Collaborative Care Just Gets Worse.....

I am a long time opponent to the expansion of the collaborative care model and have explained why in earlier posts on this blog.   At the Minnesota Psychiatric Society (MPS) conference last week, I learned that the collaborative care model had expanded to more than just the treatment of anxiety and depression.  The presenter discussed an expanded model to treating bipolar disorders based on questionnaires based screening for that disorder.  The overriding rationale for this model is that psychiatrists can't possibly see all of the patients with mental illness, therefore a more  hands off approach to care was acceptable.  The presenters were very explicit about the model not involving direct patient care in the primary care clinic.  The concern is the psychiatrist would start to to develop their own practice in the clinic and within several months their schedule would be full and they would have no capacity to see anyone else.  I can say from my experience that a primary care examination room is the wrong setting to do psychiatric consultation.  At the minimum a psychiatrist needs a service where they can take detailed notes.  Scribes are apparently on the rise these days.  I would be be very concerned about the training necessary for a scribe to record the details that I consider to be important and remain in the background during the interview.  I am a purist and believe that another person in the room produces a different interview.

The argument about expanding the collaborative care model fails at the level of the total number of psychiatrists and the total number of people needing care by psychiatrists.  Being medically trained I have always defined those people as having the most severe forms of mental illnesses.  That is the essence of having a defined number of physicians for any population and it works very well for other specialties.  The ones I have written about here include ophthalmology and orthopedic surgery.  Despite having fewer physicians available, both of these specialties cover a much larger spectrum of eye, bone, and joint disease and trauma.  They are seeing a larger number of patients and in many cases performing lengthy operative procedures on these patients.

The collaborative care model has rapidly evolved in the hands of the APA from the Diamond Project of about a decade ago.  The original Diamond Project involved collecting PHQ-9 scores in primary care setting and having case managers remain in touch with patients for supportive counseling and to review the progress of patients based on those scores with psychiatrist.  The psychiatrist recommended medication changes in order to improve treatment of the depression and improved PHQ-9 scores.  The state of Minnesota took this one step further and decided to implement widespread reporting of PHQ-9 scores from all primary care clinics as part of an accountability initiative called Minnesota Community Measurement.   Lacking any scientific or statistical merit did not slow down the politics of the least accountable (politicians) holding the most accountable (physicians ) - even more accountable.  At least one group of experts has come out against the idea of depression screening, because using the current models it eventually equates to more antidepressant exposure.  That has not slowed down health plans in the state of Minnesota or national organizations that essentially represent health plans. So far, I am unaware of any reporting of PHQ-9 changes.  I sent the project an e-mail about 5 years ago pointing out that their statistical approach was meaningless on a longitudinal basis - so it will be interesting to see what they eventually report.      

The course presented was Applying the Integrated Care Approach: Practical Skills for the Consulting Psychiatrist.  It was presented as an official American Psychiatric Association backed course and part of the Transforming Clinical Practice Initiative.  Since I have never heard of this initiative before I just assumed it was another in a series of top down decisions by an organization that I thought was supposed to support its members.  I would include the very unfavorably rated Maintenance of Certification initiative to be another in that series.

I will proceed to the end product to illustrate the general feel of this course for experienced psychiatrists.  Every psychiatrist has had on-call experience.  During those times it is common to be operating in a decision-making environment where there is either inadequate or partially adequate information to make a decision.  An example is being on call and admitting patients by some combination of phone calls or internet network connections or both.  A new patient comes in at 10 PM, it is impossible for the psychiatrist to get up and drive to the hospital to do a comprehensive admission evaluation on each patient, so temporary orders are given over the phone, until the staff psychiatrist can see the patient and refine the process in the morning.  In the uncomplicated process, this is an easy task.  The healthy patient comes in taking fluoxetine 20 mg.  The medication is continued until the next day.  But things can get much more complicated in a hurry.  What happens when you are asked to write the on-call orders for a bulimic patient with depression on bupropion who may be in alcohol and benzodiazepine withdrawal?  Or the patient who has been on escitalopram, using methamphetamine, and is complaining of some symptoms of serotonin syndrome?  What happens when a sixty year old patient comes in taking 10 different medications for hypertension,  diabetes mellitus, and atrial fibrillation?  Medications need to be modified or held and significant additional plans need to be implemented.  These are the kinds of calls that you will be making in the APAs integrated care model.  The only difference is that they will be strictly regarding psychiatric medications, but they will be all of the medications and more than just antidepressants and anxiolytics.  You must be prepared to treat bipolar disorder by proxy on partial information and assume the primary care physician has the skill set to take it from there.

 The screening instrument for bipolar disorder is the CIDI-3 developed by the World Health Organization for lay screening of large populations.  I had absolutely no luck in locating CIDI-3 anywhere on the Internet or the WHO website.  I was able to locate this Harvard site containing containing what appear to be numerous sections of the Comprehensive International Diagnostic Interview (CIDI).  To anyone familiar with structured interviews (DIS, SCID, SADS, etc) it is a the same technology.  The CIDI-3 screen described in the PowerPoint for the course had two stem questions - one for euphoria and one for irritability.  Neither of them matched my stem questions due to a lack of duration criteria and no rule outs for medical or substance use problems.  It is also not clear about how a consulting psychiatrist is going to learn about the pattern of illness from these screens.  The it seems that the precedent set by the PHQ-9 and GAD-7, that a positive screening equals diagnosis - also applies in this case.      

As I thought about all of the work that is involved in the quality treatment of bipolar disorder, I asked myself about whether all of that work and all of the necessary information transfer to the patient and family can be accomplished in a primary care setting.  There is also the idea that a medication cures the problem.  Although bipolar disorder is undoubtedly one of the most biologically based psychiatric disorders, it takes plenty of skill in managing side effects, associated symptoms (especially anxiety and sleep), and additional supportive psychotherapy.  There is also the issue of assessing suicide potential and generally functional capacity including risk for aggression but most importantly the ability to care for oneself.  In psychiatric practice - each of those dimensions amounts to an additional primary care visit.  All things considered, I don't see bipolar disorder or any type being assessed and managed well in primary care settings with a psychiatrist phoning it in.  The lecturer in this case had ample justifications - but to me that is all a reaction to excessive and continued rationing of psychiatric services.

