Ophthalmology Styled Practice As A Goal For Psychiatry (And The Rest Of Medicine)

Over the years whenever I have thought of an ideal way to practice medicine ophthalmology comes to mind.  I remember a good friend of mine telling me shortly before he became an ophthalmologist that the speciality seemed to have the ideal mix of medical and surgical interventions and they were mostly effective.  He also had the great observation that no matter what field of medicine you specialize in - the information in that field will generally be contained in two or three large volume texts.  The information always expands to that amount with specialization.   My friend was a very bright guy.

Like most specialties, I have had my fair share of personal contact with them starting with a BB gun injury in the 8th grade.  That's right - just like in the movie - I almost shot my eye out.  And just like in the movie, my father told me shortly before the accident: "Be careful with that BB gun - you will shoot your eye out!"  Within minutes, I was standing there in disbelief.  A BB had ricocheted off a steel lamp cover in our basement and instantaneously hit me in the left eye.  Within minutes I looked in the mirror and was more shocked to discover that my iris color had been replaced with blood inside the anterior chamber of the eye.  The family doctor was called and advised my parents not to bring me to their office or the emergency room, but to see the new ophthalmologist in town.  He was the only physician in town who could assess and treat this injury.  I spent a week in the hospital with both eyes covered and eventually recovered with a traumatic cataract in the lens of my left eye.  Every ophthalmologist since has said the same thing: "You are lucky that cataract is just off your visual axis and it does not affect your vision."  Even more interesting, the last ophthalmologist I saw wanted to know about my experience of seeing with a traumatic cataract just off my visual axis.  In what ways did it seem different than the other eye.  After many questions he finally said: "I am just trying to find out what it is like for you to have this cataract."  An ophthalmologist interested in my conscious state of vision?

These are some useful lessons from ophthalmology:

1.  Precise assessments based on clear markers:

There is still room for interpretation.  No two retinas are alike.  As another example, an eye doctor told me recently that prominent retinal arteries may put you at risk for glaucoma.  I saw a second eye doctor 2 weeks later who agreed that I may be in the subgroup of people with prominent retinal arteries but that does not put me at higher risk for glaucoma.  In 50 years of annual eye exams my intraocular pressures have always been normal.  I have also used the eye exam in lectures on diagnostic accuracy looking at the issue of the diagnostic accuracy of direct ophthalmoscopy versus indirect ophthalmoscopy, basically ophthalmologists versus everyone else.  The ophthalmologists win by a wide margin when it comes to detecting retinal pathology.  The odds that a primary care physician can detect these changes with direct ophthalmoscopy as a screening exam are no greater than chance.   In the days when I did a lot of direct physical examinations of patients,  I was convinced that most physicians either did a poor job of using an ophthalmoscope or were just focusing on major landmarks.  They also seemed to ignore the general clinical status of the patient.  I recall an agitated, hypertensive, young stroke patient and clear hemorrhages in the retina.  I diagnosed the retinal hemorrhages and nobody else did, but they could confirm when I told them where to look.  Like all of medicine the subjective factor is there, even in what appear to be objective assessments, but ophthalmology seems to have some of the greatest potential accuracy and reproducibility.

2.  Interventions that are fast, safe and effective:

About 8 years ago I was interviewing a patient and looked down at the wood grain of the table. It started to swirl and move in one visual field.  I was part of a big multidisciplinary clinic at the time.  The information flow among the specialists was the best I have ever seen it.  I called the ophthalmology clinic spoke with an ophthalmologist.  After about 30 seconds of symptoms he said: "You have a retinal migraine.  We can get you in this afternoon, but I doubt there is much else."  I went with that advice and have had no similar problems since.  A few years ago a family member called me on a Saturday morning and said he had sudden onset of veiled vision and floaters.  He lives in a town of about 50,000 people.  He was able to see a retinal specialist and get laser surgery on his torn retina in a matter of hours.  I have had three other relatives with retinal surgery - all very successful.  In my case about one month ago, I had a sudden onset of eye aching, massive floaters, and large bright halos surrounding the entire visual field of my left eye.  I was triaged to ophthalmology in a few hours and diagnosed with an acute vitreous detachment with a plan to observe for any retinal damage in two weeks.

3.  Interventions that clearly enhance quality of life:

Saving someone's vision needs to be at the top of anyone's list when it comes to quality of life.  Surgical specialties are generally a very active intervention by physician with very good outcomes and some complications.  From what I have seen the complication rates of eye procedures are very low and in some cases the advertised procedures being done are in excess of 10,000 - 100,000.  In many cases there is an expectation that you will be seeing the doctor 2 or 3 times and that the chances of a good outcome that will improve your life are very high.

