's see if the Big Pharma critics are as skeptical of their outcome statistics as they are of a typical pharmaceutical industry funded clinical trial. 

So far they have a solid check minus on the opioid initiative.

George Dawson, MD, DFAPA

National Behavioral Health Quality Framework - Ultimate Oxymoron?

As I pointed out in a previous post, the Substance Abuse and Mental Health Services Administration (SAMHSA) a branch of the U.S. Department of Health and Human Services is currently working with the managed care industry.  They are also the object of criticism by E. Fuller Torrey in his recent editorial and upcoming book for promoting non evidence based care of people with severe mental illnesses and in fact at many levels dismantling existing care.   With that kind of a backdrop, their e-mail to me this morning suggesting that I should review the National Behavioral Health Quality Framework (NBHQF) and provide comments as an interested member of the public should not have been very surprising.  I thought I would put that commentary here rather than letting it be buried on a government website that nobody would read.

To set the appropriate tone for my comments, the introduction section of this document identifies the major entity that the government is working with here as the managed care industry.  I consider the NCQA (or NQF) to be a proxy for the managed care industry.  That is their history as I recall it and I am not aware of any physician professional group that says otherwise.  In fact, I cannot find the American Psychiatric Association as a member of the NQF, but I am fairly certain that they used to be a member of NCQA..

Getting back to the document - six goals are identified with a page each dedicated to currently available measures and a second page that is described as "future targeted measures that are deemed important to advancing the behavioral health quality measurement."  An example of what that involves is illustrated in "NBHQF Goal 1: Effective - Promote the most effective prevention, treatment, and recovery practices for behavioral health disorders."  Not to be too much of a stickler here, but I don't really know what a "behavioral health disorder" is.  The most precise definition would be "whatever mental or psychiatric disorder that a managed care company has decided that they will pay for".  Behavioral health is basically a business term with no medical or psychological meaning.  As far as I can tell, it was designed to disenfranchise psychiatrists and other mental health providers and yet the rationale for denying treatment was always proprietary "medical necessity" criteria.   Moving beyond that we basically see a number of screening interventions for "Provider/Practitioners", a number of completely unproven interventions and quality markers, and at least 30% of the cells in the matrix are left "intentionally blank".  What exactly is there to comment on?  In the second page "payers using payment incentives to increase the use of EBP (evidence based practices)" is actually considered a quality marker.  That is a conflict of interest much greater than any pharmaceutical company scandal.  To translate, that means that managed care companies nation wide have another way to deny payment and save money based on what they consider to be an "evidence based practice." but they are rationalizing it as a quality marker.

Let me suggest how the depression assessment and screening should be done in this matrix.  First of all the screening test in this case the PHQ-9 does need to be validated as a diagnostic and outcome measure in populations.  The  current literature is extremely limited and there is no evidence that population screening for depression accomplished anything other than exposing a lot of people to antidepressants that the FDA has identified as potentially arrhythmogenic.  The cost of prescribing SSRIs to a large population as well as the electrocardiogram abnormalities is unknown.

I will briefly comment on the additional goals.  "Goal 2: Person-Centered Care".  As previously explained, this is the goal of every physician who has ever been trained in medical school.  It appears here basically as rhetoric that is designed to disenfranchise professionals and make it seem like managed care companies invented individualized care.  "Goal 3: Encourage effective coordination within behavioral health".  What jumps out of the page at me under this sparsely populated matrix is "Ratio of detox to outpatient admissions".  It is well known that managed care tactics have essentially destroyed the availability of medical detox in most communities.  I can recall being told that medical detox was not "medically necessary" by managed care reviewers.  I guess the hope was that the cost of detox could be transferred from managed care companies to non-medical county facilities.  Quality care for addictions means that there needs to be a spectrum of care.  I don't know what ratio is implied by this quality marker but I can assure you that it will favor managed care companies.

"Goal 5: SAFE - make behavioral health care safer."  Suicide, injury and death, treatment for overdoses after hospitalization, and discharges on multiple antipsychotic drugs are suggested as quality markers.  There is no evidence of what it takes to make the assessment and treatment.  To capture any problems in these areas you need a quality process, not a piecemeal check box that can be gamed so that it appears that you are providing quality care.  Measuring these variables in the absence of defining a quality process is meaningless.

"Goal 6: Affordable/Accessible: Foster affordable high quality behavioral health care...".  This continues to be an absurd priority of the partnership between the government and the managed care system. There is no more "cost effective" approach than what passes for behavioral health care.  Mental health treatment in the US has been decimated by 20 years of managed care to the point it is practically non-existent.  During that same time there has been an addition of trillions of dollars in Cardiology, Intensive Care, and Oncology infrastructure.  Even if that were not true, what is the evidence that cost effectiveness has to do with quality?  It is certainly not reflected in the previous specialties that I just listed.