And speaking of rationing - the money was discussed.  First - the psychiatrist in these consultations does not submit any billing.  The primary care clinic submits a collaborative care billing code and then they reimburse the psychiatrist.  At no point in my career as a physician employee have I ever seen an exchange like this occur where an administrative fee was not tacked on - just for the purpose of cutting the check I guess.  Second - there is all sorts of hype about how these arrangements save money in primary care settings.  Since managed care stole the field of medicine 30 years ago - there are ad nauseum articles written about cost-effectiveness.  To me it is just another buzz word for managed care.  There is no reason to expect that treating severe psychiatric disorders should be any more cost-effective than treating severe non-psychiatric medical disorders - in fact, one often leads to the other.  The lecturer in this case was very honest about that.  He pointed out the two studies that claimed costs savings and bluntly said that he doubted that would apply to clinical situations.

All things  considered, collaborative care continues to leave a bitter taste  in my mouth.  It translates to second class care for psychiatric patients based on managed care rhetoric.  The argument can be made that these are not psychiatric patients - but primary care patients who would never see a psychiatrist.  I don't know  if that is really a legitimate argument or not because it comes down to legal and political convention rather than professionalism.  In that case it depends what faction ultimately "wins."  The APA has clearly adopted it and it openly promoting it.  At the end of this course, there was the doubly ironic offer to enroll in an online collaborative care course that would result in both CME credits and also MOC credits for maintenance of certification.

I don't know how covering call suddenly becomes psychiatric innovation.


George Dawson, MD, DFAPA


Reference:

1:  John Kern.  Applying the Integrated Care Approach:  Practical Skills for the Consulting Psychiatrist.  Presented at the 2017 MPS Spring Scientific Meeting; Thursday June 15, 2017 at 1:00-5:00 PM.


Supplementary:

Above image is from National Severe Storms Lab (NSSL) web site and reproduced here per the NOAA intellectual property notice.

Ophthalmology versus Psychiatry Part 2.

Spoiler Alert: Ophthalmology always wins!

I was driving home last Friday night and for several minutes it seemed like there was a bug in my right eye.  I did the upper lid over lower lid trick a couple of times and that didn't work so I pulled over and tried to rinse it out with artificial tears.  No change at all with that maneuver and then I started to see familiar floaters and small black dots in my visual field but only on the right.  I had the exact same symptoms a year ago that led to a diagnosis of a vitreous detachment with no retinal problems.  Later that night I started to see flashing halos in the upper right visual field.  I got in to see an optometrist through my health plan and was referred immediately to a vitreous and retinal specialist today.  At a about 2PM today, I had a laser surgery procedure to fix a small retinal tear in the periphery of my right retina.

The specialist explained pathophysiology, the rationale and the expected success rate.  There is age-dependent liquefaction of the vitreous humor and in that process it can pull away from the retina.  That process can be benign like it was for me a year ago or it can lead to a "traction-event" on the retina and cause a tear.  The main reason for the laser surgery is to spot weld the tear by forming a photcoagulation scar where the laser hits and prevent a more extensive tear that could require open surgery of the eye and the risk of infection and further vision loss.  The decision for the laser surgery was an easy one, especially because I have known many people who required variations of the open surgery.  I sat in an ophthalmology exam chair with my head in a fixed position.  This video illustrates the exact procedure that I underwent today.  The laser light was green and at the end of the procedure I was completely blind in the eye for about 10 minutes and then transitioned to a violet vision and then back to normal.  This phenomenon is cause by saturation of the photoreceptors by laser light.  The procedure I underwent was much faster with repeated pulses of the laser.  If I had to estimate, I would say about 150-200 pulses of light were used.  The specialist kept me posted: "30% done.... 50% done, etc)" and also coached me on how I was doing focused on the extreme limits of my visual field.    

I had some observations about ophthalmology and orthopedic surgery last year and this year is no different.  First, I am amazed at how many of these vitreous retina specialists exist across the country.  Given my previous estimate of the total number of ophthalmologists and the numbers of people that they treat,  the distribution must be very good across the country.  Their services are certainly in demand.  Retinal and vitreous disease is clearly an age related problem.  There were 15 people in the waiting area and there was one person younger than me.  Most were considerably older and many were there to get injections to slow the progression of macular degeneration.

I am no stranger to ophthalmologists.  When I was in the 8th grade I shot myself in the eye with a BB gun and have had appointments every year to follow up on that injury.  That has also allowed me to follow the way that ophthalmologists practice.  Back in the 1960 to 1980s they did everything.  They started out with visual acuity tests, then visual fields, the intracranial pressure by tonometry and eventually the slit lamp approach.  They did the entire refraction and tried to get the visual acuity as good as possible. They proceeded to the slit lamp exam and at some point started doing retinal exams using hand held lenses and lens in conjunction with the slit lamp.  If an ophthalmologist was really flying and had a patient who was able to  cooperate - it might be possible to get all of this done in 20-25 minutes.

Things have changed drastically since that time.  I was roomed by a medical assistant who recorded the history and  took my vital signs.  In Room 2, I saw another medical assistant who took additional history, cursory social and family history (only eye diseases and diabetes in parents and siblings) and a cursory review of systems (have you had a heart attack or stroke? do you have chest pain today?).  She did visual acuity, visual fields by confrontation, and ocular motility and recorded it in the chart.  She did a slit lamp exam.  She measured intraocular pressure by some kind of digital hand held tonometer that I had never seen before.  She got my eyeglass prescription off the new lenses and did not need to do a refraction.  In Room 3, I was introduced to a scribe who told me that she would be taking notes for the specialist.  She set up twin displays with the EHR spread across.  The specialist walked in and performed indirect ophthalmoscopy by both slit lamp and standing hand held lenses.  He told me that I had a retinal tear and we discussed the surgery.  The scribe reminded him how it needed to be worded in the chart and how she was going to record it.  I electronically signed the consent form.  In Room 4, I saw a person who only did retinal scans with a blue light.  Finally in Room 5, the laser procedure was done.

This was a significant display of efficiency in terms of division of labor with a sole focus on problems related to the eye.  The social history is not that important in this case - they were only interested in marital status, offspring, and occupation.  They were not really interested in a review of systems other than a more detailed review of ocular symptoms - including my history of the BB gun injury.  They efficiently proceeded to laser my torn retina (at about the 45 minutes mark) and if the quoted statistics were correct - greatly reduce the likelihood or a major retinal tear and the need to open surgery or in the very worst case partial or complete blindness.      

Unfortunately in psychiatry we have nothing like this.  I am still doing what I have done for the past 30 years - an obsessive 240 plus point interview that included a detailed history.  My medical history, review of systems, social and family histories are all comprehensive and customized for the situation.  If I want vital signs or some examination - I have to do it myself.  In some clinics I can get checklists - but despite all of the hype about collaborative care or measurement based psychiatry those rating scales are a poor excuse for detailed questions about the problem.  The people who believe they are actually using quantitative metrics to measure care with these scales are fooling themselves.  In order to make up for the stunning lack of efficiency in psychiatric practice we have the workarounds of more and more prescribers - all asking their own questions and making their own diagnoses or we have the collaborative care psychiatrist advising primary care physicians on how to treat their patients based on rating scale scores or the questions of those physicians.