4.  A clear path to getting well:

The majority of patients seeing ophthalmologists, don't have to do much to get well.  Recognize the problem, discuss the treatment plan and risks/benefits of the surgical procedure and make the follow up appointments.  In the case of medical treatment - use the required eye drops, visual aids, diet, and protective equipment and participate in the monitoring plan.  In the patients I see with eye problems I know that many of them do not follow up.  I routinely ask about a personal history of eye trauma, visual problems, glaucoma, and macular degeneration.  In some cases I call their ophthalmologist directly about whether the medication I am about to prescribe would affect their treatment.  But generally an optimal path to care with a good outcome is outlined form most ophthalmology patients and the burden of adherence is relatively low.

Contrast that with a patient walking into a psychiatric clinic.  By that I mean a patient who gets a direct appointment with a psychiatrist.  There is no precision in the assessment.  There is a diagnostic manual that gives the appearance of precision, but it is fairly worthless unless the physician knows how to get at it and that generally involves having seen many patients with the problem.  It also involves concluding that many DSM-5 categories are so nonspecific or unrealistic that it makes no sense to make the diagnosis.  With a diagnostic manual that imprecise, markers are sorely needed and I am optimistic that we are on the verge of some.  I am optimistic that with the correct markers we will be able to define categories and clearly define treatment paradigms on those categories, but I don't expect that to resemble a DSM or an RDoC for that matter.  The burden of adherence is much higher.  Polypharmacy and keeping all of those medications straight is certainly as big a problem in primary care and the medical specialties.  Nobody else wants to see people back on an hourly basis for weeks, months, and years.

One of the fastest and safest interventions in psychiatry is electroconvulsive therapy.  In many parts of the country it is unavailable.  The FDA has some continuous program afoot to "reclassify" it.  This is the second iteration of that program since I responded to the first one years ago.  The only logical conclusion is that this is some kind of political maneuver being played out in a regulatory context.  My understanding is that reclassification would mean new sets of clinical trials to get FDA approval for devices.  It should not be surprising that very few places offer it, and thousands of patients go through endless clinical trials of antidepressants with no remission of their symptoms.  TMS (transcranial magnetic stimulation) and VNS (vagal nerve stimulation) seem far less impressive in treatment resistant populations.  Just last week a colleague also pointed out that there are probably thousands of patients who might benefit from ketamine infusions and that seems to be another procedure in limbo pending FDA considerations.  Without FDA approval, health insurers will deem a treatment experiment and not pay for it.  That is when treatment usually grinds to a halt.

Quality of life considerations should be high on any psychiatrists agenda since we learned that we treat conditions that are listed in the Top 10 of the World Health Organizations list of disabling conditions.  Unless we get robust treatment responses, quality of life is not likely to improve.  There are vast numbers of patients who are disabled and maintained on medications.  They clearly need more than the medication but the only service offered by their health plan is a series of brief visits with a psychiatrist or a prescriber, generally focused on polypharmacy.  There is no attempt at cognitive or vocational rehabilitation.  Those services are available to stroke patients but not psychiatric patients.

The path to getting well and recovering from a mental illness or addiction is often not clear.  The message has been oversimplified to "Take your medications as prescribed."  The same patient may hear "Don't do drugs or alcohol." but typically only after a problem has been identified for a while.  The average person with an addiction (according to survey literature) does not disclose that to a physician.  Most people after an acute episode of a mood disorder or psychosis - don't know where to start.  They don't know what happened to them and they don't know how to prevent it from happening again.  They may hear that they need "therapy" or "counseling" and realize that after 5 or 6 sessions, they don't like the therapist or the sessions aren't going anywhere.  What is left at that point?  Go back and see the prescriber in 15 minute lots about medications that seem to hardly have an effect or a seemingly endless series of medication trials?        

Instead of parsing words in somewhat meaningful categories we need to pick up the pace.  In my experience the people who are willing to see psychiatrists for a long period of time for pharmacotherapy, psychotherapy or both are in the minority.  It is clear that many psychiatrists end up seeing patients three or four times a year in what appears to be interminable treatment.  All the while the patients have varying degrees of disability and problematic quality of life.

