Even More Epistemic and Hermeneutical Injustice......

My latest foray into the philosophical was reading a paper by Bennet Knox (1) called “Exclusion of the Psychopathologized and Hermeneutical Ignorance Threaten Objectivity”. In it he argues for inclusion of persons affected by mental illnesses or at least as they are defined in the DSM into the scientific process of revising the DSM. He prefers the term psychopatholigized that he shortens to pathologized to other terms used in the philosophical literature. He makes the argument against a severely truncated form of psychiatry that he can conveniently describe as hermeneutically ignorant while characterizing a brief comment by Spitzer as hostile. His argument hinges on a concept of social objectivity that necessarily means all viewpoints of the psychiatrically involved including those who want to burn the profession down are valid and must be considered.

As I have stated before on this blog (and given examples) – this is a standard philosophical approach to criticizing psychiatry while ignoring what actually goes on in the field and how psychiatrists are trained. So, I will start there.

Let me start with the concept of “social objectivity” since the early claim by the author is:

“Further, insofar as the objectivity which psychiatry should aspire to is a kind of “social objectivity” which requires incorporation of various normative perspectives, this particular form of epistemic injustice threatens to undermine its scientific objectivity.”

I am not completely sure of how philosophers use the term normative here so I am assuming that it means – what other people approve of or endorse.  The other people here would be the pathologized.  He uses examples of the pathologized in this paper as members of the Hearing Voices Movement and the Autistic Self-Advocacy Network (ASAN).  He states that social objectivity is defined in two books by Helen Longino but does not include an operational definition.  Instead, he comments throughout the paper on how various circumstances do not meet these criteria.  He openly acknowledges that his argument is deficient:

“Although I can provide only a limited argument for embracing the social objectivity model in psychiatry here, my main goal is to show fellow proponents of social objectivity that the particular kind of hermeneutical ignorance I describe presents a significant obstacle to achieving it in psychiatry.”

I agree that the argument presented is very limited.  If that is the case, why should it be achieved in psychiatry?  Will it be theoretically useful in some way? 

His introduction to the need for social objectivity and objectivity in general in psychiatry is based on the philosophy of psychiatry.  More to the point non-empiricist philosophy. If that is considered, an empirically adequate model is all that is required.  Instead, he introduces three models that all suggest that values play a role in psychiatric diagnosis. He acknowledges that dysfunction is a value free criterion for diagnosis but then goes on to separate out a category of mental disorder that also contains judgements about dangerousness.  He lands on the DSM definition of dysfunction but explains it away as “there is reason to believe that it is impossible (and undesirable) to uncover dysfunctions in mental processes without reference to values.”  He goes on to explain how “a scientific process is more objective insofar as it engages a diverse array of points of view with different normative background assumptions in a process of “transformative criticism.”

There are multiple points of disagreement with this viewpoint starting with a basic misunderstanding of what psychiatry is and how psychiatrists work. The key element in the DSM that is ignored here are all of the qualifications for subpopulations ranging from cultural differences to gender differences that include a moving threshold for the diagnosis of disorders and recognizing that in some cultures or subcultures varying degrees of psychopathology are tolerated (or not) and that also includes a tendency to stigmatize individuals with that psychopathology. Breaking that down – psychiatry parses scientific objectivity and normative perspectives when it comes to diagnosis and treatment planning. That not only occurs in psychiatry but in all of medicine and it may actively include the outside input from philosophers on ethics committees.  Here are a couple of clear examples.

Example 1:

Bob is a 65-year-old married man admitted for hepatic encephalopathy from alcoholic cirrhosis. The Internal Medicine team requests psychiatric consultation for further diagnosis and referral.  The psychiatrist assesses the patient as improved (less delirious) and competent.  No other psychopathology is noted. He discussed treatment options for the alcohol use disorder and the patient is willing to listen.  He has never attended an AA meeting or been in treatment in the past. The family (wife and adult children) enter the room and are all adamant about taking the patient home with no treatment. They are angry and state several times “If he wants to drink himself to death it is none of your business doctor. Let him drink himself to death.”  The family and the patient are approached by social workers and the Internal medicine team over the next two days but he is discharged home with no treatment.

All of the people in this case were white 4^th or 5^th generation Americans. There are no assumed cultural differences, but they are implicit. Patients and families affected by substance use disorders have known patterns of adapting and some of them are not functional adaptations. Was an attempt at involuntary treatment needed in this case? The psychiatrist knew that hardly ever happens by local probate courts in substance use disorders unless there was an actual suicide attempt or the family supported civil commitment. Should adult protection social workers have been involved?  Referrals could have been made to county social workers who might invoke a societal level value judgment on this situation but instead dialogue was established with the family and they agreed to call if problems occurred and take referral numbers for additional assistance. They were also informed that the patient had a life threatening alcohol use disorder and severe complications (including death) could occur with any future episodes of drinking.

To the point of the article this example points out that DSM diagnosis (alcohol use disorder, delirium plus dysfunction) were the objective considerations. It also illustrates a point about social objectivity and that is that it needs to be elaborated for every individual patient, family, and culture/subculture specifically. Suggesting that physicians or psychiatrists don’t have the capacity for recognizing these exceptions and planning according is not accurate. Suggesting that the patient and family were ignored or that their opinions were not considered is also inaccurate.  The entire treatment and discharge plan was based on those opinions - even after the recommended treatment was rejected and the high level of risk was explained.

Example 2:

Tony is a 28-year-old man seen in hospital following a suicide attempt. He shot himself through the shoulder and is on the trauma surgery service. When interviewed by psychiatry he says” “I did not shoot myself. Sure, I had the gun pointed at myself but it just went off.  I am not suicidal and I want to leave.” He gives the additional explanation that he was using large quantities of alcohol even though he has been hospitalized for alcohol poisoning in the past. When the psychiatrist points out the dangers of alcohol poisoning including death he says “Look I already said I was not suicidal.  I was just trying to get high.  I get to the point where I don’t care if I live or die but I am not trying to kill myself.”  He has had multiple admissions for depression and suicide attempts in the past.  He is currently on a 72-hour hold pending a court hearing at that time. The psychiatrist requests a review from the Ethics Committee composed of a number of local philosophy professors. They decide that the patient should be released despite the recommendation to the court for extended treatment of the substance use disorder and depression.  During the hearing the psychiatrist testifies that he has seen this type of treatment work and that he considers the patient to be at very high risk.  The court releases the patient. A week later he is found dead from acute alcohol poisoning.

Again, there are no major cultural differences in this case but clear subcultural differences based on the patient’s family and social history.  The psychiatric diagnoses are clear and indisputable.  The clinical judgment of the psychiatrist based on risk factors was also clear. The value judgments introduced here are the probate court and Ethics Committee as a proxies for society’s charge to balance a persons need for autonomy against their need for protection.  Those decisions were spread over multiple people and agencies outside of the field of psychiatry.  

