The Florida Psychotherapeutic Medication Guidelines

This month's Journal of Clinical Psychiatry has a lead article about medication guidelines for adults with major depressive disorder.  Is is an apparent function of the Florida Medicaid Drug Therapy Management Program For Behavioral Health.  It is hard to imagine a title with more inappropriate terms for what psychiatrists do with medications.  At least until I read the title of the article: "Florida Best Practice Psychotherapeutic Medication Guidelines (FPG) for Adults with Major Depressive Disorder."  Here is a little insight into what I have difficulty with.  Treatment with medications is not psychotherapy.  Psychotherapy almost always needs to accompany medication treatment at one level of intensity or another.  But providing medication alone is not psychotherapy.  That is an important distinction because one of the common misconceptions is that a medication will solve common life problems like interpersonal problems at work or home and it will not.  The second issue is the idea of medication "management".  As one of my colleagues used to say: "Pharmacists manage medications we treat patients".  The term should also be anathema to any psychiatrist who was around when billing and coding guidelines were invented.  The term came to mean 10-15 minute appointment that reduced psychiatric treatment to a brief discussion of a medication.  They were two of the lowest reimbursement codes in the coding scheme and they handily allowed psychiatric treatment to be split off from the rest of medicine and reimbursed at a lower rate.  And finally the term behavioral health.  This is a long standing business term to indicate a managed care environment with business supervision rather than a mental health environment with psychiatric supervision.  All of these terms suggest that managed care companies and the government have more to do with these guidelines than psychiatrists.

Sure enough, looking at the partners for this project the majority are behavioral health organizations or managed care companies followed closely by government organizations, other associations, and three psychiatry departments out of 24 organizations.  The article itself describes the process as being the result of a multistakeholder Florida Expert Panel.  The stakeholder word always makes me cringe.  Whenever I have seen it in medicine and psychiatry nothing good has ever come of it.  There are only two stakeholders in medical treatment - the physicians and the patient.  I can stretch that to the family if they are still actively involved.  I don't want to see anybody else in the room.

The  authors detail their rationale for yet another guideline.  They state:

"Notwithstanding the public health priority of MDD, as well as increasing public, academic.  and policy attention given to MDD, misdiagnosis or delayed diagnosis and failure to incorporate appropriate measurement based care are significant modifiable deficiencies in current practice."

If only that were true.  In a state where there is widespread PHQ-9 screening. the screening tool suddenly becomes the diagnosis.  Measurement based care suddenly becomes the collection of meaningless cross sectional scores from clinics all over the state listing a diagnosis of MDD.  If only real life worked like intensive clinical trials out to prove a hypothesis.

They go on to list several other reason for their guideline.  They cite the American Psychiatric Association (APA) guideline as a "conflation" of empirical evidence and expert consensus - suggesting that nothing is sacred about expert consensus and that the patients seen by experts may not be the same as patients seen by other physicians.  They suggest that guidelines derived from pharmacological trials may be limited by suggesting that they may have limited generalizability due to trail designs and conditions that rule out certain conditions, but don't discuss other problems in experimental design.  They discuss limited long term follow up and measurement of functional capacity as a limiting factors.  Given that the authors don't really intend to correct any of these criticisms it is difficult to see that as a rationale for the new guideline.  Instead they say that their consensus process was their overarching principle in writing the FPG along with providing guidance (especially to primary care physicians) to provide safe and effective treatment for depression.

The authors use a hierarchical approach to tiers of treatment without using an algorithm.  Level 1 is initial treatment and Levels 2, 3, and 4 are basically used if the initial levels of treatment are ineffective or not tolerated.  There are few surprises for any psychiatrist who is used to treating depression, especially referrals from primary care physicians.  Given the stated concerns about the biasing effects of clinical trials sponsored by pharmaceutical companies for specific FDA indications, there were not many qualifiers about the addition of an "atypical antipsychotic approved for major depressive disorder (ie. aripriprazole, brexpiprazole)" at Level 2.  Level 2 is basically a failure of Level 1 antidepressant monotherapy.  In fairness switching to another antidepressant monotherapy at Level 2 is a suggested option.  The clear concern that the authors have about second generation antipsychotics in their scheme is metabolic rather than neurological side effects.  I have found a significant number of neurological side effects from aripiprazole including Parkinson's syndrome, akathisia. and tardive dyskinesia from these medications.  Nowhere in the paper are the diagnostic skills listed as important for the physicians.  In the emphasis about measurement based care there are no rating scales for drug induced neurological disorders.  The question of safer augmentation strategies are not discussed.