The other limiting factor is the lack of value assigned to the psychiatric evaluation.  I have not seen the bill for laser eye surgery - but I can speculate that it will be many times what I am paid for a comprehensive evaluation in roughly the same period of time that it took to diagnose and repair my retinal tear.  With the division of labor, the ophthalmologist was seeing 7-8 times as many patients in an hour than I can see.

To me that is both the most positive aspect of clinical psychiatry, but also its downfall.  Psychiatry is too complicated to commoditize.  Don't get me wrong - it happens all of the time.  Very few psychiatrists who are not in private practice have the luxury of talking with people for an hour.  That makes patient experiences highly variable.  We have to find a model that takes us out of the 1970s but also provides more clear cut results.  Ophthalmology has clearly been able to do that.  Science and treatment in medicine is better with precise measurement.  There is nothing about rating scales that I would call precise.

With my retina and vitreous problems I have come to another conclusion.  Training in Geriatric Psychiatry is designed to increase sensitivity to ageism and and biases against the elderly.  I have had plenty of that training.  Now that I am technically a geriatric person myself, I can speak with authority -  aging is an inescapable disease.  I hope someday there is a better solution.

But that is a topic for another post.



George Dawson, MD, DFAPA        





















  

Psychiatry With And Without A Conscious State

One of the great attractions of psychiatry for me - is the skill set that you have to develop to understand a person's real problems.  By real problems - I mean the problem or problems that brought them in to see you in the first place.  I am not talking about the problem listed on a referral sheet, or spoken in a telephone call, or even described to you by another physician or family member.  Advocacy groups and some psychiatrists tend to be self congratulatory on the amount of information about psychiatric disorders that is out there.  There is an excessive amount of confidence in lists of symptoms being the same thing as a diagnosis.  Any psychiatrist will tell you that the number of people who walk into the office and proclaim they have depression, bipolar disorder, or attention deficit-hyperactivity disorder is at an all time high.  They typically come to that conclusion by some combination of listening to TV ads or friends and family members.  In some cases they are directed to Internet sites where they can take a brief quiz to determine the diagnosis.  In almost all cases they are wrong.  Interviewing people to come up with both diagnoses and diagnostic formulations - is a considerable skill set that cannot be replicated by handing that person a symptom checklist or interviewing them like a talking checklist.

The problem in cases of self-diagnosis is that most people have a limited awareness of what diagnosable mental illness is.  They get their ideas from a static checklist or advice from a person who has not seen hundreds of people with the condition.  That process is often a checklist by proxy as in "I read this checklist in a magazine and you seem to have the symptoms.  You must have bipolar disorder."  In many ways that is like reading a manual about how to repair a complicated problem with your car.  Some untrained people may be able to pull that off, but the vast majority will fail.  The failure will occur at the level of pattern matching with the severe problems as well as the appropriate assessment of biases along the way.  That is not to say that experts are free of bias, but they are less susceptible to the common biases that occur along the way largely due to an accumulation of patterns that they have encountered over the course of their careers.

To develop the best possible understanding of psychiatric diagnosis and how it works might require consideration of some overlapping models of the conscious state in humans.  Consciousness is a complicated process concept, but it basically refers to the collection of mental processes that result in a stable personality and behavior over time.  An example of elements of consciousness is included in the representation below.  It contains descriptions that are found in the writings of David Chalmers and other authors on consciousness.  Chalmers breaks consciousness down into the easy problems or readily observable properties of consciousness and the hard problem.  The hard problem involves figuring out how the neurobiological substrate can generate conscious states and how those states are all unique.  There are a lot of theories about how that might happen, but none of them have been proven.

 The psychiatric assessment is trying to determine the parameters listed in the box at the right.  Some of the properties of consciousness are listed in the box at the left.  There is not a clear correlation between these elements, but what needs to be elicited in the interview will be determined to a large extent by the conscious state of the individual.  As an example, if I am interested in asking about sleep, I routinely take a sleep history that goes back to childhood.  I ask about insomnia, nightmares, night terrors, sleepwalking, and all of those states over the decades that gets me to the current age of my patient.  As an adult I ask about whether or not they have had polysomnography, whether they snore or have restless legs at night.  I ask them about the medical and non-medical treatment they have received for insomnia and if there were any complications.  I have to observe whether or not the person can reasonably respond to those questions or not and a lot of that depends on their conscious state.

In order to make a psychiatric diagnosis of a basic mood disorder, the primary criteria is that there has been a phasic mood disturbance for a certain duration.  In the case of depression the primary DSM-5 criteria is:  "Depressed mood most of the day, nearly every day, as indicated by subjective report or observation made by others" or  "Markedly diminished interest or pleasure in all, or almost all activities, most of the day, nearly every day."  That basic distinction taxes the conscious state of many people who are already diagnosed with mania or depression.  Wait a minute - "most of the day, nearly every day" - don't I have good days and bad days."  The number of people who make that observation when they are asked the specific question is significant.  When I hear that response, I remember the pre-DSM Feighner criteria for intermittent depression.  In those days it was acceptable to have good days and bad days.  Today in a complicated process occurring in the person's conscious state they need to decide if this phasic mood disturbance really applies or if there are other reasons for endorsing a positive response.  If they are handed a standard checklist for depression like the PHQ-9, the conscious thought process is much different than a psychiatrist asking them about an all encompassing mood disorder rather than "good days or bad days."

The process might even have to take a step farther back when the patient states:  "Wait a minute doc, I am not sure that I know what anxiety or depression really is.  Aren't they the same thing?  Doesn't one turn into the other? Can you explain it to me?"  This is a much different interview than a person coming in and declaring a problem.  This person is aware that some kind of problem exists.  They may have learned that from feedback from a spouse or an employer.  They don't know what to call it.  They might be aware of physical distress, but be unable to make the connection to emotional perturbations.  Is their concept of a disorder the same as the person who comes in declaring themselves to have the problem.  Probably not, but it is apparent to me from interviewing tens of  thousands of people over the past thirty years that everyone has a slightly different idea of the problem.  It is obvious that it is also a much different situation when the patient is handed a checklist of symptoms of depression and makes what is essentially a series of forced decisions about if they have depression and how severe it is.   Consciousness researchers have used the thought experiment about the color red for years.  That is, my experience of the color red, is probably different from your experience of the color red.  In other words, my conscious state processes the color red in a different and unique way compared with your conscious state.  Why would that not be true with regard to the various types of depression and anxiety?