These basic case examples (I say basic because they are encountered in acute care psychiatry every day and multiple times a day) illustrate a few facets of social objectivity.  First, it is poorly defined.  Second, it is impossible to achieve primarily because is consists of an infinite number of subsets that cannot be averaged if the expected result is to achieve active input into the field of psychiatry. Third, for social objectivity to be useful it needs to be recorded as unique for every person that comes into treatment and handled as it was in the above vignettes.  That way the relevant considerations of every unique history and constellation of signs and symptoms can be evaluated in the proper context. It turns out that technique has been around in clinical psychiatry for as long as I have been a psychiatrist and it is called cross cultural psychiatry.

For 22 years, I practiced on an acute care unit where we had access to professional interpreters who were fluent in both the language and cultures of several countries as well as the hearing-impaired population who used American Sign Language to communicate.  There were 15 language interpreters who spoke a number of African and Asian languages in addition to Spanish. Professional interpreters do a lot more than translate languages - they also interpret cultural and subcultural variations as well as normative behaviors. We had access to telephone interpreters in any language if we encountered a patient outside of the hospital staff expertise. The interviews were lengthy and often incorporated family members, community members, and in some cases local shaman. Without this intensive intervention attempting to assess and treat these problems would be a set up for the epistemic and hermeneutical injustices the author refers to. In fact, treatment would have been impossible. In completing these assessments there was not only an elaboration of the stated problem, how the relevant community conceptualized that problem, a discussion of how it may be treated psychiatrically and the rationale for that treatment, as well as whether the family wanted the patient treated in general or more specifically in the hospital and whether their shaman or medicine man would be involved.

These are just a few examples of how social objectivity is approached in clinical psychiatry.  The result is that values are incorporated that are important to the patient and their family even if they affect diagnostic thresholds and treatment planning.  That is also clearly stated in the DSM.  It is a much more practical and personalized approach than trying to incorporate all of those opinions into the DSM diagnosis and it gives a voice to many more people than would be involved in that process. It also considers a multitude of local factors (budgets and attitudes of social service agencies, budgets and attitudes of local courts, community resources, etc.) that all factor prominently in values-based decision making.

The other important aspect of an all-inclusive process for social objectivity is that the normative thinking of some - may result in exclusion rather than inclusion. Normative thinking based on beliefs can be political thinking and in the past two years we have seen that lead to fewer rights for women, the banning of books, a widening scope of gun permissiveness in a society rocked by gun violence, gross misinformation about the pandemic, and an attempt to overthrow the elected government of the United States. These are all good examples of how including normative thinking outside the scope of medical practice could lead to disruption of the entire field. The author suggests that the opinions expressed do not need agreement - they only need to be aired. That strikes me as the basis for a very bad meeting. Unless there is basic agreement on the values and rationale for a diagnostic system – I think Spitzer has a point that opinions for the sake of stating an opinion is a futile exercise especially if it is not in basic agreement with medical and psychiatric values and ethics.

The author defines hermeneutical ignorance in psychiatry somewhat clearer. He suggests that marginalized groups (like the pathologized) develop their own conceptual resources that are not shared with other groups.  The example suggests that willful hermeneutical ignorance results when the marginalized group does not share the conceptual resources and the dominant group (inferring psychiatry) are unaware of the resources or dismiss them.  There are numerous examples of how this is not the case with psychiatrists.  Obvious examples include Alcoholics Anonymous and other 12 step groups as well as community psychiatry programs that actively use advocates and develop resources with the active input from people with severe mental illness who are affiliated with specific programs. Psychiatrists see a general knowledge about non-psychiatric resources as necessary to provide people with additional assistance.  In many cases that can include discussions of how to better utilize the resource and what to expect.  

There are several additional points of disagreement with the author on many points where he seems unaware of how psychiatrists actually practice or he is unwilling to give credit where credit is due. The best example is his description of Spitzer’s brief commentary (2) on a paper written in Psychiatric Services. He was responding to a lead paper (3) on including patients and their families in the DSM process. The author characterizes Spitzer’s general attitude toward the idea as hostile and characteristic of injustices that he writes about but important context is not given.  Spitzer was the major architect of DSM criteria and studied the process for decades. He wrote a comprehensive defense of psychiatric diagnosis in response the Rosenhan study that has been discredited. He was also responsible for removing homosexuality from the DSM and he did that by directly engaging with activists who presented him with clear information about why it was not a diagnosis. Critics like to use the homosexuality issue as a defect with psychiatry while never pointing out it was self-corrected and that correction happened decades before progress was made at societal levels.  Even now there is a question about whether societal progress is threatened by the normative thinking and agenda of conservative groups. Spitzer was responding to the political aspects of the process with political rhetoric. 

The best argument against inclusion in the original paper was:  “The DSM process is already compromised by excessive politics.” by several groups who are not psychiatrists.  That argument has been expanded in the past 18 years to the point where it is a frequent criticism in the popular media. Even in the original paper the authors suggest that these political processes may have stifled innovation and scientific progress.

Psychiatry has not “escaped” from considering values – as noted in the above examples they are incorporated into clinic practice when the specific social and cultural aspects that apply to a certain patient are explored and considered.  Contrary to philosophical opinion – the pathologized are not a marginalized group to psychiatrists. It is who we are interested in seeing and treating.  Our interest in treatment goes beyond what is typically considered evidence-based medicine. We are interested in any modality that might be useful and that includes using resources developed or available to the people who need them. It is clear that the DSM has been overly politicized and it is routinely mischaracterized in the media. Adding  additional elements - some that have strictly political agendas that include the destruction of the field - adds nothing to improving that process. There are existing avenues for that input and they are readily available outside of the DSM process in day-to-day psychiatric practice.

 

George Dawson, MD, DFAPA

 

References:

 

1:  Knox B. Exclusion of the psychopathologized and hermeneutical ignorance threaten objectivity. Philosophy, Psychiatry, & Psychology. 2022;29(4):253-66.

2:  Spitzer RL. Good idea or politically correct nonsense? Psychiatr Serv. 2004 Feb;55(2):113. doi: 10.1176/appi.ps.55.2.113. PMID: 14762229.

3:  Sadler JZ, Fulford B. Should patients and their families contribute to the DSM-V process? Psychiatr Serv. 2004 Feb;55(2):133-8. doi: 10.1176/appi.ps.55.2.133. PMID: 14762236.

