Psychiatrists work for patients - not for pharmaceutical companies

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

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

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

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

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

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

George Dawson, MD

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

How Can Psychiatry Save Itself? Part 2.

Ronald Pies, MD just published his second article in a two-part series on "How American Psychiatry Can Save Itself". This essay contains specific recommendations for change. I was surprised to see that it was written from the perspective of "the American public is disenchanted with psychiatry and how the profession needs to address these issues". He attributes the public relations problem to a number of factors including the lack of "robustly effective, well-tolerated treatments", ties to the pharmaceutical industry, the declining use of psychotherapy, the public's lack of understanding of current effective treatments, and essentially political attacks by anti-psychiatry groups and other sources.

It is disappointing to see the formulation of the problem as basically one of public relations. Dr. Pies observes that the public really doesn't care about what was or what is in the DSM or the model that is used for mental illness. It is historically obvious that the only reason that psychiatry has been tolerated over the years has been our availability to treat people with obvious problems. It is difficult to deny that mental illness exists when you have brought your catatonic family member into the emergency department because they have not been able to eat or drink for two days. That fact alone is the reason that decades of anti-psychiatry abuse has been a nuisance but has not destroyed the profession. The main problems these days is that it has morphed into a brisk business for many of our detractors and whatever legitimate media is out there does not seem to be able to separate the wheat from the chaff.  In the case of psychiatry there is an incredible amount of chaff.

Dr. Pies has six fairly specific recommendations based on this public relations problem. I have listed them in table below along with my responses. This places him at a distinct advantage because I am in the position of reacting to his statements. I will offer my solutions further along in the article and hope for his rebuttal or the rebuttal of anyone else reading this article.

Dr. Pies	Dr. Dawson
1. Change the name of the DSM to the Manual of Neurobehavioral Disease or MND. Another option would be Manual of Psychiatric Disorders.	I generally avoid the term "behavioral" because it is a political term used by managed care companies to disenfranchise psychiatry or behavioral neurologists to suggest that they know more about human behavior than psychiatrists do.  Every time we use the word "behavioral" rather than psychiatry we lose to somebody.  Neuropsychiatry anyone?
2. Emphasize the importance of suffering and incapacity as hallmarks of disease and eliminate any condition that lacks those features.	I don't think the DSM is that confused in the "Cautionary Statement" or "Definition of Mental Disorder" (xxi) when it describes mental disorders as "a clinically significant behavioral or psychological syndrome or pattern that occurs in individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or loss of freedom.” There are additional details.
3. Separating clinical descriptions of disease from research oriented criteria using prototypes for the clinical descriptions.	This might be a useful public relations move but experienced clinicians already do this and there is some movement in DSM5 to already capture this, namely the elimination of schizophrenia subtypes.
4. Understand diagnostic categories as tools in the service of medical-ethical goals.	I think that experienced clinicians also currently do this.
5. Biological data is regarded as supporting but not finding disease categories and the diagnoses would remain clinical.	That is probably a state-of-the-art, but biomarkers may be fast approaching that can define more homogeneous categories of disease and more specific and successful treatments can be offered.
6. Parsimony with regard to the number of diagnostic categories.	Agreed and at some point we should be able to use mechanisms of disease to parse the categories. A hopeful but at this point speculative example would be the role of the ventral tegmental area in both addictions and amotivational syndromes.

From the opinions I have offered it should be apparent that I think this plan is a fairly weak one. In order to come up with a strong plan, the major problem affecting psychiatrists and the delivery of psychiatric services needs to be in clear focus. When I look at Dr. Pies suggested solutions he has public relations and the diagnostic manual in his focus. I suppose you could argue that public relations is always important and that the diagnostic manual is essentially a public relations nightmare particularly when you're considering the arguments of people who are not trained clinicians and who have their own agendas and are looking for easy press.  I don't think the American Psychiatric Association has the resources to engage the thousands of anti-psychiatry and special interest groups who want to make headlines by critiquing the DSM5.

In order to save American Psychiatry the problem needs to be clearly recognized. The single most destructive force to American Psychiatry without a doubt is managed-care and that includes managed care companies that are for-profit, managed care companies that are not-for-profit, pharmaceutical benefit managers, and government agencies that are using managed care strategies to ration psychiatric care.   Within the space of two decades they have essentially shut down half of the inpatient bed capacity, they have turned inpatient units into high-volume and very low quality discharge mills, they have created a similar assembly line in outpatient clinics, they have added hours of free work from physicians frequently to justify their financial decisions, and they claim to be one of the great purveyors of quality treatment in medicine in the United States. How can that travesty possibly be ignored? All of the other threats to American Psychiatry pale in comparison.  We have become a profession that is essentially defined by the managed care industry.

To reverse that trend and actually save psychiatry the following steps need to be taken:

1. Managed care, pharmaceutical benefit managers, and managed-care tactics being applied by the government and government proxies need to be clearly identified as the problem. There needs to be a concerted effort to reverse the political and tactical gains made by this industry and most importantly reclaiming the quality ground. The managed care industry is currently represented by NCQA, and its role as an accreditation entity. Anyone who has looked at their standards for mental health care should be appalled. Every professional organization that has psychiatrists as members should be critiquing this organization and posting their own quality standards.

2. Professional psychiatric organizations need to maintain the edge in terms of quality and standard of care guidelines. We cannot afford to have guidelines that are 5 to 10 years out of date they need to be up-to-date and current. If the American Psychiatric Association is not up to the task, other professional societies should post current guidelines in their areas of expertise. You cannot possibly win political battles against an industry special interest group by using dated and incomplete guidelines and standards of care. An excellent example of psychopharmacology guidelines is available on the British Association of Psychopharmacology website.