 That brings me to another conceptualization that is often used to look at diagnoses like the dementias, schizophrenia, and attention deficit-hyperactivity disorder.  The abilities to plan, act, and perform these acts successfully is often referred to as executive function.  Although these functions tend to be arbitrary and arrived at by consensus, they have always been important in psychiatric diagnoses.   Major mood disorders, schizophrenia, and neurocognitive disorders may all have varying degrees of impairment in executive function.  Testing specific functions and trying to correlate them with behavior at the clinical level is frequently disappointing except in cases of significant brain damage.  By inspection, it is apparent that there is an overlap between executive functions and consciousness - but not a complete mapping by any means.  DSM-5 has a fairly extensive table on six Neurocognitive Domains (pages 593-595) that describes executive function as one of these domains.  Executive function is defined as planning, decision-making, working memory, inhibition, mental flexibility, and responding to feedback.  Clear examples of what can be observed in each case are given.  Neurocognitive disorders are clear problems in consciousness.

The common psychiatric approach to diagnosis and treatment is what I would call a biomedical approach.  It was elaborated on by George Engel in his famous paper on the biopsychosocial approach to medicine, but it was practiced extensively before that paper was written.  A lot of the social and familial aspects of this interview were undoubtedly influenced more by epidemiology and genetics rather than consciousness factors.  It has been known for some time that you make be more likely to have a heritable illness if it runs in your family or it occurs in members of your occupation.  But what does a psychiatrist also need to know about how anxiety develops.  Can it be transmitted directly from a parent who is a "worry wart" to a child?  Does the child recognize it at the time?  Do children remember when their father was enraged or their parents were fighting and they were wide awake listening to it all night long?  Do people remember what it was like to "walk on eggshells" due to all of this adversity occurring during their childhood?  Do all of these incidents affect elements of their conscious state that keep them stuck in what are defined as psychiatric disorders?  Without a doubt.

 Conscious states are important in both the diagnosis and treatment of psychiatric disorders, but for the purpose of this post I am ending on diagnostic considerations as noted in the first slide of this series.  I will briefly comment on the importance of each dimension.


Interview Context:  Psychiatrists are called on to provide services in a wide variety of environments.  The appropriateness of the environment for both assessment and treatment needs to be assured.  It is common for a third party to want to restrict access to the time of psychiatrists by rationing their time with the patient or total time allowed to see each patients.  Times vary greatly from system to system.  In some cases, a the time allocated for a new evaluation is 30 minutes and in others it can be up to 90 minutes.  I have completed complete interviews at both ends of the spectrum, but the limiting factor can never be some preconceived notion by an administrator.  The patient's conscious state is the limiting factor.  That includes how they respond to the psychiatrist and the introductory process of the interview.  It also depends on a quiet confidential environment and whether there are any observers in the room.  I have had many colleagues tell me that their interaction with patients is definitely affected both other people in the room.  This is a factor that can affect both the conscious state of the psychiatrist and the person being interviewed.

Empathy:  All psychiatric trainees learn a lot about empathy in early interviewing courses.  The necessary prelude to empathy is therapeutic neutrality.  That is a confusing term to nonpsychiatrists, but it essentially means not bringing in any extraneous interpersonal factors or emotions into the interview of a specific patient.  That ability is gained by self-analysis, experience, and in some cases personal psychoanalysis.  From the patient perspective, emotional reactions often surface as part of longstanding patterns of behavior.  They are often proximate to the problem at hand and very relevant in the initial interview situation.    

Empathy is taught as essentially a cognitive appreciation of the patient's emotional state.  The single best definition of empathy is from Sims in his book on descriptive psychopathology.   “In descriptive psychopathology the concept of empathy is a clinical instrument that needs to be used with skill to measure the other person’s internal subjective state using the observer’s own capacity for emotional and cognitive experience as a yardstick. Empathy is achieved by precise, insightful, persistent and knowledgeable questioning until the doctor is able to give an account of the patient’s subjective experience that the patient recognizes as his own.”  Sims captures the dynamic basis of the interview in this definition.  An empathic interview should result in a patient feeling very understood by the end.

Intellectual Capacity:  The intellectual capacity of the patient may vary considerably based on the psychiatric disorder they are experiencing.  By intellectual capacity, I am not referring to IQ scores.  I am referring to the ability of both the patient and the psychiatrist to recall and process information and consider a maximum number of explanations for what the patient is going through.

Emotional Capacity:  In the dyadic interview, the emotional capacity of both the psychiatrist and patient are important.  Can the patient describe the extent of any emotional disruption and the time course of that process.  Are they psychologically minded or can they appreciate social or psychological etiologies for these symptoms or do they view the problems as being treated only with a medication.  Psychiatrists are to a large degree self-selected on the basis of their interest in emotional problems. Many psychiatrists have had first hand experience in families where members have had a mental illness or addiction.  They had experience with all of the difficulties of getting that family member adequate treatment.  They recognize that these problems are very real and are generally highly motivated to provide treatment and advocacy.  As previously noted in the discussion of empathy, the ability to experience the emotional states of patients and describe them is necessary.  Sampling one's emotional state during the interview can also provide insights about the interview process, diagnosis, and overall meaning of the information being discussed.  As the average age of psychiatrists has increased, they have also seen thousands of patients with different kinds of emotional problems and successfully treated them.    

Information Content:  I find it surprising that the information content of diagnostic interviews is never estimated and the importance is never really taught.  There may be a correlation with the length of the interview, but not necessarily.  I can interview a person who gives brief high information content responses and do a reasonably good assessment in 30 to 45 minutes.  I can talk with a person who digresses and gives a lot of irrelevant details and still not have what I need at the end of 90 minutes or an hour.  The person who can assist me in doing the brief interview is not as common in my experience and I would say they represent 5% or 10% of the people I have seen.  There are also the Augenblick diagnoses or ones that can be made in the blink of an eye.  If I see a person with catatonia, delirium, or a stroke - I may not have to have them say anything to me.  Those rapid diagnoses will precipitate a thought process about what else needs to be ruled out and what tests need to be done immediately to confirm the diagnosis.  The information content in an interview is bidirectional and probably encompases severe channels including speech and paralinguistic communication.  The paralinguistic channel also contains information about the affiliative behavior of the participants.

Therapeutic Alliance:  An optimal diagnostic and treatment relationship flows from therapeutic alliance between psychiatrist and patient.  In other words - both are working together on a problem or set of problems that is bothering the patient.  It proceeds lie all patients interactions in medicine on an informed consent model.  Acute care psychiatry often involves the assessment and treatment of patients who are being detained on an involuntary basis because of safety concerns and in that situation the psychiatrist can be perceived as an agent of the state.  In that case and in many cases of long term treatment, it is often a good idea to review this principle with people in treatment to reorient them to the process.  Even a person who is being briefly seen for medication can have a problem in treatment if they perceive a psychiatrist a being poised over a prescription pad, ready to address their briefly stated problems with a new prescription.