With regard to the issue of weight gain as a medication side effect, a strategy listed is "select medications that have a low relative risk of weight gain and metabolic syndrome".  A couple of related issues come up including the fact that a significant number of patients walk into the clinic with high BMI, but they are there for the treatment of depression.  Should the diagnosis of obesity and/or metabolic syndrome be made and managed along with the depression?  What about the patients who gain significant weight on either aripiprazole or brexpiprazole?  They definitely exist. What about clinicians who have developed successful strategies for using atypical antipsychotics with minimal to no weight gain?

There are also the very common problems of insomnia associated with depression that does not resolve with antidepressant therapy and significant anxiety with or without panic attacks.  Major depression with psychotic features and major depression with mixed features were discussed as important variants and special interventions not commonly used in primary care were included like electroconvulsive therapy (ECT) or transcranial magnetic stimulation (TMS).  It was acknowledged that lack of patient acceptance and availability of these treatments might result in using various medication combinations that may be less effective.  Vagal nerve stimulation was recommended as a level 4 treatment and I have serious reservations about that being effective for anyone.  

All in all the FPG is what I would expect from a collection of stakeholders, some of whom were listed as representatives of managed care companies.  Rather than have these stakeholders rehash strategies that have been around for 20 years, there was an opportunity to design a comprehensive system of care for patients with depression and there is no evidence that has happened.  There is a reason why people don't go in to psychiatry and some of those reasons don't bode well for the assumption that everyone in the system will now be doing comprehensive assessments like psychiatrists.  A system of mental health care designed by stakeholders could possibly develop state- of-the-art resources for neuromodulation (TMS, ECT, deep brain stimulation), sleep studies, monitoring the cognitive effects of depression and antidepressants, detoxification and addiction treatment, and reasonable inpatient and residential resources.  That same system would have designed in timely assessments of difficult problems like MDD with psychosis by psychiatrists.  Adequate numbers of psychotherapists or pilot programs looking at computerized cognitive behavior therapy for sleep, depression, and anxiety would be more useful that one or two crisis oriented sessions with no specific orientation.  A blanket statement about the utility of evidence-based psychotherapies without adequate numbers of therapists to carry it out is not helpful in any way.

We need system redesign by stakeholders, not stakeholders making more guidelines while pretending that they know something about quality.
    



George Dawson, MD, DFAPA

Synopsis:

If certain stakeholders in a system, have:

-all of the money
-all of the power
-sophisticated electronic health records that are set up more for administrative than clinical purposes.

They may have an obligation to design the system to optimize care rather than telling the people delivering the care what they can do in a poorly integrated system of rationed resources by applying strategies that are already well known.  

References:

1: McIntyre RS, Suppes T, Tandon R, Ostacher MJ,  . Florida Best Practice Psychotherapeutic Medication Guidelines for Adults With Major Depressive Disorder. J Clin Psychiatry. 2017 Jul;78(6): 703-713.

2: Ostacher MJ, Tandon R, Suppes T. Florida Best Practice Psychotherapeutic Medication Guidelines for Adults With Bipolar Disorder: A Novel, Practical, Patient-Centered Guide for Clinicians. J Clin Psychiatry. 2016 Jul;77(7):920-6. doi: 10.4088/JCP.15cs09841. PubMed PMID: 26580001.

3: Gartlehner G, Gaynes BN, Amick HR, Asher GN, Morgan LC, Coker-Schwimmer E, et al. Comparative Benefits and Harms of Antidepressant, Psychological, Complementary, and Exercise Treatments for Major Depression: An Evidence Report for a Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016;164:331-341. doi: 10.7326/M15-1813.