All of this care is delivered by 19,216 ophthalmologists who are addressing an impressive array of eye diseases and injuries.  As previously noted there are 49,070 psychiatrists also addressing a lot of illness and disease.  Just like my previous argument about orthopedic surgeons, I have never heard of any shortage of ophthalmologists.

Ophthalmology teaches us that there is a much better way and we should be designing those paths of care instead of the giving it over to the business people and politicians.  A critical question on the idea of a shortage of psychiatrists is how much of that is due to the inefficiencies suggested above including interference from politicians and business organizations.



George Dawson, MD, DFAPA

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.

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

First Episode Psychosis

There is an interesting study in the July JAMA Psychiatry on the treatment of first episode psychosis (FEP).  The authors conclude that this is the first study that shows major advantages of an antipsychotic discontinuation strategy over maintenance therapy.  FEP has always been a topic of interest to me because for 22 years I ran an inpatient unit and about 10% - 20% of the admission were patients with FEP.  For the purposes of the study FEP encompassed the diagnoses of schizophrenia, schizophreniform   disorder, schizoaffective disorder, brief reactive psychosis, delusional disorder and psychotic disorder not otherwise specified (NOS).  There were no diagnoses of mood disorders or organic disorder with psychotic symptoms.  Thirty six percent had a comorbid alcohol or substance use disorder.  In the original study 7 years earlier, 128 patients were randomized into a DR (dose reduction/discontinuation) and MT(maintenance treatment) arms.  A few things are striking as I look at this study.  The first is the relatively small N of patient in the study and the diagnostic heterogeneity.  In the subgroup analysis at 7 years (Figure 3.) there were a total of 5, 6, 8, and 14 patients in the subgroups.  Some of the diagnostic categories imply more chronicity than others.  

From an experimental standpoint I have concerns about the addition of that last three categories - delusional disorder, brief psychotic disorder, and psychotic disorder-NOS.  In my experience, delusional disorder is often not associated with much functional impairment and patients often do not benefit from or want to take any medications.  They can be engaged in psychotherapy but maintaining them in therapy is often problematic unless there is an associated crisis in their lives.   Brief psychotic disorders also have a good prognosis.  I recall presenting data to families concerned about this problem based on a review of what was primarily Scandinavian literature from the 1980s suggesting that up to 50% of patients with a diagnosis of "brief reactive psychosis" experienced remissions.  Schizoaffective disorder has similar problems with the manic subtype having a course and prognosis similar to bipolar disorder and the depressive subtype having a course and prognosis similar to schizophrenia.  In clinical practice it is extremely common to see bipolar patients misdiagnosed with schizoaffective disorder and I have always wondered how that impacts on the studies of course and prognosis.  At any rate, adding these diagnostic categories (31% of the total sample) biases this study toward better outcomes.

The dose of haloperidol is interesting.  I started to practice inpatient psychiatry in an era of very high dose antipsychotic medication.  It did not take long to figure out that this was a bad idea.  It also did not take long to look at the basic science behind antipsychotic medication dosing.  A key figure in the early days of dopamine receptor pharmacology was Phillip Seeman, PhD who wrote an excellent review in American College of Neuropsychopharmacology's The Fourth Generation of Progress.  His graph of D2 receptor dissociation constants versus free neuroleptic in plasma water correlated well with antipsychotic dose provided a sound rationale for lower doses and also monitoring plasma levels of antipsychotics.  In my experience the only people who need higher doses of antipsychotics are rapid metabolizers of a particular drug with lower than expected levels.  With haloperidol that usually translates to a dose of 2-4 mg/day.  That is consistent with the dose ranges in the diagram in Figure 2 of this paper.  There is also a distinct group of people who have such neurotoxicity from antipsychotic medications that they should probably never take them.  That is also why I am member of the Movement Disorder Society.

Another interesting aspect of this paper is the psychopathology ratings.  When I noticed the diagnostic heterogeneity and the likelihood of remission, the logical question is what the ratings show.  In this study the  Positive and Negative Syndrome Scale (PANSS).  I had experience   with the brief versions of these scales.  Each dimension is rated on a 7 point Likert scale from 1 (normal) to 7 (extremely severe).  The PANSS is widely accepted as being psychometrically valid.  There is not a consensus on the interpretation of scoring and what might mean remission.  In this study we have to track back to the original description of the sample (3) and we observe the average baseline PANSS P score as 9.9 for the DR groups and 10.7 for the MT group.  The average PANSS N score was 13.1 for the DR group and 14.0 for the MT group.  For the purpose of contrast, the authors of this article expressed their concern about the interpretation of PANSS scores illustrate their concern by presenting ratings for an agitated patient with schizophrenia and paranoia.  The PANSS P score of 28 had improved to 24 by the end of the study and the PANSS N score was unchanged at 22.  