Structure:  The psychiatrist has a responsibility to structure the interview so that the time is ultimately used to get results for the patient.  That means a singular focus on the patient, how the patient is proceeding in the interview, and how they are presenting the information.  That can mean giving additional information about the interview to the patient, providing necessary definitions, and doing whatever can be done to enhance the information content of the interview.  The introduction to the patient is critical because to this day there is still confusion over the definition of psychiatry.  I generally tell everyone my name, my years of experience, and present them with my business card.  After that I clear up any questions about psychiatry.  Some people ask about where I trained and I provide them with that information.  Some ask for clarification about the interview as we proceed.  A common question is: "Do you want the long version or the shirt version?"  Some early questions are also red flags and may be an indication of strong biases by the person being interviewed that may even preclude the interview itself.  Some of those decisions may also depend on the interview setting.  An example might be religion as a selection factor.  If a person tells me that they can only talk to a Christian using their specific definition and they want to ask me questions to determine my status, it might be easy to suggest that they see someone else in an outpatient setting, but a lot more difficult if you are the only available psychiatrist on an inpatient unit.

Technical Skill:  Like most professions, there is some variation in the interview and interpersonal skills of psychiatrists.  A psychiatric interview requires technical skills that psychiatrists have been focused on since early in their training.  Those skills are the focus of courses, seminars, books, papers and direct observation by training supervisors.  Since the oral board examinations have stopped, psychiatric residents now do the equivalent of oral board examinations on interview techniques during their training.  During an interview, a psychiatrist is listening for patterns and inconsistencies.  A psychiatric interview is not an interrogation.  In an interrogation, the interviewer generally has a bias and asks very leading questions to confirm that bias.  That style is evident in any number of police and crime television shows and films that are easily accessed these days.  In a psychiatric interview, the psychiatrist is developing hypotheses about diagnoses and formulations and inconsistencies with those hypotheses.  The interview itself can be very nonlinear and the psychiatric directs the interview from one major cluster of information to another.  A parallel process during the interview is recognizing the person's mental state and its potential origins.  Empathy as noted above is a critical aspect of that process.

Psychiatry is currently being practiced with an implicit rather than explicit focus on consciousness.  Making consciousness more explicit adds a lot to assessment and treatment.  The idea that every new patient being seen is truly a unique individual based on their conscious state is a primary organizing factor.  Their experience of mental distress is unique and can only be categorized with the broadest categories.  That emphasis creates a high bar for anyone who wants to be a good psychiatrist.  That psychiatrist by definition will critique each interview while they are documenting it and consider what was missed.  That psychiatrist will also critique any practice setting that requires them to interview patients according to electronic health record forms, diagnose people based on rating scales, or respond to patients in a stereotypical manner.  The recent emphasis on collaborative care is also a dead end in terms of consciousness.  The idea that a psychiatrist looking at rating scales and "managing populations" without ever talking to any of those patients is absurd from the standpoint of conscious states and diagnostic precision.

Human consciousness doesn't work that way and psychiatrists can't either.




George Dawson, MD, DLFAPA

New England Journal of Medicine Discovers Assertive Community Treatment

I have been a reader and subscriber to the New England Journal of Medicine (NEJM) every year since medical school.  One of the first courses they taught us in those days was Biochemistry and being an undergrad chem major I had a natural affiliation with many of the biochem professors.  The format in those days was lectures focused on the major topics and seminars to take a more detailed look at the experimental and theoretical aspects of the field.  They were fairly intensive discussions and critiques of research papers selected by the professors.  The department head was the mastermind behind this technique and one days he discussed his rationale for it.  He hoped that every medical student coming through that course would continue to read current research.  He strongly recommended subscribing to and reading the NEJM not just in Medical School but for years to come.  In my case it worked.

One of the sections that you don't hear too much about is the clinicopathological exercise that comes out each week.  It is basically a publication of formal case records of Massachusetts General Hospital and the associated findings and discussions.  These case reports are interesting for a couple of reasons - they show patterns of illness that clinicians can familiarize themselves with and they show at least some of the diagnostic thinking of experts.  During the time I have been reading them, they also discuss psychiatric comorbidity of physical illness and medical etiologies of psychiatric symptoms.  At one point I was a member of an informatics group and was very interested in studying this section of the NEJM from a psychiatric perspective.  At that time it seemed that I was the only psychiatrist with that interest.  With modern technology a study like this is more possible than ever.  For example, searching the case records feature of the NEJM from December 1989 to December 2015 yields a total of 31 cases of psychosis.  The etiologies of these cases range from purely medical etiologies, to delirium associated with the medical condition to pure psychiatric disorders with no specific medical etiology.  I have never seen this referred to as a teaching source for psychiatric residents admitting patients to acute care hospitals or consultation liaison services, but I could see it serving that function.  Instead of the usual lectures on medical psychiatry that typically contain PowerPoint slides of the "240 medical etiologies of psychosis" - a discussion of common mechanisms noted in these cases might be more instructive and be a better source for acquiring pattern matching capacity to broaden diagnostic capabilities.  It also put the DSM approach to psychiatry in proper perspective.  Knowing the lists and definitions of psychosis is nowhere enough to be a psychiatrist in a medical setting.  A seminar including this material can make these points and teach valuable skills.

That brings me to the case this week A Homeless Woman with Headache, Hypertension, and Psychosis.  Two of the authors are psychiatrists and the third is an internist.  The authors describe a 40 year old homeless woman with a diagnosis of schizophrenia and severe hypertension and how they established care over a number of years using the Assertive Community Treatment (ACT) model of care.  The patient's history was remarkable for a 12 year history of psychosis characterized primarily by paranoid and grandiose delusions.  She was homeless sleeping in public buildings for about 4 years and that seemed to be due to the thought that she needed to stay outside to watch over people.  She had a brief episode of treatment with olanzapine during a hospitalization about 5 years prior to the initiation of care by the authors, but did not follow up with the medication or outpatient treatment.  She was also briefly treated with hydrochlorothiazide 4 years earlier with no follow up care or medication.   She was admitted for treatment of a severe headache and a blood pressure of 212 systolic.  At the time of the admission physical BP were noted to be 208/118 and 240/130 with a pulse of 95 bpm.  She had bilateral pitting edema to the knees and bilateral stasis dermatitis.  She had auditory hallucinations consisting of voice of God and Satan and grandiose delusions.  Lab data showed a microcytic anemia.  She had standard labs to rule out myocardial infarction and vitamin deficiency states.  Blood pressure was acutely stabilized and she was discharged on lisinopril, thiamine, multivitamin, omeprazole, and ferrous sulfate.  The final diagnoses include schizophrenia, cognitive impairment associated with schizophrenia, hypertension, and homelessness.