4: Qaseem A, Barry MJ, Kansagara D, for the Clinical Guidelines Committee of the American College of Physicians. Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients With Major Depressive Disorder: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016;164:350-359. doi: 10.7326/M15-2570.

How Should APA Guidelines Work?

The guidelines of the American Psychiatric Association (APA) are an interesting story in how guidelines are important if used correctly by professional organizations.  The whole idea behind a profession is that the practitioners in that area have special expertise and that the expertise is standardized to some degree.  Standardization is useful in the case of physicians to assure the safety of the practitioners and so that people have some idea of what to expect in terms of safe and effective care.  Over a decade ago the APA began producing guidelines for practice in various areas of the field.  I thought it was an exciting development.  The guidelines were initially sent along with the monthly copy of the Journal of the American Psychiatric Association.  All of the guidelines are available publicly on this web site, but hardly anyone knows about them.  I make this statement because one of the many red herrings that the critics of psychiatry use is that psychiatry has no standards of care.  They seem quite shocked to find that these guidelines exist and address their complaints directly.  

I was asked to critique one of the existing guidelines and suggest how these guidelines could be used more effectively.   In looking at the guidelines web site, it is apparent that some of the guidelines have not been updated in quite a while.  Publication dates range from 2000 - 2010.  Given the pace of clinical research 5 years might be somewhat acceptable, but 10 - 15 is probably not.  Another issue that the APA needs to grapple with is the diagnostic manual versus treatment approaches.  There is widespread confusion about whether or not the DSM-5 is a guidebook for treatment as opposed to a guidebook for diagnoses.  The APA actually two approaches to treatment guidance - the guidelines themselves and a text entitled Treatment of Psychiatric Disorders (TPD).  TPD is currently in its 4th edition and it has gone from a series of two volume detailed text to a more basic single volume text.  That text was published in 2007.  Some of the chapters in the previous editions provide some of the most detailed information on the pathophysiology and treatment of certain disorders that could be found anywhere.  At that level of analysis, the APA has gone from providing outstanding information on the pathophysiology and treatment of psychiatric disorders to a relative vacuum over the past 10 years.

For the purpose of a more detailed analysis I will consider the Practice Guidelines on Substance Use Disorders and the associated Quick Reference Guide and Guideline Watch - a 2007 update of the original 2006 guideline.  I looked at the Guideline Watch first because it should reflect the latest literature reviews and treatment guidelines.  The document reviews medication assisted treatment of tobacco and alcohol use disorders with varenicline, naltrexone and acamprosate.  The document was a good summary of the literature at the time but it needs a serious update.  Since then there have been more extensive studies of the genetics, combination therapies, re-analysis of existing studies and side effects of naltrexone, acamprosate, and varenicline including use in specific psychiatric populations.  In at least one case, the current literature supports a course of action that is exactly the opposite of what is recommended in this document.  That course of action is: " Given its high potency and partial agonist activity at central nicotinic acetylcholine receptors, varenicline should not be combined with alternate nicotine replacement therapies."  An inspection of the references for varenicline notes that additional research has been done in this area and should be discussed.      

The Quick Reference Guide contains extensive tables from the original guideline so I will go directly to that document.  At first glance it looks like a significant document more than 200 pages long.  But about 177 of the 276 pages of the document are relevant text.   The rest are references and polls of various expert groups on what they consider necessary for a guideline.  Looking at the Table of Contents, the first thing that is apparent is that only a subset of substance use disorders is being considered.  Although it is likely that nicotine, alcohol, marijuana, cocaine and opioids represent the majority of abused substances psychiatrists treating addiction see a broader array of compounds being abused.  The full gamut of abused compounds should probably be addressed in the guideline whether or not there is a consensus about treatment methods or not.  The safety of users and treatment setting considerations will still need to be considered as well as the need for further assessments.  A good example would be Hallucinogen Persisting Perceptual Disorder and what might be the best assessment and treatment.  If the guidelines are supposed to apply to clinical practice then patterns encountered in clinical practice need to be addressed.  If the APA does not address them - governments and managed care companies will, most frequently to the detriment of patients.