4:  Dawson G. More on epistemic injustice.   https://real-psychiatry.blogspot.com/2023/01/more-on-epistemic-injustice.html

5:  Dawson G.  Epistemic injustice is misapplies to psychiatry.   https://real-psychiatry.blogspot.com/2019/07/some-of-greatest-minds-in-psychiatry.html

Eye Clinic Follow Up

I went back in today for a one week follow up of laser surgery for a retinal tear.  An acute problem always brings some issues into focus so I thought I would continue on about some comparisons of psychiatry with modern medical technology as well as some of the differences that cast some advantage to psychiatrists.   As usual there are always political implications.  I have the added advantage of showing the retinal scans from today, courtesy of the clinic.  As most patients know, experience with getting results like this from clinics is highly variable.  Most of that confusion is a direct result of the Privacy Rule that started under the Clinton administration and ended under the Bush administration.  It is complicated by CFR42, a federal regulation that directly impacts the release of sensitive data and the way it can be released.  after the recent modification to make it clearer and easier to get date, one of the clinics I go to will no longer e-mail me graphical data.  That is the outcome I expected when special interest attorneys get involved in health care law.

The visit itself went very well.  The clinic demonstrated the same efficiency.  The retinal exam included scans of both eyes by physical examination of only the affected eye.  The scribe was in the room and she picked up an error in the original note and corrected it.  The conclusion was no change in retinal opacities  (blood in the vitreous) - but well sealed off laser site with resolving retinal edema.  In the manner of most proceduralists that I have encountered, it was time for questions.  No spontaneous advice.  I carefully outlined the physical activities that I am involved in and was advised that I could resume with nor restrictions.  I had stopped taking 81 mg of aspirin a day on my own initiative and was advised that I could resume that.  The only additional information was follow up in 6 weeks and call if problems.

That call if problems is always a tricky proposition.  With the retinal opacities from the original tear the large amoeba-like blob over about 1/3 of my visual field was still there, but over the course of the day it comes and goes.  At times there are about 20-30 very small black dots floating around in that eye.  Given what I know about brain adaptation to let's say prism viewing, I wondered if my brain was adapting to the retinal opacities and only showing me the clear visual field.  There were times when it seemed worse, but I concluded that unless it was consistently worse, I should probably not call the clinic.  I arrived at that conclusion on my own. but confirmed  it with the retinal specialist between now and the next appointment.

I also thought about the time it takes me to coach patients about how to self monitor and also warn them about rare side effects.  I can spend 10-20 minutes on serotonin syndrome,  neuroleptic malignant syndrome, prolonged QTc interval, drug induced liver disease, priapism, metabolic syndrome, and diabetes mellitus.  And that is after we have discussed progress and medication side effects.  When I thought about the complication rates quoted to me for retinal/vitreous detachments and tears and the success rate of laser surgery - I am telling people about many potential complications that are a thousand to ten thousand times less likely to occur.

That is the range I am living in.  I am not complaining about it.  I think it is much more reasonable to have informed patients who understand that taking a medication is not a walk in the park or a miracle cure.  I am concerned that despite my detailed explanations and accompanying literature many people do still not understand it or just ignore it.  On the other hand I have had people with known problems like cardiac problems come back and recite everything I told them about potential cardiac problems and what to watch for.  The side effect that bothers most people is the potential for weight gain, but most of them can be assured that there is a strategy to deal with that problem.  If a medication is effective, people will want to take it even if there are potential problems with it including weight gain and ECG abnormalities.

The measurement technology used in ophthalmology is interesting.  The human retina is unique enough to allow it to be used for biometric identification.  No two retinas are identical and technically even though retinal tears have similar characteristics they are all in a unique biological landscape.

Technology clearly differentiates ophthalmology from psychiatry.  We remain stuck in the 1960s with an obsessive narrative that classifies but probably does not diagnose.  Depending on who you read, phenomenology is there to some degree.  Ophthalmologists done't really need to depend on objective descriptions of symptoms - they can see what the problem it.  I just read an article on a consensus treatment guideline  for depression that adds absolutely nothing to the field beyond what a psychiatrist has learned in residency training in the past 15 years.   At the end of the day we have no retinal scan that we can hand a patient and say: "This is your problem and this is what we did to fix it in about 1 hour."

And that is what we need.



George Dawson, MD, DFAPA


Supplementary:

I could not fit this into the body of the post anywhere but age-related retinal and vitreous diseases seem like a major oversight in medical education to me.  I studied geriatric psychiatry and geriatric medicine and the major focus was on age related causes of blindness that were essentially chronic illnesses.  As far as I can tell age-related acute retinal and vitreous problems are a major epidemic and every physicians should know how to diagnose them and how fast they need to be triaged and referred (fast).


                    

  

When To Not Prescribe An Antidepressant?

I encountered that interesting question just last week.  Antidepressant medications have been around for a long time at this point and they have an increasing number of indications.  Everywhere around the Internet there are algorithms that make prescribing these drugs seem easy and automatic.  Qualify for the vague diagnosis and follow the line to the correct antidepressant. At the same time there is plenty of evidence that their use is becoming less discriminate than in the past, largely due to the use of checklists rather than more thoughtful diagnostic processes.  It is common for me to encounter people who have been put on an antidepressant based on a "test".  When I ask them what that test was it is almost always the PHQ-9 or GAD-7, checklist adaptations of DSM criteria for depression and anxiety that can be completed in a couple of minutes.  There is a significant difference between the checklists and the diagnostic process as I pointed out in a previous post about the sleep question on the checklist compared with more detailed questions about sleep.  The list that follows contains a number of scenarios that will not be accessible by a checklist.  In those cases a more thorough diagnostic assessment may be indicated.

1.  Intolerance of antidepressants - Every FDA package insert for medications includes this warning, usually referring to an allergy or a medical complication from previous use.  In addition to allergic reactions (which are generally rare with antidepressants), there a number of significant problems that preclude their use.  Serotonin syndrome can occur with low doses and initial doses in sensitive individuals.  In the case of the more potent classes of serotonergic medications - the SSRIs as many as 20% of patients will experience agitation, nausea, headaches, and other GI symptoms.  By the time that I see them, they will tell me the list of antidepressants that made them ill and that they cannot take.  It is an easy decision to avoid medications that are known to make the patient ill.

2.  Behavioral intolerance of antidepressants - SSRIs in particular can have the effect of restricting a person's emotional range to a narrow margin.  They will typically say: ""I don't get low anymore but I also don't get as happy as I used to get."  A person who is affected in that way finds that to be a very uncomfortable existence.  Many have been told that they will "get used to it" - a frequently used statement about these medication related side effects.  I have never seen anyone get used to a restricted range of emotion and I tell them to stop it an not resume it.  I avoid prescribing antidepressants form that class and that class is typically SSRIs.

While I am on the topic, I frequently use the following vignette when discussing the concept of "getting used to" side effects:

"Many years ago I treated a man who came to me who had been taking a standard antidepressant for about 7 years.  He was not sure that he was depressed anymore.  He was sure that he had frequent headaches and very low energy.  I recommended that we taper him off the antidepressant and see how he felt.  He came back two weeks later and said: 'Doc - I feel great.  For about the last 6 years I felt like I had the flu every day and that feeling is gone.'  That is my concern about 'getting used to a medication'.  It may mean that what you really get used to is feeling sick.  That is why I encourage everyone that I treat to self monitor for side effects, and if they happen we stop the medicine and try something else."