The authors provide a good discussion of diagnosis of primary and secondary psychotic disorders and provide some guidance on timely medical testing for metabolic, intoxicant, and neurological abnormalities.  Delirium is identified as more of a medical emergency and necessitating more scrutiny.  The idea that delirium can be mistaken for psychosis is a valuable point that is often missed during emergency assessment especially if the patient has a pre-existing psychiatric diagnosis on their medical record.  The authors sum up screening tests that are necessary for all patient with psychosis and the tests that  are reserved for specific clinical concerns like encephalitis, seizures, structural brain disease, and inflammatory conditions.  They also suggest screening for treatable conditions and inflammatory conditions.

There is a good section on the follow up care that this patient received.  She was seen in a clinic for the homeless, where problems were gradually noted and worked on with her full cooperation.  This is not the typical approach in medicine where it is assumed that the patient will tolerate a complete history and physical exam and then cooperate with any suggested medical testing and treatment.  In this case, the practical problems of foot care were addressed.  She was eventually seen in 60 visits over two years.  By visit 19 she described concerns about cognitive symptoms and by visit 33 she was accepting treatment for psychosis with olanzapine.  She eventually allowed a more complete treatment of here associated physical symptoms including an MRI scan of the brain and treatment for migraine headaches.  The authors point out that tolerating medical and psychiatric uncertainty is a critical skill in treating people who need to habituate to medical systems of care.  A more direct approach is alienating.  It does tend to create anxiety in physicians about what is being missed and not addressed in a timely manner.  There is always a trade off in engaging people for long term care in more stable social settings and pushing to maximize diagnosis and treatment in a way that they might not be able to tolerate.  The ACT model stresses the former.           

There are some very relevant ACT concepts illustrated in this article.  First and foremost the rate at which medical interventions are prescribed depends almost entirely on the patient's ability to accept them.  This is at odds with the timeliness of medical interventions that most physicians are taught.  I say "almost entirely" in this case because the authors were very fortunate that the patient cooperated with treatment of extreme hypertension.  One of the common hospital consultations for psychiatric is a person with a mental illness and life-threatening illness who is not able to recognize it.  Even on the subacute side of care there are many tragedies due to patient with mental illness not being able to make decisions that could have saved their life.

I think that there are also some very practical applications for psychiatry on an outpatient basis.  Most patients with severe mental illnesses are never going to see a primary care provider 60 times before starting treatment.  It only happens in a subsidized setting with physicians who are highly motivated to see a certain approach work.  The care model described in the paper is certainly not the collaborative care model that some authors, the American Psychiatric Association (APA), and the managed care industry keeps talking about.  There is also the obvious point that people don't go into primary care because they like talking with people who have severe mental illnesses.  Psychiatrists need to see these people either in ACT teams or community mental health centers.  It won't work in a standard managed care clinic seeing a patient who is this ill - 2- 4 times a year for 10 - 15 minutes. ACT psychiatrists need to know about primary care providers who work better with the chronically mentally ill or people with addictions and make the appropriate referrals.  All psychiatrists should be focused on blood pressure measurements and work on getting reliable data.  Funding for psychiatric treatment often precludes ancillary staff present in all other medical settings to make these determinations.  Existing collaborative care models in primary care clinics can get blood pressure measurements on the chart but restrict patient access to psychiatrists.  

This Case Report is a good example of what can happen with a real collaborative care model that focuses on the needs of a person with severe chronic mental illness.  It is a model of care that I learned 30 years ago from one of the originators and it is more relevant today than ever.  It is also a model of care that is currently rationed and provided in the states where it is available to a small minority of patients.  It is not the method of collaborative care that you hear about from the APA, the managed care industry, or government officials.  It should be widely available to all psychiatric patients with complex problems.


George Dawson, MD, DFAPA


References:

1: Shtasel DL, Freudenreich O, Baggett TP. CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 40-2015. A 40-Year-Old Homeless Woman with Headache, Hypertension, and Psychosis. N Engl J Med. 2015 Dec 24;373(26):2563-70. doi: 10.1056/NEJMcpc1405204. PubMed PMID: 26699172.

2:  New England Journal of Medicine Case Records of MGH x psychosis (on Medline).  Shows 101 references as opposed to 31 on NEJM search engine and 10 on basic Medline search.

3:  Marx AJ, Test MA, Stein LI. Extrohospital management of severe mental illness.Feasibility and effects of social functioning. Arch Gen Psychiatry. 1973 Oct;29(4):505-11. PubMed PMID: 4748311.

4:  Stein LI, Test MA, Marx AJ. Alternative to the hospital: a controlled study.Am J Psychiatry. 1975 May;132(5):517-22. PubMed PMID: 164129.

5:  Test MA, Stein LI. Alternative to mental hospital treatment. III. Social cost.  Arch Gen Psychiatry. 1980 Apr;37(4):409-12. PubMed PMID: 7362426.

6:  Stein LI, Test MA. Alternative to mental hospital treatment. I. Conceptualmodel, treatment program, and clinical evaluation. Arch Gen Psychiatry. 1980 Apr;37(4):392-7. PubMed PMID: 7362425.

7:  Weisbrod BA, Test MA, Stein LI. Alternative to mental hospital treatment. II.   Economic benefit-cost analysis. Arch Gen Psychiatry. 1980 Apr;37(4):400-5. PubMed PMID: 6767462.


Attribution: 

Photo at the top of this post is by Jonathan McIntosh (Own work) [CC BY 2.5 (http://creativecommons.org/licenses/by/2.5)], via Wikimedia Commons.  Original photo at https://commons.wikimedia.org/wiki/File%3ARNC_04_protest_77.jpg

For The Last Time - Collaborative Care Is Not Psychiatric Care

I decided to post my response to the pro-collaborative care post “Experiences in Implementing Collaborative Care” by Sanchez on this blog so that it would be more readable and contain active links.  In reading this blogpost and the accompanying links it is apparent to me that these models have little to do with psychiatry.  The link to the article by Sanchez and Adorno describes a psychiatrist who is in clinic for direct consultation with patients for 4 hours per week and is otherwise available for curbside consultation.  Contrary to some of the initial responses this requires no special training on the part of psychiatrists.  Psychiatrists currently do that every day.  The other element that jumps out of this material is that this is behavioral health or in other words managed care.  Take the psychiatrist out of the picture and you have a method for providing more detailed primary care and supportive services to patients with mild if any psychiatric illness.  Given managed care’s lack of physician time with patients this is certainly a good idea.  It might actually save psychiatrists time when they find themselves explaining medications and drug interactions for medications prescribed by primary care physicians. Promoting this as psychiatric care and suggesting that this is the future of psychiatry (see Worcester) is a clear mistake.  At the level of large healthcare organizations, it allows them to say that they are providing “behavioral health care” while the needs of patients with severe mental illnesses are neglected and their care is shifted to another system that may include a local jail.