The guideline uses the following conventions for the treatment recommendations.  They are conventions frequently see in professional guidelines:

[I] Recommended with substantial clinical confidence.
[II] Recommended with moderate clinical confidence.
[III] May be recommended on the basis of individual circumstances.

The introductory section does not suggest who the guidelines are written for.   This is a critical aspect of the document.  There is an implication that it is for psychiatrists based on the statement about a comprehensive psychiatric evaluation but I think that needs to be more explicit.  It is not uncommon for managed care companies to send letters that deny care to psychiatrists.  The letter often contains a list of guidelines that an insurance company reviewer used to deny the care.  The APA needs to be explicit that these guidelines are intended for use by the psychiatrist who has personally assessed and is treating the patient and not by an insurance company employee or contractor who is sitting in an office reading through paperwork.  Somewhere along the line professional organizations seem to have lost track of the concept that only direct assessment and treatment of the patient was considered the correct way to do things.  Putting it in all guidelines is a critical first step.

The next thing I would change in terms of guidelines is breaking out the treatment setting recommendations into separate sections in table form.  For example the Hospitalization guidelines are copied into the Supplementary section of this post.  They are all very appropriate and I doubt that there are any reasonable clinicians that would have a problem with them.   The problem is that these services are rationed to the point that it is difficult for any reasonable clinician to implement them.  By that I mean that a psychiatrist cannot get a patient meeting these criteria into an inpatient detox or treatment setting based on these criteria.  As an example, consider the patient who says they are drinking 1 liter to 1.75 liters of vodka per day for 6 months.  They describe uncomplicated symptoms of alcohol withdrawal (shakes, sweats, hangover symptoms and drinking in the morning to suppress these symptoms).  I think the person in this vignette meets criteria 2 for hospitalization and detox at least.  A significant number of patients presenting to emergency departments with this pattern of findings are not hospitalized.  Many are sent out with a supply of benzodiazepines to detoxify themselves.  Many are sent to county detox facilities where there is no medical coverage or so-called social detoxification settings.  None of these non-hospitalization options are realistic approaches to the problem.  Giving a person with an alcohol use disorder a bottle of benzodiazepines for home detox ignores the uncontrolled use and cross addiction aspects of the primary disorder.  It is highly likely that person will ingest the benzodiazepines all at once or use them to treat the morning withdrawal symptoms of the disorder.  Social detoxification is an equally suboptimal approach.  It depends on probabilities.  It is more likely that the person transferred to that setting will leave due to the adverse environment and go back to drinking or undergo withdrawal and not experience delirium tremens or withdrawal seizures.  Over the past 30 years, the managed care industry has refused to consider admissions in practically all of these situations often whether there was psychiatric comorbidity or not resulting in the rationing of care at the initial assessment in the Emergency Department.  There must be an awareness that clinical guidelines don't operate in a vacuum.  Having a guideline in place that nobody can use is not the best approach to providing quality care.   Managed care companies can deny inpatient care on practically any of the 7 inpatient criteria simply by saying that they do not exist.    

On the treatment side there are inconsistencies noted in the recommendations and editing problems.  For example, there are 49 references to "12-step" and 2 references to 12 steps.  One of the first statement one encounters is:  "The efficacy of treatment is related to the amount of psychosocial treatment received. The 12-step programs, hypnosis, and inpatient therapy have not been proven effective."  That characterization of 12-step recovery is inconsistent with just about every other reference in the document.  Where it is suggested it is footnoted with a "I" designation or "substantial clinical confidence."

Rather than critique other sections based on data that was not available at the time that this guideline was posted, I thought I would end with a comment on the process and general philosophy of professional guidelines.  Right at the top of this guideline is a section entitled "Statement of Intent".  The crux of that argument is contained in the paragraph (p. 5):

 "The American Psychiatric Association (APA) Practice Guidelines are not intended to be construed
or to serve as a standard of medical care. Standards of medical care are determined on
the basis of all clinical data available for an individual patient and are subject to change as scientific
knowledge and technology advance and practice patterns evolve. These parameters of
practice should be considered guidelines only. Adherence to them will not ensure a successful
outcome for every individual, nor should they be interpreted as including all proper methods
of care or excluding other acceptable methods of care aimed at the same results........"