That advice sounds straightforward but it is not.  I still get people who think that they need to "get used to" a medication and will only tell me in a face-to-face interview.

3.  Lack of a clear diagnosis - many of the people I see were started on an antidepressant during an acute crisis situation like the sudden loss of a significant person in their life or a job or their financial status.  There is no real evidence that antidepressants work for acute crisis situations, but some doctors feel compelled to prescribe a medication because it makes it seem like they are trying to help the patient.  I have also heard the placebo response rationalized for these prescriptions.  A similar cluster of symptoms can be observed along with the associated anxiety, but in the short term the main benefits to be gained will be from medication side effects like sedation rather then any specific therapeutic effect.   The real problem is that the medications don't get stopped when the crisis has passed.  I may be seeing a person who has been taking an antidepressants for ten years because they had an employment crisis or divorce at that time and have been taking the medication ever since.  They have been tolerating the medication well for that time, but it now takes a lot of effort to convince them that they don't need the medication and taper them off of it.

I try to prevent those problems on the front end by not prescribing antidepressants for vague, poorly defined emotional problems or crisis situations where they are not indicated.  In my experience, psychotherapy is a more effective approach and it helps the affected person make sense of what has been happening to them.

4.   An unstable physical illness is present - that can mean a number of things.  The commonest unstable physical illness that I routinely deal with is hypertension with or without tachycardia.  Patients and their doctors will often go to extraordinary lengths to avoid treating hypertension even hypertension that is outside of the most current and most liberal guidelines.  I am told that the person has "white coat hypertension".  How do they know that is all that they have?  Have they ever had a normal blood pressure reading outside of a physician's office?  Would they be willing to purchase their own blood pressure device, monitor their blood pressures at home and bring me the readings?  I have had people become angry at me because of these suggestions, even after a thorough explanation of the rationale.  It is almost like patients expect a psychiatrist to hand them a magical pill that takes care of all of their problems.  As an example the following warning if from the FDA package insert for milnacipran but most antidepressants don't include this warning - even when they might affect blood pressure:

"Elevated Blood Pressure and Heart Rate: Measure heart rate and blood pressure prior to initiating treatment and periodically throughout treatment. Control pre-existing hypertension before initiating therapy with FETZIMA"

There are a number of conditions ranging from glaucoma to angina that need treatment before antidepressants can be safely prescribed.  In some cases I am not happy with the pharmacotherapy for associated medical conditions.  Desiccated thyroid rather than levothyroxine for hypothyroidism is a good example.  Why is desiccated animal thyroid gland being used in the 21st century instead of the specific molecule?  In many cases, I will refer the patient to see a specialist and they will never come back because their real problem has been solved.  I posted about cervical spine disease some time ago after I had a number of patients come in for treatment of depression.  What they really had was insomnia from cervical spine disease and when that chronic pain was addressed their depression resolved completely.

I will run into some situations where I insist the patient see a specialist (generally a Cardiologist) to get an opinion on safety of treatment.  This used to be called "clearance" by the Cardiologist but for some reason that term has fallen out of favor.  I think the "clearing" specialists don't want the designation, but from my perspective the patient is not going to get the antidepressant that we discussed unless the Cardiologist agrees.

5.  The patient prefers not to take the medication - I think that patients are often surprised at how easily they can convince me to not prescribe a medication.  Many expect an argument.  I will supply them with the information they want and direct them to reputable sites on the Internet where they can read as much as they want about the medication.  I am very willing to discuss their realistic and unrealistic concerns.  I will attempt to correct their misconceptions  and also provide them with my real life estimate of how many people tolerate the medication and the common reasons why people stop it.  I fully acknowledge that I cannot predict if a medication will work for them or give them side effects.  At the end of that discussion, if they don't want to try the medicine that is fine with me.  I have absolutely no investment in prescribing medication for a person who does not want it.  If the person has clear reservations, I let them know they don't have to come to a decision right in the office - they can go home and think about it and call me with their decision.  I am never more invested in the medication than the person who is taking it.  I will also provide them with feedback on whether or not their decision seems reasonable or not.

6.   Additional patient preferences -  Many people will talk with me about antidepressants and say that they want to solve their problems with psychotherapy, exercise,  or some other non-medical option.  Many people will also talk about drugs, alcohol, cannabis,  hallucinogens, psychedelics, and other drug based treatments for depression.  I can offer people what is known about the scientific basis of treatments for depression and encourage effective non-medical treatment where it is indicated.  I do not endorse the use of the use of alcohol or street drugs for treatment and let people know that I cannot prescribe antidepressant medication if those other substances are being used.  That includes "medical marijuana".  There is a risk for serotonin syndrome with various combinations of stimulants, hallucinogens, and/or psychedelics in combination with antidepressants.  Some web sites that profess to provide neutral advice to people who want to experiment will often have some posts on how to mix these medications to get enhanced effects.  None of that advice should be considered safe or reliable.  It is an indication to me that the person cannot be expected to take the prescription reliably.

7.  Context - very important consideration.  Seeing a person who has just survived a suicide attempt in the intensive care unit is a much different context than seeing a long  line of people who are dissatisfied with life for one reason or another.  Twenty three years of acute care work taught me that medical interventions are much more likely to work for clear cut severe problems than vaguely defined problems.  There are many people who are looking for a fast solution to difficult problems.  When I suggest to them that environmental factors need to be addressed or that they may benefit from psychotherapy or even more explicitly that psychotherapy will work better for your problem than medications - I am often met with resistance.  Common replies are that they cannot commit that kind of time or energy to psychotherapy.  Since most managed care companies discriminate against psychotherapy - many will tell me that their copays are too expensive.  If I point out that their work schedule or job is the problem - they will give me many reasons why they can't change it.  Treatment becomes conditional - as in - I am hoping that this antidepressant will work because I cannot change my life in any reasonable way and I can't do psychotherapy.

8.  Commitment to treatment - too many people come in and expect the prescription of an antidepressant to not only solve the problems but that nothing else is required of them except to show up for an occasional appointment.  If I want to see medical records like exams, labs, imaging studies, ECGs. EEGs, pharmacy records or other information it is generally not an option.  I need that information before any prescription occurs.  The same is true if I need to order these tests and see the results.  I am quite capable of having a discussion of the costs of these orders and that is why I have a preference for not repeating tests and looking at existing results.  That does not prevent the occasional complaints about how I am interested in making money off the person by ordering basic tests, even though I do not get anything at all for ordering tests.