3. The education of future psychiatrists is critical and that makes the issue of managed care and assembly-line psychiatry an even more immediate problem. We cannot possibly expect psychiatrists to train for an additional one or two years if they are going to be paid $22 or less to see a patient. There are not enough "medication management" visits in the world to fund for that additional training and a professional salary. Unless concrete changes occur in the practice landscape the future of current psychiatric training is at risk and there is no point in speculating on how it can be enhanced.

4. In the event that adequate funding is available for training and the future profession I would recommend changes in the total time of residency and psychotherapy training but in a different manner than that suggested by Pies.  I would opt for adding a two-year neuroscience rotation and pool resources with departments of neurology and neurosurgery for a joint rotation to focus on the latest neuroscience applications to psychiatry, neurology, and neurosurgery. In the near future genomics and neuroscience will be required training and the associated philosophy can be taught at the same time during discussions of modeling at various levels.

In terms of psychotherapy, the first thing that we can do is recognize the progress that has been made in residency programs as well documented in the Archives article by Weissman, at al.  It was not that long ago that a number of "biological psychiatrists" were walking around and annoying the rest of us by proclaiming that "I don't do talk therapy".  A psychiatrist trained in psychotherapy applies that continuously in their work and uses it to inform the structure of treatment. Some of the best psychiatrists that I have encountered do psychotherapy in as little as 10 or 20 minutes and the patients they saw during that time found those discussions to be very beneficial.

Psychotherapy today can also be informed by the New England Journal of Medicine article written by Kandel over 30 years ago when he described how neuronal plasticity is affected by human encounters. The teaching of psychotherapy today can be used both as a technical tool to teach patients and a heuristic tool to teach staff and residents about human consciousness and its biological basis. Newer forms of psychotherapy such as Acceptance Commitment Therapy and Mentalizing therapy provide theories and an explicit roadmap and how to provide research proven and effective psychotherapy that takes human consciousness into account.

5. Political attacks by prominent government officials cannot be tolerated. It is no longer acceptable to suggest that all psychiatrists are corrupted because some psychiatrists are being paid to give presentations for drug companies or to do research. The suggestion that the DSM5 is corrupted, by ties to the pharmaceutical industry can be dealt with. There are clear strategies to deal with some of the blanket claims by Congressional critics.  I can never understand how an entire profession became criticized because of the fact that some members were legitimately being paid to work by the pharmaceutical industry. I cannot understand how a member of Congress can decide to investigate private employment arrangements between an employee and employer or say nothing when no problems are found. I cannot understand how member of Congress with significant conflicts of interest is allowed to treat our profession with impunity when his conflicts of interest are never discussed.

6. Board certification has become a business that is rapidly aligning itself with the business of running medical boards and managed-care corporations. The goal of ongoing professional education should be to bring all practitioners up to the same standards and there is no reason that board examinations are necessary. There is no evidence that they can achieve that goal. This was clearly an arbitrary political decision by the American Board of Medical Specialties and it should not be tolerated by practitioners in the field. There is precedent for forming independent boards and I would refer to the American Society of Addiction Medicine as a clear example. If the ABMS, is no longer relevant - a better solution would be to form a new board that meets the needs of clinicians instead of purported political goals.

7. Quality based standardization of local practice is an attainable goal. One of the practical problems in any medical specialty is the fact that there are outliers. There is a robust solution to this and the best example I can think of is the Wisconsin Alzheimer's Institute Dementia Diagnostic Clinic Network.  The network is a statewide collaboration of independent clinics that receive guidance and updates from a central university-based clinic specializing in the diagnosis and treatment of dementias. Patients anywhere in the state of Wisconsin or their physicians can refer to a local clinic to receive state-of-the-art diagnostics and treatment recommendations. This model solves two problems for psychiatry. The first is access to state-of-the-art psychiatric treatment and the second is practice drift by practitioners especially the outliers. It also solves a third problem of ongoing education.  There is no reason why collaborative networks like this one could not be established for mood disorders, addiction, schizophrenia, anxiety disorders, and personality disorders. Training at all levels could be guided by the principle that psychiatric residents need to have the necessary skills to get into these networks and implement the guidance suggested by the central academic center.

That is the path I would take to save American psychiatry. It is not an easy path but it is a realistic one. Any psychiatrist who has been practicing for the past 10 or 20 years realizes that the practice environment has deteriorated rapidly and despite all of the talk about a shortage of psychiatrists, the current lot of psychiatrists is being worked to death and they are trapped in a paradigm that results in high volume and low quality work.  The main problem is that there is no foreseeable professional organization that can carry it out. The APA does not have the political will, expertise, or leadership to do it and in that regard the future does not look good. I think that also implies that the APA has really underestimated how far psychiatry has fallen and how much they have played a role in that fall.  I see an occasional glimmer of hope, but as long as we have an ineffective structure and an election process that rewards academic achievement rather than a vision for psychiatry in the 21st century, progress will remain difficult if not impossible. We have already been replaced by a generation of "prescribers" in some areas and managed-care and the government would not complain if that occurred everywhere.

George Dawson, MD

Ronald Pies, MD.  How American Psychiatry Can Save Itself: Part 2.  Psychiatric Times March 2012, vol XXIX, No 3: 1, 6-8.

Myrna M. Weissman; Helen Verdeli; Marc J. Gameroff; Sarah E. Bledsoe; Kathryn Betts; Laura Mufson; Heidi Fitterling; Priya Wickramaratne. National Survey of Psychotherapy Training in Psychiatry, Psychology, and Social Work.  Arch Gen Psychiatry. 2006;63(8):925-934.

Kandel ER. Psychotherapy and the single synapse. The impact of psychiatric thought on neurobiologic research. N Engl J Med. 1979 Nov 8;301(19):1028-37.

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.