I was trained to do collaborative care in the Assertive Community Treatment (ACT) model of Test and Stein in 1987.  For three years following residency, I did collaborative care with a case management team out of a community mental health center.  We provided comprehensive medical and psychiatric care to every person on the team and that included determining medical needs and making referrals for testing and treatment if I felt the patient’s medical problems were not being addressed.  In that model of care, the psychiatrist is a physician coordinating medical and psychiatric care for people with severe mental illnesses and significant medical comorbidity.  All of the care comes from a personal relationship with each patient.  The psychiatrist sees the patient frequently and knows them well.  We were tremendously successful in helping people stay out of hospitals, helping them live independently, providing 24/7 crisis coverage, reducing the total amount of medications prescribed, and getting them medical care for significant problems that were misdiagnosed or that they had refused to get care for. As far as I know, the community psychiatry models are being taught in most residency programs and the number of these programs has increased significantly since I was trained.

The problem with current models of collaborative care is that the psychiatrist does not or provides minimal medical or psychiatric care.  One central question is – what model are we talking about? The original model in a JAMA article points out that the psychiatrist does not see the patient at all but reviews rating scales.  The new model from a group consulting to the American Psychiatric Association (APA), has put the psychiatrist in the role of seeing the occasional patient, probably similar to the link to the Sanchez and Adorno article.  The remaining links are less specific.

The responsibilities outlined in both the AMA and APA models are not really psychiatry.  Instead they can be seen as an extension of a process initiated 20 years ago by managed care companies to ration access to psychiatrists and psychiatric care.  Everybody reading this knows what that means.  We currently have no useful inpatient treatment besides crisis care based on “dangerousness” criteria.  The largest psychiatric hospitals in the country are county jails.  We have limited to no access to detox facilities despite being in the midst of an opiate epidemic.  Access to psychiatrists is rationed and it is not uncommon to be told that a psychiatrist will be available for a 10-15 minute discussion of medications only.  Psychotherapy that resembles the psychotherapy delivered in research studies is rarely if ever provided.  In their place we have models where patients fill out a checklist and get placed on a medication as soon as possible.  That is occurring in the context of clear evidence that in many cases antidepressants already exceed the actual diagnosis of major depression.  It also occurs in the context that depression screening has no evidence basis and in most cases screening equates with diagnosis.

The current models of collaborative care can easily be done without a psychiatrist.  I think that is really the point.  Anybody can look at a PHQ-9 score and an antidepressant algorithm and put somebody on an antidepressant.  It is ironic that when psychiatrists and other physicians are being told that it is important to go through maintenance of certification procedures in addition to continuing medical education that the federal government and professional organizations have recommended such a low standard.  On the other hand it does seem like the logical conclusion of the marginalization of psychiatry and psychiatric services by the insurance industry and federal and local governments.

What is a proactive position for psychiatry?  First, recognize that this model is not the model for providing psychiatric services.  If anything it highlights the well known fact that there are two tiers of care for mental illnesses.  Psychiatrists have adapted to managed care rationing by refusing to accept insurance and changing to a cash only basis.  I recently saw this compared to how dental care is rationed and I think that is an accurate comparison.  Excellent dental care is available but the odds are the patient will pay for it.  Second, this form of rationing will probably continue the current managed care tradition of rationing psychiatric services.  It will not lead to any improvement in the availability of inpatient services, detoxification services, or psychotherapy for people with severe mental illnesses.  It will allow these companies to advertise collaborative care along with all of the other business services that are marketed as improvements to their patients.  Third, there is the undeniable connection between PHQ-9 scores and medication exposure at a time when the FDA has issued a warning on a widely prescribed antidepressant.  Fourth, with the widespread use of the PHQ-9 and availability of administrative data it is just a matter of time before somebody publishes papers based on the data showing a marked increase in the prevalence of depression.  Some researchers and many clinicians equate a PHQ-9 score with a diagnosis of depression.  Fifth, psychiatrists need to remain focused on providing a high standard of care to people with severe mental illness, neuropsychiatric problems, and people with significant medical comorbidity.  There are many internists and family physicians who are very competent in prescribing antidepressants and using typical augmentation strategies.  They are also using fewer benzodiazepines to treat anxiety disorders.  That constitutes a first line of medical care from the primary care side for mental illness in this country.

Collaborative care should not be confused with psychiatric care and psychiatrists should not be confused about this being a new model for them to follow.

George Dawson, MD, DFAPA

References:

Sharon Worcester.  Future of psychiatry may depend on integrated care.  Clinical Psychiatry News.  April 2014.  page 1.

The Model of Psychiatric Care for the Future

Collaborative Care – Even Worse Than I Imagined

     

APA Continues to Hype Managed Care

This YouTube video is fresh off my Facebook feed this morning from the APA.  It features American Psychiatric Association (APA) President Jeffrey Lieberman, MD discussing the advantages of a so-called collaborative care model that brings psychiatrists into primary care clinics.  I have critiqued this approach in the past and will continue to do so because it is basically managed care taken to its logical conclusion.  As opposed to Dr. Lieberman's conclusion, the logical conclusion here is to simply take psychiatrists out of the picture all together.

A prototypical example of what I am talking about is the Diamond Project in Minnesota.  It is an initiative by a consortium of managed care companies to use on of these models to monitor and treat depression in primary care clinics in the state of Minnesota.  In this model, patients are screened and monitored using the PHQ-9 a rating scale for depressive symptoms.  Their progress is monitored by a care manager and if there is insufficient progress as evidence by those rating scales, a psychiatrist is consulted about medication doses and other potential interventions.  The model is described in this Wall Street Journal article.  As is very typical of articles praising this approach it talks about the "shortage" of psychiatrists and how it will require adjustments.  In the article for example, the author points out that there would no longer be "one-to-one"  relationships.  There are two major problems with this approach that seem to never be not considered.