The other part of treatment does involve agreeing to take the medication reliably and following the other recommendations that can be very basic.  If someone tells me that they are drinking two pots of coffee per day and they are anxious and can't sleep but are unwilling to stop the coffee because: "I know that I can drink two cups of coffee and still fall asleep" - I am probably not going to be able to do much with an antidepressant.  The same is true for somebody binge drinking a 12-pack of beer every night after work.  The effects of common substances like caffeine and alcohol are contrary to the goals of treating anxiety and depression with or without medication.

9.  Mania - it is possible for people who have taken antidepressants for years to become manic either while taking the antidepressant regularly or when the antidepressant has been disrupted.  Even though the incidence of mania from antidepressants is low and the treatment of bipolar disorder depressed includes an antidepressant-atypical antipsychotic combination (olanzapine-fluoxetine combination or OFC) stopping the antidepressant acutely is the best idea.  Many people discover at that point that mood stabilizers seem to work much better for their periods of depression than antidepressants.                              
10.  Misunderstanding the treatment alliance - fortunately treating depression and anxiety is not like treating standard medical problems.  Most office visits for new general medical and surgical problems are one or two visits in duration.  A medication is prescribed and it either works or it doesn't.  When it doesn't the problem either resolves on its own or becomes a chronic problem.  One of the best examples anywhere is acute bronchitis.  Over the past decades - tons of antibiotics have been prescribed for no good reason.  Acute bronchitis generally resolves on its own in young healthy people.  I try to be very clear with people that their response (good or bad) to the medication is in no way guaranteed.  I let them know that these medications are moderately effective at best and then only in the hands of somebody who knows how to rapidly switch them up and in some cases augment them.  Even then there will be some people who do not respond.  The key to all of that treatment is communication and it may require significant patience on the part of the patient.  It may also require more frequent appointments then they anticipated especially is associated problems like suicidal thinking and psychosis are also being addressed.

Those are my thoughts about the question of who I would not prescribe an antidepressant to.  I hope to transform those thoughts into dimensions in a useful graphic.  Feel free to let me know if I missed anything.



George Dawson, MD, DFAPA

High Intensity Movement Disorders Conference

I have been a member of the Movement Disorder Society since 1993.  I decided to join after having nothing but positive experiences at the annual Aspen courses led by Stanley Fahn, C. David Marsden, and Joseph Jankcovic.   Although Dr. Marsden has passed away, the course is still being given by two of the original lecturers with additional faculty.  The level of scholarship and expertise in this conference is really not approached by many venues these days.  Each conference provided participants with a 700 page textbook like syllabus on everything that you ever wanted to know about movement disorders.  Once you attend a conference like this it is a life transforming event.  Suddenly you are following the lecturers, you read what they write and you acquire some of their books.  I changed my Neurology text to Neurology in Clinical Practice because both Jankcovic and Marsden were editors.  I also received the video material and text of Movement Disorders,  the official journal of the International Parkinson and Movement Disorder Society.

People often ask why I am member of what is predominantly a neurological society?  In Minnesota there were only three psychiatrists who were members of the organization. Stan Fahn asked me that himself at one of the conferences.  I don't remember exactly what I said, but he thought my answer at the time was acceptable.  It comes down to clinical expertise and with the confluence of the dorsal and ventral striatum - neuroanatomy.  Back in the days that I went to medical school, nobody talked about the ventral striatum only the dorsal striatum and even back then, the main clinicopathological correlate was movement disorders.  As medical students we learned primarily about Huntington's Disease, Wilson's Disease, and Parkinson's Disease.  Nothing at all about dystonias or other disabling movement disorders and their treatments.  Nothing about the last members of the generation afflicted by what we called in those days post-encephalitic Parkinson's and all of the associated neuropsychiatric morbidity.   In my rotations at Milwaukee County Hospital and affiliated institutions I saw all kinds of undiagnosed or poorly diagnosed movement disorders.   There were no movement disorder specialists in those days and no treatments except for Parkinson's.  The quality of care is slightly improved today in that referral to movement disorder specialists and an appropriate diagnosis can occur, but the total number of these specialists is very small.

That is where psychiatrists need to fill in the gap.  My initial interest was tardive dyskinesia and describing the motor disorders of patients who in many cases had never been exposed to a medication.  But it quickly became recognizing the early manifestations of idiopathic and iatrogenic movement disorders and using these diagnoses in a comprehensive diagnostic approach to the patient as well as the treatment plan.  When you take that approach it is an eye opener.  In my role as a consultant it is amazing how much undiagnosed movement disorder pathology is out there.  A couple of examples will illustrate the problem.  About 50% of young adults with childhood diagnoses of Attention Deficit-Hyperactivity Disorder (ADHD) who have been treated with stimulants have a movement disorder usually in the form of vocal tics, motor tics, or Tourettes.  About 100% of those patients tell me that nobody has ever told them about those diagnoses before.  Of course there is an exhaustive list of medication and environmental exposures that can lead to tic disorders, so there is a question of whether something occurred since childhood.  In the same population there are a group of people with choreiform movements and predominately extensor muscle tone.  They are not aware of the movement disorder and nobody has mentioned it before.  It is as though clinicians consider these movements to be part of ADHD.  One of my observations about tardive dyskinesia has been that the overall prevalence of the disorder has dropped off significantly with the advent of atypical antipsychotic medication.  That does not mean that is has gone to zero and the augmentation of antidepressants with aripiprazole seems to be a new source of that disorder.  Most significantly, the people who are at greater risk for the problem do not seem to have been carefully screened ahead of time.  They are not routinely assessed for akathisia or other early motor symptoms like micrographia, diminished arm swing,  or hypophonia.

The course was presented by three neurologists Cynthia Comella, MD; Rajesh Pahwa, MD; and Jerrold L. Vitek, MD, PhD.  It was presented by the University of Kansas Medical Center and all of the brochures and specific courses are available on this web site.  The course was unusual in its rapid presentation of topics and strict adherence to that schedule.  There were ten presentations by the faculty varying in length from 20 to 55 minutes in duration.  The morning presentations covered Parkinson's and Parkinsonism, Restless Leg Syndrome, Tremor Disorders, and Movement Disorders in Psychiatry.  The afternoon covered Dystonia, Chorea, Tics, Neurotoxin and Deep Brain Stimulation for Neurological and Psychiatric Disorders.  The entire set of PowerPoints (without the videos) was included in the course syllabus.  The slides were all very readable in a standard format.  The Psychiatric Aspects of Movement Disorders was a very interesting presentation because it covered a wide range of problems that acute care and geriatric psychiatrists come in contact with including Parkinson's Disease and the associated psychiatric comorbidity, Tardive Dyskinesia, Neuroleptic Malignant Syndrome, Serotonin Syndrome, and Psychogenic Movement Disorders.  Interest in these topics may reflect exposure to the problem.  In seeing patients with Parkinson's and psychosis for example one of the commonest problems is that antipsychotic medications will generally make their psychosis worse.  The only exception to that is clozapine and that comes with a host of comorbidities and monitoring issues itself.  One of the presenters suggested that quetiapine is a default choice in many cases even though it is not ideal and efficacy is low.  A new medication for the treatment of psychosis in PD was mentioned called Pimavanserin.  It is a selective serotonin 5-HT2A inverse agonist without significant activity at dopaminergic, histaminergic, muscarinic, or adrenergic receptors.  Practical approaches to treating dementia, anxiety, and depression associated with PD were also discussed.