I don't really agree with that approach.  The concerns about saying that these are standards of care is a medico-legal one and I have rarely found that to be a sufficient basis to practice medicine.  An example would be litigation against a psychiatrist for not following the stated standards of care in a malpractice suit.  This may seem protective of psychiatrists for varying practice styles but it also has the more insidious effect of basically allowing any standard of care to apply.  A walk down the street to a different hospital results in an admission for medical detoxification when the first hospital discharges the patient with a prescription of lorazepam and a promise to follow up with their primary care MD.  The resulting business incentive practice creep results in a complete lack of detoxification and a lack of any standards of medical care.  The default standard is whatever businesses decide to pay for.  My observation is that results in an unacceptable level of medical care.  And further:

"The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment
options available....." 

I agree with the statement but let's face it,  the judgment of the psychiatrist frequently has very little to do with the judgment of the psychiatrist or what options are ultimately considered in the working alliance with the patient.  Practically all inpatient and residential care these days is dictated by managed care companies and insurance companies irrespective of what a psychiatrist would recommend or a patient would accept.  These are standards of care that are forced on psychiatrists and patients rather than the prospective quality based standards.

Stepping back from that fact medical standards play a peripheral role to what businesses want and that unacceptable standard has been present to one degree to another for the past 30 years, I don't think a new approach in guidelines is too much to ask for.  I don't think it is too much to ask that APA guidelines be up to date, internally consistent, inclusive, actually apply as a standard of care as opposed to using business standards as the default, and be used to advocate for the best possible treatment settings for psychiatrists and their patients.  There are a number of specific methods that can be used and I will discuss them when the draft version of the latest  Practice Guidelines for the Psychiatric Evaluation of Adults comes out this year.


George Dawson, MD, DFAPA


References:

Work Group On Substance Use Disorder.  Practice Guideline For TheTreatment of Patients WithSubstance Use Disorders,  Second Edition.  American Psychiatric Association.  This practice guideline was approved in December 2005 and published in August 2006.


Supplementary 1:   These are the hospitalization guidelines from the APA Substance Use Disorders Guideline.

"Hospitalization is appropriate for patients who 

1) have a substance overdose who cannot be safely treated in an outpatient or emergency department setting

2) are at risk for severe or medically complicated withdrawal syndromes (e.g., history of delirium tremens, documented history of very heavy alcohol use and high tolerance); 

3) have co-occurring general medical conditions that make ambulatory detoxification unsafe; 

4) have a documented history of not engaging in or benefiting from treatment in a less intensive setting (e.g., residential, outpatient); 

5) have a level of psychiatric comorbidity that would markedly impair their ability to participate in, adhere to, or benefit from treatment or have a co-occurring disorder that by itself would require hospital level care (e.g., depression with suicidal thoughts, acute psychosis); 

6) manifest substance use or other behaviors that constitute an acute danger to themselves or others; 

or 

7) have not responded to or were unable to adhere to less intensive treatment efforts and have a substance use disorder(s) that endangers others or poses an ongoing threat to their physical and mental health [I]."      (p.  11).

Psychiatrists Implicitly Asked To Fill In Large Gaps

I didn't realize this until relatively late in my career and it has been interesting to counsel several younger colleagues about not making the same mistakes.  Psychiatrists are continuously called upon to make up for significant deficiencies in the system.  Any one of these gaps can lead to a crisis situation that the psychiatrist has to address immediately or lapses in the quality of care.  In the extreme case they can render care impossible.  Many of these deficiencies also require a considerable time commitment by the psychiatrist.  That time is usually not compensated and often takes valuable time away from spouse and family.  The deficiencies are the direct result of rationing resources and not having enough resources available.  Another variation is that some of the staffing personnel available have no training or experience in how to assess and treat mental health problems or even discuss problems with psychiatric patients.  There are many people who are assigned to that role and I am convinced they make things worse rather than better.