The first is the standard of care.  There are numerous definitions but the one most physicians would accept is care within a certain community that is the agreed upon standard provided by the same physician peers.  In this case care provided by all psychiatrists for a specific condition like depression.  There are professional guidelines for the care of depression and in the case of primary care guidelines for care provided by both family physicians and internal medicine specialists.  One of the tenants of this care is that physicians generally base treatment of an assessment that they have done and documented.  The only exception to that is an acceptable surrogate like a colleague in the same group covering a physician's patients when they are not available.  That colleague generally has access to the documented assessment and plan to base decisions on.  This is the central feature of all treatment provided by physicians and is also the basis for continuity of care.  As such it also forms the basis of disciplinary action by state medical boards and malpractice claims for misdiagnosis and maltreatment.  An example of disciplinary action based on this standard of care is inappropriate prescribing with no documented assessment or plan - a fairly common practice in the 1980s.

In all of my professional life, the standard of care has been my first and foremost consideration.  It is basically a statement of accountability to a specific patient and that is what physicians are trained to be.  Curiously it is not explicit in ethics literature and difficult to find in many state statutes regulating medical practice.  That may be due to the entry of managed care and the introduction of business ethics rather than medical ethics.  It also may be due in part to an old community mental health center practice of hiring psychiatrists essentially to refill prescriptions rather than assess patients.  This is addressed from a malpractice perspective by Gutheil and Appelbaum in their discussion of malpractice considerations and how they changed with the advent of managed care:

"Managed care is one omnipresent constraint.  Patients and clinicians must work together to fashion an appropriate treatment plan to take into account available resources and given the contingencies faced by the patient.  If that plan-properly implemented-fails to prevent harm to the patient, the clinician should not face liability as a result." (p 164).

They go on to explain how ERISA - the Employee Retirement Income Security Act of 1974 indemnifies managed care companies and their reviewers from the same liability that individual physicians have.  They cannot be sued for negligence and the resulting harm.  So managed care can take risks without concern about penalties as opposed to physicians who are obliged to discuss risks with the patient.  Managed care organizations can also implement broad programs like depression screening and treatment without a physician assessment and consider that their standard of care.

The second problem with the so-called collaborative care approach is that there is no evidence that it is effective on a large scale.  I pointed out this criticism by a group of co-authors including one of the most frequently cited epidemiologists in the medical literature.  That group has the common concern that a rating scale is a substitute for an actual diagnosis and everything that involves and given the recent FDA warning on citalopram.

Both of these concerns bring up an old word that nobody uses anymore - quality.  It is customary today to use a blizzard of  euphemisms instead.  Words like "behavioral health", "managed care", accountable care organizations", "evidence-based", "cost-effective" and now "collaborative care".  According to Orwell, the success of such political jargon and euphemism requires

"an uncritical or even unthinking audience.  A 'reduced state of consciousness' as he put it, was 'favorable to political conformity'." (3 p. 124)

Dr. Lieberman uses a lot of that language in his video.  The critics of psychiatry in the business community do the same.  There appears to be a widespread uncritical acceptance of these euphemisms by politicians, businesses and even professional organizations.

An actual individualized psychiatric diagnosis and quality psychiatric care gets lost in that translation.


George Dawson, MD, DFAPA

1.  Beck M.  Getting mental health care at the doctor's office.  Wall Street Journal September 24, 2013.

2.  Gutheil TG, Appelbaum PS.  Clinical Handbook Of Psychiatry And The Law. 3rd edition. Philadelphia: Lippincott Williams & Wilkens.  2000, p 164.

3.  Nunberg G.  Going Nucular: language, politics, and culture in confrontational times.  Cambridge: Perseus Books Group, MA 2004.

4.  American Psychiatric Association Principles of Medical Ethics with Annotations Espcially Applicable to Psychiatry.  2009 version.

Collaborative Care Model - Even Worse Than I Imagined

I wrote a previous post about the APA backing the so-called collaborative care model and provided a link to the actual diagram about how that was supposed to work.  I noted a more elaborate model with specific descriptions of roles in the model in this week's JAMA.  The actual roles described on this diagram are even more depressing and more predictive of why this model is doomed to fail in terms of clinical care.  It does succeed in the decades long trend in marginalizing psychiatry to practically nothing and providing the fastest route to antidepressant prescriptions.

Wait a minute - I thought psychiatrists were the Big Pharma stooges who wanted to over prescribe antidepressants and get everyone on them?  Well no - it turns out that there are many government and insurance company incentives to assure that you have ultra rapid access to antidepressants even when psychiatry is out of the loop.  You don't need a DSM-5 diagnosis.  You don't need to see a psychiatrist.  If you pulled up the diagram in JAMA, you would discover that the consulting psychiatrist here has no direct contact with the patient.  In fact, about all that you need to do is complete a checklist.

Copyright restrictions prevent me from posting the diagram here even though I am a long time member of both organizations publishing them.  I do think that listing the specific roles of the psychiatrist, the care manager and the primary care physician in this model is fair and that is contained in the table below:

Roles in Collaborative Care Model

Care Manager	Monitors all patients in the practice Provides education Tracks treatment response May offer brief psychotherapy Describes patient symptoms and response to treatment to psychiatrist. Informs Primary care Physician of treatment recommendations from the psychiatrist
Primary Care Physician	Makes initial diagnosis and prescribes medication Modifies treatment based on recommendations from psychiatrist
Psychiatrist	Makes treatment (medication) recommendations. Provides regular psychiatric supervision. Has no direct contact with the patient.

  

see JAMA, June 19, 2013-Vol 309, No. 23, p2426.

As predicted in my original post, the psychiatrist here is so marginalized they are close to falling off the page.  And let's talk about what is really happening here.  This is all about a patient coming in and being given a PHQ-9 depression screening inventory.  For those of you not familiar with this instrument you can click on it here.  It generally takes most patients anywhere from 1 - 3 minutes to check off the boxes.  Conceivably that could lead to a diagnosis of depression in a few more minutes in the primary care clinic.  At that point the patient enters the antidepressant algorithm and they are they are officially being treated.  The care manager reports the PHQ-9 scores of those who do not improve to the "supervising" psychiatrist and gets a recommendation to modify treatment.

This is the model that the APA has apparently signed off on and of course it is ideal for the Affordable Care Act.  It is the ultimate in affordability.  The psychiatrist doesn't even see the patient - so in whatever grand billing scheme the ACA comes up with - they won't even submit a billing statement.  The government and the insurance industry have finally achieved what they could only come close to in the past - psychiatrists working for free.  Of course we will probably have to endure a decade or so of rhetoric on cost effectiveness and efficiency, etc. before anyone will admit that.

Keep in mind what the original government backed model for treating depression was over 20 years ago and you will end up shaking your head like I do every day.  Quality has left the building.

George Dawson, MD, DFAPA