The overall context for the references here are important to keep in mind.  The authors original experiment (3) was an 18 month follow up of FEP following 6 months of remission of positive symptoms according to the PANNS.  It basically showed at that point that only 20% of patients can discontinue medications in the acute phase and that the relapse rate was twice as high with the DR than the MT strategy (43 versus 21%).  The current article (2) recruited members of the original trial and did the same intervention after 6 months of remission and assigned them to DR and MT groups and showed that the DR patients had twice the symptomatic and functional recovery rate than the MT patients (40.4 vs. 17.6%).  Looking at the baseline and study completion PANNS score for both studies yields the following:

All PANNS scores are  mean(SD)	Study 1				Study 2
	Baseline		End of Trial		Baseline		End of Trial
	DR	MT	DR	MT	DR	MT	DR	MT
PANNS P	9.9(2.8)	10.7(3.0)	11(4.3)	10.8(3.8)	9.79(2.96)	10.78(3.15)
PANNS N	13.1(4.6)	14.0(5.6)	12.1(5.2)	13.3(6.2)	12.87(4.8)	13.96(5.51)
PANNS G	24.6(6.2)	26.4(6.9)	24.7(7.3)	24.9(6.7)	25.27(6.44)	26.45(6.62)

Although I could not find PANNS scores for the end of the second study, the scores in all categories across studies are strikingly similar.  PANNS, BPRS, and CGI scores have recently been investigated by Leucht, et al who conclude that a change of a 10 point reduction of a PANSS score was the equivalent of mild clinical improvement and a 50% reduction was consistent with “much improvement” in an acutely ill non-refractory sample (5).

I think the reasonable conclusions from this study are:

1.  Mildly symptomatic populations with FEP may be cautiously tapered off low dose antipsychotics over time and experience better functional recovery.  Tapering earlier in the course has a higher risk of relapse.

2.  The treatment recommendation for low dose antipsychotic medication in mildly symptomatic populations is sound practice according to this report.  Another important aspect is that minimal side effects were reported in standard measures in this study.  It is still common to find patients discharged from hospitals on the equivalent of 10-20 mg haloperidol and show up for their first outpatient visit with metabolic or neurological side effects.

3.  FEP needs further study.  I suppose we can wait for a large initiative and I may have missed one in progress, but the best approach at this time would be for large clinics and hospital based programs to all develop FEP clinics staffed by interested staff and networked to share information.  This study highlights that following the remission of psychotic symptoms is not enough and the common practice of following people in an outpatient “medication management” visit is not enough to restore functional capacity or quality of life.  There is also the question of the availability of psychotherapy for people who can successfully taper off antipsychotic medications and for those who cannot.  I have found that psychotherapy is often a useful treatment for people who cannot tolerate low dose antipsychotic medication.

4.  The authors describe reasonable concerns about their study including that fact that they may have selected the “best half” of the subjects from the original trial.  The subjects that were nonparticipants in the second study were described at “functioning at a lower level, less adherent to therapy and more difficult to engage.” But it is difficult to see that in the rankings at baseline.  They also point out that the raters were not blind and suggest that probably would not account for the degree of difference.  Based on studies of clinics that deal well with certain chronic disease (like cystic fibrosis) motivated clinicians with a stake in the treatment method and outcome clearly can make a difference and that might be reflected in ratings.  They discuss a mechanism to account for gains in functional capacity in the DR arm and that is basically less impairment of dopamine signaling and possible impairment in drive, motivation and functional capacity.  They recommend follow up studies of up to 7 years “or longer” in duration to look at these trends.

Finally, there is really no reason why principles discovered in an FEP study or a psychotherapy study of psychosis cannot be applied to patients who have histories of recurrent psychotic episodes.  Highly motivated clinicians can apply these treatment modalities if they have the opportunity.  It is really no different than large scale (but much better funded) efforts in other specialties where the treatments and outcomes are in a state of flux.  A good example would be electrophysiological ablation of atrial fibrillation.  There has been some opinion about the implications of this study for the idea of life-long maintenance therapy but it is equally damning for the model of seeing patients in 15 minute visits and asking them about positive symptoms and medication side effects.  There has always been a need for a much broader focus on cognition and functional capacity.