Community mental health centers are often places where the deficiencies exist.   They depend on government funding sources and the bureaucracy involved with some of these sources is only exceeded by the lack of adequate funding.  In many places, the managed care model is adapted and that means that nearly all patient concerns are translated into medication complaints of the form "I am having problems because I am not taking enough medication(s)."  Frequently the patients adapt to saying the same thing.  Any astute psychiatrist walking into this setting may see all of the usual markers including most drugs being prescribed at or above the manufacturers suggested maximum dose, far too many benzodiazepine and sedative hypnotic prescriptions, drugs being prescribed for questionable indications, medications being prescribed for a condition that should be treated first with psychotherapy (and the affected patients never received that therapy), and a lot of medications being prescribed to patients who clearly have a substance use problem.   There is generally a lackadaisical approach taken to the medical side of monitoring the patients including no monitoring or intervention for the metabolic side effects of medication, no attention to drug interactions, and no diagnosis and treatment of the neurological effects of medication.  Psychiatric practice is simplified to a contracted practitioner prescribing medications for a broad array of problems.  In many cases staff from the mental health center will call that practitioner when they are not on site and the request and/or response will be an increase in medication dose or a new prescription for medications.

Inpatient psychiatric units tend to attract psychiatrists with a lot of medical expertise and an interest in those matters.   The first problem is often a lack of medical services in terms of consultants or the necessary hardware.  Unless there are medical consultants and a clear delineation of responsibilities this may result in a significant additional time commitment to psychiatrists.  Thinking of admissions, the first step is who does the history and physical.  After a comprehensive psychiatric assessment it might only take an 20 minutes to do a medical review of systems and physical exam.  Depending of the medical complexity of the patients it may take an additional hour or two.  The second point is what is now called medication reconciliation.   That means that all of the medications the patient taking for medical and psychiatric purposes.  That is very easy in the case of one medication.  It is not so easy when a patient cannot accurately report their medications or they are taking up to 20 medications.  Those medication may include several apiece for chronic medical conditions like hypertension and diabetes mellitus.  There are also decisions that need to be made about which medications can be restarted and which medications need to be acutely discontinued.   That can lead to hours of time for an admission procedure that in a typical system of care is supposed to take an hour or less.  There is a strong incentive for administrators to have the same physician cover both the medical and psychiatric side of inpatient treatment.  It is far more cost effective for medical consultants to see patients elsewhere in the hospital.   Young psychiatrists wanting to do both jobs should be aware of the fact that most places would be more than willing to have you commit that kind of time.

Other residential settings can lead to problems similar to inpatient psychiatric units, but tend to be less intense on the admission side.  In many cases psychiatrists are consultants to a number of facilities like corrections, drug and alcohol treatment facilities, and nursing homes.  All of these settings present unique challenges to rational psychiatric care ranging from subtle to more obvious.  In many cases the obvious problems seem to escape notice by many of the people in charge today who have no clinical training.

An example of some of the most subtle but disruptive problems are the psychodynamics of treating groups of people in an environment with a significant number of treatment staff.  In that setting some of the characteristic psychodynamics of people with personality disorders occurs and leads to significant problems.  A  couple of good examples include staff splitting and projective identification and I will deal with these defense mechanisms extensively in a second post.  In this post I will give a hypothetical example of how disruptive these defenses can be in a staff and an administration that is poorly set up to deal with them.

Consider Dr. A. a seasoned inpatient psychiatrist with many years of experience.  Dr. A is highly regarded by the inpatient staff and her colleagues, but not so by administrators in her department.  With administrators, she is regarded as having a length of stay that is too long, because she refuses to discharge patients with inadequate evaluations or evidence that they will not be able to adequately function.  She has had several meetings with department administrators on this subject but stands her ground on what she sees as professional standards as opposed to managed care guidelines.   Nevertheless, she does feel the pressure from the administrators and does end up discharging a young man to a group home.  He has difficult to treat bipolar disorder and diabetes mellitus Type II and she made the difficult decision to treat him with an atypical antipsychotic despite the metabolic warnings for this class of medication.  He did not have all of the markers of adequate progress for discharge that she likes to see but he was sleeping well and no longer grandiose.  