The most fascinating part of the course was the section on deep brain stimulation (DBS).  A fairly detailed description of the procedure was given.  Deep brain stimulation is currently FDA approved for Essential tremor and Parkinsonian Tremor and Parkinson's Disease with humanitarian device exceptions for Primary Dystonia and Obsessive Compulsive Disorder.  This section was presented by Dr. Vitek who has a wide range of experience with this method.  Before and after videos of children and adults with disabling movement disorders were presented and the results were striking.  The general concept presented was that any "circuit disorder" was a potential candidate for DBS and that is consistent with the current literature on the subject.  The other important concept is that with DBS there are no permanent changes in the brain apart from the low risk of placement complications.  That is not true for neurosurgical techniques that have been used for the same neurological and psychiatric complications.  In the case of DBS the stimulator can be reprogrammed, turned on or off in a number of configurations, and turned completely off.  An unexpected benefit of the DBS presentation was a look at brain images from a 7 Tesla MRI scan.  The resolution of these images was incredible arguably as good as artistic renderings of brain anatomy.  Take a look at the side by side comparisons to what is currently clinically available.

Everything considered this was an excellent conference and I recommend it to anyone if it comes to your area.  I think it could be used by practicing psychiatrists who want to get up to speed on movement disorders, residents wanting to do the same thing, and psychiatrists studying for their boards in geriatric psychiatry.  It also raises a larger question of just what psychiatrists should be able to diagnose and treat?  What should they know at a theoretical level?  Based on my experience, psychiatrists seem to be the specialists that are most likely to be confronted with an undiagnosed movement disorder in patients who have seen primary care physicians or pediatricians.  Psychiatrists are also specialists who should be the experts in how to recognize and prevent motor complications of medications used to treat psychiatric disorders.  Psychiatrists have also been using the same interview and mental status exam technology for the past 50 years.  Changes need to be incremental and the logical first change that seems in order is to be able to recognize, diagnose, and treat or refer movement disorders encountered in standard psychiatric practice.  Psychiatrists interested in neuroscience with also find this a very interesting area for ongoing study.  And subspecialists like geriatric psychiatrists are probably going to need to know the difference between tauopathies and synucleinopathies.

This course is a good one to get you on that road.


George Dawson, MD, DFAPA        


Attribution:  My own picture shot at the John Rose Oval in Roseville, Minnesota.



  

A Basic Question About Anxiety

For the past 5 years I have seen more anxiety than in the first 24 years of my career.  I just realized last night that is one of the consequences of being an acute care psychiatrist.  In that setting, I am sure that I have seen more people with schizophrenia, bipolar disorder, severe depression, catatonia, dementia, and delirium than most psychiatrists.  If the anxiety was present it was associated with a severe disruption caused by the major psychiatric diagnosis.  When that syndrome was treated, the associated anxiety and insomnia also resolved.  I think that inpatient docs also get a fairly skewed perspective of what kinds of problems the average person is looking for help with.  Now that I am no longer seeing an acute care population it seems pretty clear that most people present with a mixture of anxiety and depression.  They present with varying levels of sophistication to give the history of the problem.  It is common for me to hear: "I am not sure that I know the difference between anxiety and depression.  Can you explain it to me?"  It is also common to hear combinations of symptoms or descriptions that cross over from one category to another.  A good example would be getting a referral for the assessment of "hopelessness" and learning that happens only during a panic attack and in the complete absence of depression.

Symptom severity and the perception of that severity turns out to be another problem.  Some people are fairly intolerant of the slightest bit of worry, especially if it leads to insomnia.  Others have a pattern of hyperarousal at night.  When their head hits the pillow, it is not a time to fall asleep.  It is a time to worry about what happened that day, the kids, the spouse, finances, and work.  Many of those folks are chronically sleep deprived but they are used to it and don't really complain about it.  A few will go to an even higher level of worry.  At that point their thoughts "race" (another cross-over symptom), but they seem more concerned about insomnia than anxiety.  In the people with severe early onset anxiety it is very common for that to morph into depression - a phenomenon written about by several researchers.  It is also common to see that happen on a week to week basis - with reports of anxiety dominating one week and depression the next.  After I define the symptoms for people I always try to ask a question about which syndrome is dominant this week and get the expected scatter of symptoms.  It is not surprising to me that these diagnoses have some of the lowest reliabilities of DSM-5 diagnoses in field  trials.  Critics of course point to problems with psychiatric diagnosis or the diagnostic manual.  Nobody seem to make the obvious point that this may reflect how people actually experience their problems.

I consider the developmental approach to psychiatric diagnosis the best one, especially when you have enough time to do that kind of work.  It requires constructing a timeline of symptoms across the lifetime of the patient.  It is necessarily biased by the imperfections of human memory including the reports of events that may not have really happened.  With anxiety and depressive disorders there are major landmarks that need to be discussed including sleep problems (insomnia and nightmares), school refusal or phobias, relationships with major attachments figures, losses of attachment figures, psychological trauma, and other forms of childhood adversity.  When I do that I notice that two patterns seem to emerge.  In one case, there are a number of people with what I would call an unremarkable developmental history in terms of events that might be associated with anxiety or depression.  At the other extreme are people with multiple events who have developed what I would call an anxious temperament.  Worry and some associated physiological symptoms are part of their personality.  They worry about everything.  They may know that they come from a long line of "worriers" and recognize these traits.  They have insight into the fact that they "overthink" everything and they are seen as being far too cautious about life.  They appear anxious, jittery and jumpy at times.  I am usually not the first physician seeing them and they have been treated with all manner of psychiatric medications with very few positive results.  They may be at risk for addiction, because some of them are looking for a medication that just "turns my mind off".   If they are prescribed a potentially addictive drug for that purpose, the dose required to turn off the mind is often very close to the euphorigenic dose and addiction results.  The people with anxious temperament do not have an episodic problem with anxiety, like some research articles describe.  It is with them all of the time.  I think it is also associated with other personality traits and disorders that makes treatment even more difficult.