Are there problems with this approach?  It turns out there are major problems and here are just a couple:

1.  Administrative data - administrators have significant biases that seem to impact on so called quality markers across the board.  They don't seem to understand their biases and the major biases include not really knowing anything about medical quality,  thinking that medical quality can be derived from what is basically administrative data (length of stay, readmissions, etc.) and at this point in time having so much political leverage from government backing that they don't really have to pay attention to the considerable number of people out there who know a lot more about quality.  As I have documented on this blog this is a thirty year trend and all of that is captured in the NBHQF.  Any who has followed quality markers over the last two decades will probably have made the observation that business heavy entities like managed care systems are information averse.  By that - I mean that they collect a large amount of data  but it is really not enough data or the right data.  Great examples are HEDIS data and PHQ-9 scores.  Is it really possible to collapse medical quality in to what are really simplified demographic parameters?  No more than knowing that 50% of 85 year old men have coronary artery disease.

2.  Business practices trumping medical practice -  on this blog I have also reviewed these practices and will focus on one this glares in this report - "person-centered care".  For years HMOs and their administrators were focused on "population based care".  They scoffed at the notion that people or patients needed to be treated on an individual basis.  This was at the peak time when they were deciding that everyone with a certain condition should be hospitalized for a the same number of days and it was a "quality problem" if the length of stay in the hospital was too long.  Nobody ever complained if the length of stay was too short.  Many of the thought leaders in managed care go to that position by basically promoting these ideas.  Why is the managed care industry suddenly behind "person centered care".  You won't see the history recorded anywhere but a lot of it goes back to the primary care physician as gatekeeper.  If you assume that you can managed populations of people with the same interventions, you can tell your subscribers that they have to get "referrals" from their primary care physician for any tests or consultations that are viewed outside of the population norm.  This was happening on a large scale in the 1980s and 1990s but subscribers rebelled against it.  After all they were paying good money for insurance coverage and not seeing it back in what they were interested in for health care.  The gatekeeper function disappeared and suddenly even managed care subscribers could directly seek consultations and referrals that they were interested in.  Patient centered care from the managed care industry was basically determined by the market and the failed theory of their thought leaders about managing populations rather than treating individual people.

Physicians have always been taught that patient care is highly individualized.  The question is will they continue to let the government, business entities, and non-evidence based practices masquerade as quality.  Looking at the quality of physician commentary in the media, in journals, and on blogs is not very hopeful.  It is clear that physicians would prefer to blame themselves or one up one another rather than look at the true problems with the health care system and what bureaucrats and businessmen are calling quality.

George Dawson, MD, DFAPA

SAMHSA.  National Behavioral Health Quality Framework (NBHQF)

Straight Talk About the Government Dismantling Care for Serious Mental Illness

The ShrinkRap blog posted a link to an E. Fuller Torrey and D.J. Jaffe editorial in the National Review about how the government has dismantled mental health care for serious mental illnesses and some of the repercussions.   Since I have been saying the exact same thing for the past 20 years, they will get no argument from me.  Only in the theatre of the absurd that passes for press coverage of mental illness and psychiatry in this country can this subject be ignored and silenced for so long.  It was obviously much more important to see an endless stream of articles trying to make the DSM-5 seem relevant for every man.  The stunning part about the Newtown article is the commentary about what government officials responsible for policy have actually been saying about it.

The authors waste very little time examining the sequence of events in the Obama administration following the Newtown, Connecticut mass shooting.  President Obama initially stated he would "make access to mental health care as easy as access to guns." and set up a Task Force under Vice President Biden to make recommendations.  The authors argue that the agency that was consulted, the Substance Abuse and Mental Health Services Administration (SAMHSA) promotes a model of treating mental illness that has no proven efficacy, does not discuss serious mental illnesses in its planning document, ignores effective treatments for serious mental illnesses and actually goes so far as to fund programs that block the implementation of effective treatment programs.  In an example of the obstruction of effective programming by SAMHSA funded programs following the Newtown mass shooting:

"But, alas, the situation is even worse. SAMHSA does not merely ignore effective treatments for individuals with severe mental illness. It also funds programs that attempt to undermine the implementation of such treatments at the state and county level. One such program is the Protection and Advocacy program, a $34 million SAMHSA program that was originally implemented to protect patients in mental hospitals from abuse. It was kidnapped by civil-liberties zealots and has been used to block the implementation of assisted outpatient treatment, funding efforts to undermine it in at least 13 states. For example in Connecticut, following the Newtown massacre of schoolchildren, the federally funded Connecticut Office of Protection and Advocacy for Persons with Disabilities testified before a state-legislature working group in opposition to the proposed implementation of a proposed law permitting court-ordered outpatient treatment for individuals with severe mental illness who have been proven dangerous. The law did not pass."  (page 3, par 2.)

In other words, a SAMHSA funded program was opposed to a law in Connecticut that could potentially reduce violence from persons with severe mental illness.

