Radicals and Reformers for Managed Care

I was struck by a post on the Critical Psychiatry blog this AM.  Duncan Double discusses his experience at a meeting of the radical caucus at the APA on Sunday.  His main argument was the need to abolish psychiatric diagnostic systems - specifically the DSM, but he mentions that you can apparently provide psychiatric services without an ICD diagnosis in the UK.  But then he makes this astonishing comment: " The American psychiatric system has become very dependent on DSM for billing purposes, but I'm sure the insurance companies could develop an alternative system unrelated to DSM. "


I am positive that the American insurance industry would like nothing better than to establish their own "alternative system unrelated to the DSM'.  In fact, they are doing it already with a host of measures that they can use to basically deny care or dismantle systems of care.  The managed care industry in the US has selectively discriminated against psychiatric services for the past 20 years to the point that most states have little service availability.  The motivation for managed care is clear - shift hundreds of billions of dollars away from providing care to persons with mental health and chemical dependency problems and into the pockets of the insurance industry.  We are talking about an industry where the CEOs can make an annual salary of millions of dollars and in a famous case the CEO received a $1 billion dollar bonus.


Stated in another way, the "American psychiatric system" is no system at all.  There is hardly any availability of psychotherapy services.  Most people are restricted to a handful or less of 15 minute visits with a psychiatrist every year.  The length of stay in hospitals is appallingly short by UK or European standards and people are asked to leave if they are no longer "suicidal".  It is psychiatrists on the one hand being severely restricted in attempting to provide care and a predatory insurance industry trying to make disproportionately more money off policy holders with mental health problems on the other.   The government is not a passive player in this effort with most state governments abdicating their role in caring for the indigent and the uninsured often by using managed care tactics.  All of this happens independent of any DSM or ICD diagnosis.  At the national level, there is a long list of interests who favor the same tactics in order to maintain leverage over doctors and the clinical care advocated by doctors.


Critical psychiatry would rather "Occupy American Psychiatric Association" rather than "Occupy Wall Street" .    I guess we can add them to the managed care  list.  That is exactly the type of reform that the politicians want.

A Consciousness Based Model

One of the criticisms of psychiatric treatment in particular drug therapies is that essentially nothing is known about psychopathology, neurobiology, or human genetics and therefore claiming that drug therapy is treating a pathological state is erroneous (1). "Chemical imbalance" can be used as a red herring along the way and I will try to address that in a later post.  In that post, I also hope to address the issue of disease states and whether or not they need to be strictly measurable.

For now, I want to discuss a model that I have used in clinical practice for the past decade that addresses both the issues of recovery and whether or not the drug altered state or treating an underlying pathological state is really the issue.  Let me start by saying I think it is irrelevant for the purposes of treatment.  I am first and foremost a clinical psychiatrist and not a researcher and my priority is at all times patient care.   My goal is to treat alterations in a person’s conscious state and restore their level of functioning with medications and/or psychotherapy that have been shown to work.   My goal is also not to introduce any new problems such as sedation, mood changes, rage, perceptual problems, ataxia, false memories, vertigo, or any number of subjective changes commonly seen as "side effects".

I found that the best way to proceed is to have an explicit discussion of the person’s conscious state and whether it has undergone any transformation associated with the reasons why they are seeing me.  I focus on the typical stream of consciousness that occurs each and every day and how it may have changed over the previous weeks or months or years.   I ask about whether or not getting back to that conscious state is a reasonable goal.  I point out that the phenomenology associated with a person's cognitive and emotional changes (2) can be followed in at least two dimensions at once - the psychopathological and the normal.

There are obviously problems with my approach. The subjective assessment of a psychopathological state and the subjective assessment of the baseline conscious state are difficult to do and they take time.  There are a large number of markers of psychopathological states but not so many for normal conscious states.  I often end up discussing broad outlines that include the typical stream of consciousness, fantasies, daydreams, defense mechanisms, distracting thoughts and typical thought patterns in certain situations such as driving into work each day.   I also ask about a global assessment and whether at any point during treatment the person feels like their original conscious state has been restored.   It adds another goal to treatment that is focused on restoring the self rather than just treating symptoms.

George Dawson, MD, DFAPA

1: Moncrieff J, Cohen D.  How do psychiatric drugs work?  BMJ. 2009 May 29;338:b1963.

2: Andreasen NC. DSM and the death of phenomenology in america: an example of unintended consequences. Schizophr Bull. 2007 Jan;33(1):108-12. Epub 2006 Dec 7.