In an effort to resolve this problem of episodic generalized anxiety versus anxious temperament I sent an e-mail to one of the top anxiety experts in the world.  He has hundreds of publications and is a co-author of what is considered on the the most authoritative texts on this subject.  I had that text sitting on my library shelf.  He agreed with my assessment of the problem but referred me back to a chapter in his text written by Kathleen Brady and colleagues on substance induced anxiety.  I read that but ended up on a section on the phenomenology of generalized anxiety disorder (GAD).  That section suggested a different phenomenology based on age.  The chapter by Taylor, et al had more detail on trait, temperaments and endophenotype models and I was able to take a closer look at endophenotypes in reference 5.  The Venn diagram below is based on the high points in this chapter.  It also confirmed by longstanding conviction that temperament are traits discussed about children and general and specific personality traits are discussed with adults.

Looking at the state of the art here it is apparent that a diagnosis of GAD does not provide anywhere near the level of information that is needed to treat it.   That is important because people are walking in to see psychiatrists with the expectation that there is a quick cure for the problem.  They will generally not get that if a checklist diagnosis is made based on GAD symptoms and they are given a prescription.  It is easy to see how some people will believe that blunting their levels of arousal with a non-specific sedating effect from a benzodiazepine is treating their anxiety.  Those same traits put people with high levels of trait anxiety at risk for alcohol and substance use problems.  More comprehensive formulations of anxiety need to be done that incorporate these factors in order to break the pattern of chronic anxiety and in some cases associated substance use.   Telling a person that they have generalized anxiety and treating them with medications alone, will probably not be enough to address the problem.  That is also the message that trainees might get when they consider research articles or read any modern text of psychopharmacology.  One text (6) provides stratified algorithms of decision-making for acute and chronic generalized anxiety, phobic disorders, PTSD, OCD, and panic disorder.  The authors do name specific psychotherapies in the algorithms and in some cases show that a trial of psychotherapy may be prudent before medications but all of the treatment is predicated on diagnoses rather than specific subtypes of the main conditions.  For example, there are a number of people with chronic anxiety who also have elevated heart rates (greater than 100 beats per minutes), marginal blood pressure and cardiac awareness in that they can sense their heart pounding in their chest when they are trying to sleep or they are in a quiet room.  These sensations are often a source of excessive worry and increased anxiety.  In the primary care setting there are many physicians who do not treat sinus tachycardia in the absence of a clear medical cause for it.  Is this a type of anxiety (endophenotype?) that should be treated with beta blockers? Does it require more than that for the cerebral component of anxiety or just the beta blocker?  Will physical exercise or psychotherapy treat the chronic tachycardia?  Are otherwise healthy patient with tachycardia excluded from clinical trials for anxiety on that basis?  And what constitutes an adequate medical evaluation for these patients?  Even today, I don't think that anyone has the answers to these questions and the same can be said for many other variants of generalized anxiety.

I have never seen a clinical trial of patients with anxiety and persistent tachycardia and doubt that I will.  If I had to guess, I would say that very few people are asked if they have cardiac awareness and whether that perception increases their anxiety.  I would also guess that (like hypertension) many of these patients do not have their vital signs followed very closely.  These are just a few of the ways to break down this very heterogenous syndrome and why further analysis is necessary.



George Dawson, MD, DFAPA


References:


1:  Dan J. Stein, MD, PhD; Eric Hollander, MD, and Barbara O. Rothbaum, PhD.  Textbook of Anxiety Disorders. Second Edition.  American Psychiatric Publishing, Inc.  Washington DC,  2010.

2:  Sudie E. Bach, Angela E. Waldrop, and Kathleen T. Brady.  Anxiety in the Context of Substance Abuse.   In Stein, et al, pp 665-679.

3:  Steven Taylor, Jonathan S. Abramowitz, Dean KcKay and Gordon JG Asmundson.  Anxious Traits and Temperaments.  In Stein, et al pp. 73-86.

4:  Lazlo A. Papp.  Phenomenology of Generalized Anxiety Disorder.  In Stein, et al pp.159-171.

5:  NLM Collection on Anxiety Endophenotypes

6:  Phillip G. Janicak, Stephen R. Marder, Mani Pavluri.  Principles and Practice of Psychopharmacotherapy, Fifth Edition.  Wolters Kluwer Lippincott Williams and Wilkins.  Philadelphia, 2011.

Attribution:

Attribution for the painting at the top of this post is is Edvard Munch [Public domain], via Wikimedia Commons.  This is a reproduction of an original work that is in the public domain based on US Copyright Law.


Supplementary 1:

I was sent a question about my comment in the above post about anxiety and morphing into depression and where that is referenced in the literature.  The earliest reference I have is in ES Paykel's text Handbook of Affective Disorders from 1982.  In the chapter by Roth and Mountjoy "The distinction between anxiety states and depressive disorders." the authors state:

"Clancey, et al (1978) reported that 49 of 112 (43.8%) anxiety neurotics developed secondary depression during a 4 - 9 year follow up period."

1: Clancy J, Tsuang MT, Norton B, Winokur G. The Iowa 500: a comprehensive study of mania, depression and schizophrenia. J Iowa Med Soc. 1974 Sep;64(9):394-6, 398. PubMed PMID: 4425518.

There are more of these articles and it may take me a while to find them due to the usual discussions about comorbidity and similar biological substrates:

2:   Martin C. [What is the outcome of childhood anxiety in adulthood?]. Encephale. 1998  May-Jun;24(3):242-6. Review. French. PubMed PMID: 9696917.

3:   Kessler RC, Keller MB, Wittchen HU. The epidemiology of generalized anxietydisorder. Psychiatr Clin North Am. 2001 Mar;24(1):19-39. Review. PubMed PMID: 11225507.

"The strong comorbidity between GAD and major depression, the fact that most people with this type of comorbidity report that the onset of GAD occurred before the onset of depression, and the fact that temporally primary GAD significantly predicts the subsequent onset of depression and other secondary disorders raise the question of whether early intervention and treatment of primary GAD would effectively prevent the subsequent first onset of secondary anxiety and depression."

4:   Kessler RC. The epidemiology of pure and comorbid generalized anxiety disorder: a review and evaluation of recent research. Acta Psychiatr Scand Suppl. 2000;(406):7-13. Review. PubMed PMID: 11131470.

"Results arguing that GAD is an independent disorder include the finding that GAD is usually temporally primary in cases of comorbidity with major depression, that primary GAD is a significant predictor of subsequent depression and that the course of GAD is independent of comorbidity."

5: Angst J, Vollrath M. The natural history of anxiety disorders. Acta Psychiatr Scand. 1991 Nov;84(5):446-52. Review. PubMed PMID: 1776498.

"The course is often characterized by a certain chronicity that manifests itself in residual symptoms and mild impairment in social roles even after many years and is frequently complicated with depression."

6:   Beesdo K, Knappe S, Pine DS. Anxiety and anxiety disorders in children andadolescents: developmental issues and implications for DSM-V. Psychiatr Clin North Am. 2009 Sep;32(3):483-524. doi: 10.1016/j.psc.2009.06.002. Review. PubMed PMID: 19716988; PubMed Central PMCID: PMC3018839.