The patient in question is discharged and returned in 3 weeks.  He is agitated and manic.  Dr. A notes that the patient saw a practitioner in the time he was out of the hospital and the dose of medication was cut in half.  That acute dose reduction was associated with the recurrence of manic symptoms.  Dr. A ordered the full dose of the medication and to contain the patient also ordered 1:1 staffing to redirect him from conflicts with other patients.  There was a hospital wide initiative to reduce the amount of 1:1 observation time.  On of the nursing staff suggests that the patient is getting special treatment because Dr. A has the "hots" for him.  The patient was regarded as attractive and referred to Dr. A as his "girlfriend".  None of the nursing staff notice that the staff person doing the 1:1 observation was verbally accused by the patient of stealing money from him during the previous hospital stay.  Part way through the shift the patient punches the staffer in the arm with a good amount of force.  The staff person is not injured, but an inquiry is held.

Dr. A walks into the inquiry and notices the administrators, some of them from the various disciplines on the unit.  The administration of disciplines in this hospital is in a silo manner like most hospitals with separate administration for physicians and nurses.  The question the group will consider is apparently the accusation by the nursing staff that Dr. A was prescribing an "inadequate" amount of antipsychotic drug even though the orders clearly show that the patient was given a dose that was beyond the maximum FDA recommended dose and the patient has diabetes - a reason for caution when using this class of drugs.  None of the staff in the room was aware of the previous confrontation that the patient had with the staff that was assaulted.  By making these points Dr. A seemed to be able to satisfy the requirements of the inquiry but suddenly out of left field, one of the nursing administrators suggested that Dr. A had a "communication problem" with the nurses and had in fact "ignored" one them.   The entire room of administrators seemed to be in agreement about this despite the fact that all of the nursing staff working that day had been interviewed an none of them had seen this pattern.

The final result was that the panel decided that Dr. A would meet with the inpatient director and the aggrieved nurse on a regular basis to focus on the "communication problem" that Dr. A allegedly had.

The case of Dr. A is an excellent example of staff splitting the resulting very negative outcome for Dr. A.  The reality of the decision is that Dr. A had done nothing wrong.  She is very competent and used to making tough decisions in impossible situations like the one described above.  Her professional competence includes neutrality toward patients and she has never acted in an inappropriate manner with any patient.  In this case the process results in her being treated like a novice and punished for something that never occurred.  All of this is the result of treating a patient with difficult problems, and a lack of understanding on the part of the staff and the administrators about what was happening in terms of interpersonal dynamics.  Dr. A ends up being scapegoated and her confidence in decision making is temporarily affected until she can put the pieces together and figure out what happened.  Watching how the key staff interact in similar situations in the future is also helpful. 

What gap occurred in the scapegoating of Dr. A?  The best psychodynamic hospitals have group meetings for staff to examine the dynamics especially in the treatment of patients with complicated problems or complicated developmental histories.  Most acute care hospitals have no team meetings at all.  The basic premise is that the wards are short term holding tanks until the medications kick in and the patients can be discharged.  These days the medications don't even have to kick in as patients are discharged with a significant amount of symptomatology.  There is no analysis or discussion of defense mechanisms and projection that results in threatening behavior is generally handled as an acute psychotic symptom with medication.  I have really never seen any hospital administration recognize that this is a shocking deficiency and in many cases the splitting is worsened by administrative maneuvers.  Having an administrator with no clinical training  dictate how complicated patients with aggressive behavior are handled is a great example.

These large gaps also translate into a lack of quality in psychiatric care.   It is what happens when businesses and governments marginalize the role of physicians and exaggerate the importance of business administrators.  The practical implications are that psychiatrists should really avoid practice situations with these obvious gaps.

It would be great if the American Psychiatric Association would step up and comment on how these gaps should be closed but they appear to be disinterested in what is happening to the practice environment for psychiatry.

George Dawson, MD, DFAPA



 

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