SAMHSA administrators are quoted at times in the article. Any quote can be taken out of context but the characterizations of severe mental illness as "severe emotional distress", "a spiritual experience" and "a coping mechanism and not a disease" reflect a serious lack of knowledge about these disorders.  The idea that "the  covert mission of the mental health system ...is social control" is standard antipsychiatry philosophy from the 1960s.  How is it that after the Decade of the Brain and the new Obama Brain Initiative  we can have a lead federal agency that apparently knows nothing about the treatment of serious mental illnesses?  How is it that apart from  some fairly obscure testimony, no professional organizations have pointed this out?  How is it in an era where governments at all levels seem to demand evidence based care, that a lead agency on mental health promotes treatment that has no evidence basis and ignores the treatment that is evidence based?

Having been a long time advocate for the prevention of violence by the treatment of severe mental illnesses my comments parallel those of the authors.  Inpatient bed capacity in psychiatry has been decimated.  They point out that there are only 5% of the public psychiatry beds available that there were 50 years ago.  It is well known that people with mental illnesses are being incarcerated in record numbers and some of the nation's county jails have become the largest psychiatric institutions.  Where are all of the civil liberties advocates trying to get the mentally ill out of jail?

Only a small portion of the beds available can be used for potentially violent or aggressive patients and that number gets much smaller if a violent act has actually been committed. Most of the bed capacity in this country is under the purview of some type of managed care organization and that reduces the likelihood of adequate assessment or treatment.  The discharge plan in some cases is to just put the patient on a bus to another state.

Community psychiatry is a valuable unmentioned resource in this area.  In most of the individual cases mentioned in this article, the lack of insight into mental illness or anosognosia is prominent.  It is not reasonable to expect that a person with anosognosia will follow up with outpatient appointments or even continue to take a medication that treats their symptoms into remission.  Active treatment in the community by a psychiatrists and a team who knows the patient and their family is the best way to proceed.  All of this active treatment has been cost shifted out of insurance coverage and is subject to budget cuts at the county and state level.

Civil commitment laws and proceedings are probably the weakest link in treatment.  Further cost shifting occurs and violent patients often end up aggregating in the counties with the most resources.  Even while they are there, many courts hear (from a budgetary perspective) that they are committing too many people and the interpretation of the commitment law becomes more liberal until there is an incident that leads to the interpretation tightening up again.  Bureaucrats involved often become libertarians and suggest that commitment can occur only if an actual violent incident has happened rather than the threat of violence.

Although Torrey and Jaffe are using the extreme situation of violence in the seriously mentally ill to make their point, the majority of the seriously mentally ill are not violent.  They need the same resources.  It has been thirty years of systematic discrimination against these people, their families and the doctors trying to treat them that has led to these problems.  I pointed out earlier on this blog the problem I have with SAMHSA and the use of the term "behavioral health".  The problems with SAMHSA and current federal policy are covered in this article and I encourage anyone with an interest to read it.  If history is any indication, I don't expect anything serious to come of the criticism.  I anticipate a lot of rhetorical blow back at Dr. Torrey.  But as a psychiatrist who has worked in these environments for most of my career, his analysis of the problem is right on the mark.

George Dawson, MD, DFAPA

E. Fuller Torrey & D.J. Jaffe.  After Newtown.  National Review Online.

White House.  Now Is The Time.  The President's plan to protect our children and our communities by reducing gun violence.  January 16, 2013.

SAMHSA Aligned with Managed Care

When you have been as sensitized as I have to the rebranding of mental health services as "behavioral health" by the managed care industry - seeing a government agency promoting that brand is difficult to take.  I got an e-mail from SAMHSA this morning that does exactly that. The subsequent spin on behavioral health and health care reform needs to be read to be believed.  It is something that only a government bureaucrat or managed care administrator could actually believe.

This is an interesting excerpt: "Twenty years ago, even some in the behavioral health field didn't think recovery was possible."  Maybe that was why they were telling me that people in the throes of detoxification were now stable after three days.  Insisting that subscribers to their managed care insurance should be discharged home and that they could go to outpatient treatment despite repeated failures is certainly consistent with that statement.

Their spin on the PPACA is even more incredible with this summary statement: "Providers will also face new payment mechanisms such as capitation, episode rates, and team based payments rather than based on services provided."  That statement alone is proof that nobody at SAMHSA seems to understand that capitation was the primary mechanism that managed care used to dismantle mental health and addiction services to the abysmal level that they currently exist at.   Either that or they understand perfectly. 

This web page confirms what I have been saying for the past twenty years.  The government, in this case the federal government has been colluding with the managed care industry to marginalize the expertise of professionals and to continue to disproportionately ration care to anyone with a mental illness or an addiction.  The managed care industry and federal and state governments can spin that anyway that they want, but they can't get rid of the dismal record of the past 20 years or the fact that the government is now obviously promoting it.