"The development of secondary depression seems to be a particularly frequent and concerning heterotypic outcome of anxiety disorders. Is this a characteristic of anxiety in general rather than an issue of specific anxiety disorders or anxiety features (such as panic, avoidance, accumulation of risk factors)? Or is this related to an overarching anxiety or anxiety-depression liability, possibly through shared etiopathogenetic mechanisms (eg, neurobiology)?"

The authors of this study have a table summarizing the outcomes of childhood anxiety showing that in studies where is was mentioned 10/17 studies found depression as an outcome of anxiety.  This reference is available for free online.

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).

2015 and......

I was going to try to post about alcohol consumption prior to New years Eve, but am still working on that post.  Instead, I found myself reacting to a post on LinkedIn entitled "10 Warning Signs That Your Psychiatrist Is Not A Good Fit" by Amanda Itzkoff, MD.  Look for it on LinkedIN if you are a member and see what you think.  I found it fairly stark and negative.  I found myself immediately typing up my own top ten list on how you know you have found a competent psychiatrist.  That may not fit the usual blogger message that critical statements that apply to only a few is the only reason for commentary.  One of my reasons for writing this blog is that the tremendous number of colleagues who I personally know are all very competent and the list is a composite of what anyone would find walking in to talk with any one of them.  That list follows.

I had thought about posting a list of what I plan to continue to do here in the coming year but decided that was unnecessary.  You can certainly go to any number of blogs to find out what is wrong with psychiatry or psychiatrists.  Much of it is hyperbole.  I hope that you will find what I write here is a realistic antidote to those other sites.

    Top Ten Signs Your Psychiatrist Is Competent

1.  You are understood.

Your psychiatrist makes it very clear to you that he/she understands the problem and all of the mitigating factors by formulating the problem and treatment plan, restating it to you, and giving you useful advice.  That also includes discussing the relationship that you have with the psychiatrist and any concerns that you have about it.  That is one aspect of seeing a psychiatrist that differs from seeing other physicians.  You should be comfortable bringing up any concerns and clarifying any potential misunderstandings.  Your psychiatrist should also be able to answer the basic question about whether you have any diagnosis or problem that requires treatment.  Your psychiatrist should be focused on a discussion of your problems and your best interest should be the focus of treatment.

2.  Your psychiatrist is an expert.

Your psychiatrist has technical expertise in the field and is comfortable discussing new treatments and innovation in the field ranging from psychotherapy to brain science.  That includes an awareness of the current limitations of treatment.

3.  Your psychiatrist knows medicine.

During the initial assessment and beyond, your psychiatrist pays close attention to any other medical problems that you have and how the treatment he/she prescribes might affect those conditions.  That includes being able to diagnose new medical conditions that can lead to psychiatric presentations and ordering the appropriate tests to follow potential complications of any new treatments or how new treatments might impact existing conditions.  That includes a willingness and an ability to talk with the other generalists and specialists providing your medical care.

4.  Your psychiatrist takes enough time.

The assessment and treatment of complicated problems takes time.  Many psychiatrists are in clinics where there are allowed only brief periods of time (10 to 20 minutes) for assessment and treatment.  Many people are satisfied with that amount of time, but if you are not - a different treatment setting may offer more time.  That can be discussed with the current psychiatrist and a referral to psychiatrists practicing in different settings can be obtained.

5.  If medications are involved your psychiatrist thoroughly explains the risks, benefits, and limitations of treatment.

Like most areas of medicine, medical treatments have their limitations.  That includes medications that are not completely effective in alleviating symptoms, side effects, and occasional very serious side effects.  Your psychiatrist should be able to help you negotiate that area and provide you with more detailed information for further study on request.  You should believe that your psychiatrist is taking any concern you have about side effects very seriously.  The discussion of side effects is as important as a discussion of potential therapeutic effects.  Any informed discussion of medical treatment should also include a discussion of non-medical approaches.  Many people are surprised to learn than non-medical approaches are more effective than medications in the treatment of several severe mental health problems.

6.  Your psychiatrist knows about addiction.

A significant number of people being treated by psychiatrists have problems with addiction.  Addiction can cause psychiatric problems and complicate the care of psychiatric problems.  Even if your psychiatrist is not an addiction specialist, he/she should be able to advise you in how to get well and not increase the risk for relapse if you are sober.  Your psychiatrist should also be able to advise you in approaches to your problems if you are not sober.  Chronic pain is also an associated problem and your psychiatrist should be able to make an assessment of your chronic pain problem and how it affects associated mental health and addiction problems.   

7.  Your psychiatrist is able to tell you about things that you do not want to hear.

That can cover a broad range of topics from your expectations about medication and psychotherapy, to unrealistic expectations, to boundary problems involving what appear to be straightforward problems like filling out a disability form.  One example would be concerns about a diagnosis of Attention Deficit-Hyperactivity Disorder (ADHD).  A lot of adults seek treatment for this problem and in many cases they are also expecting an approach that leads to enhanced cognition.  A consulting psychiatrist should be able to say that they do not have ADHD and that stimulant medications are not currently indicated for cognitive enhancement.  

8.   Your psychiatrist is concerned about your safety.

One of the characteristics of some mental health problems is that the safety of the person involved is compromised.   Psychiatrists are trained to make these assessments and determine a plan to address the problem.  Many psychiatric disorders result in impaired insight and judgment that is restored once the primary problem is treated.  It is often useful to have a discussion about that in advance.  Some states have a psychiatric advanced directive that is useful to direct your care in the event of an acute episode of illness that affects your judgment.  We live in a litigious society and physicians are often accused of “covering” themselves by making very conservative decisions.  These decisions are most likely driven more by safety concerns than malpractice concerns.  

9.   Your psychiatrist is willing to talk with your family.

You should be certain that your confidentiality is protected at all times per an explicit agreement with your psychiatrist.  That agreement should include emergency contingencies and advise you about the statutes in your state that affect confidentiality.  You should also expect that when you want your psychiatrist to talk with your family that he/she will do that.  For certain aspects of treatment planning such as discharge planning from hospitals and gathering diagnostic information, discussions with family are critical.

10.   Your psychiatrist is mindful of your financial concerns.

Mental health services are the most rationed services in medical care in the US.  That typically results in more out-of-pocket costs for people receiving psychiatric care than other types of medical or surgical care.  Your psychiatrist should be able to discuss the cost aspects of all forms of care.  That includes medication costs and also the cost of ongoing psychotherapy. Cost effective alternatives for both psychotherapy and medical assessment and treatment should be as easily discussed as any other aspect of treatment.  Your psychiatrist is often placed in an impossible situation by the insurance industry.  The insurance industry often makes it seem like your psychiatrist is responsible for decisions that are really the result of insurance industry rationing.  Any concerns you have about the financial basis for decisions should be clarified with your psychiatrist.

Happy New Year!

George Dawson, MD, DFAPA