George Dawson, MD, DFAPA

1: McGorry P, Alvarez-Jimenez M, Killackey E. Antipsychotic Medication During the

Critical Period Following Remission From First-Episode Psychosis: Less Is More.
JAMA Psychiatry. 2013 Jul 3. doi: 10.1001/jamapsychiatry.2013.264. [Epub ahead of print   PubMed PMID: 23824206. 

2: Wunderink L, Nieboer RM, Wiersma D, Sytema S, Nienhuis FJ. Recovery in

Remitted First-Episode Psychosis at 7 Years of Follow-up of an Early Dose

Reduction/Discontinuation or Maintenance Treatment Strategy: Long-term Follow-up

of a 2-Year Randomized Clinical Trial. JAMA Psychiatry. 2013 Jul 3. doi:

PubMed PMID: 23824214. 10.1001/jamapsychiatry.2013.19. [Epub ahead of print]

3: Wunderink L, Nienhuis FJ, Sytema S, Slooff CJ, Knegtering R, Wiersma D. Guided

discontinuation versus maintenance treatment in remitted first-episode psychosis:

relapse rates and functional outcome. J Clin Psychiatry. 2007 May;68(5):654-61.

PubMed PMID: 17503973.

              

4:  Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome scale (PANSS)

for schizophrenia. Schizophr Bull. 1987;13(2):261-76. PubMed PMID: 3616518.

5: Leucht S, Kane JM, Etschel E, Kissling W, Hamann J, Engel RR. Linking the

PANSS, BPRS, and CGI: clinical implications. Neuropsychopharmacology. 2006

Oct;31(10):2318-25. Epub 2006 Jul 5. PubMed PMID: 16823384.

Concentration of Effort, Academics, and Managed Care

I follow the Nephron Power blog because I have maintained a life long interest in Nephrology or at least since I found out what it was in Medical School.  The conventional wisdom at the time was "Oh you're going into psychiatry - take as many medicine electives as possible because you will never have the chance to do medicine again."  If there are any medical students reading this - I ended up doing another 22 years of following renal function, treating people who were delirious and in renal failure, treating manic patients who were in renal failure waiting for a kidney transplant, and consulting with Nephrologists.  I  can say without a doubt that the Nephrologists who I worked with are some of the brightest, most thoughtful and hardest working people I have ever known.

I still  consider the Renal Service where I worked in medical school to be the model for academic medicine and how to teach medical students and residents.  It was located in two adjacent hospitals and headed up by a cranky old guy.  I say "old" realizing that he was probably about the same age that I am right now and he had the appearance of being cranky like a lot of old guys can get.  You could tell he was very bright, very interested and not above giving the medical students a hard time.  He made sure that on all of the consults we had conducted the appropriate "liquid biopsy" by performing our own urinalyses on patients we were seeing.

We rounded three times a day seeing all of the hospitalized patients in the morning, clinic patients in the afternoon, and hospital consults in the evening and at night.  My last action as a medical student was staffing two Renal Medicine consults at about 8PM the night before I graduated.  The other team members included another two attendings, two fellows, three Internal Medicine residents, and another medical student.  The physical layout of the service was two hospital wings and a very busy clinic with a separate day for a Hypertension clinic.  The hospital service was in the same hospital as the transplant team and we would also care for patients with transplant complications.

The  atmosphere on this service was electric.  Everyone was on time, interested, bright, academic and effective.  To this day - I consider this team from the 1980s to be the prototype for what a teaching service in a Medical School should be and in many ways how serious medicine should be provided.  When I left the hospital that night after the last two consults staffings of my medical student career I can remember thinking - should I have gone into medicine and become a nephrologist?  My fantasy in psychiatry became to recreate this model or at least parts of it in psychiatry.

Flash forward 26 years.  Most people would be fairly surprised to find out that you can come close to my fantasy in very few psychiatric units.  The patient flow into and out of many psychiatric units generally does not depend on academic considerations like providing the best medical and psychiatric care to patients.  In most cases patient flow does not depend on the judgment of psychiatrists.  My ability to care for patients with the most severe illnesses did not come about because there is an elite cadre of psychiatrists who are academically interested and have the necessary resources to provide that level of care.  It came about because the system where I worked needed a place to put these folks and I happened to be a psychiatrist who was interested in all of their problems.

I got very close to recreating at least the inpatient side of my old Renal Medicine service, but these days there are just too many administrative problems along the way.  It is impossible to take a learned approach to medicine and psychiatry with administrators breathing down your neck about an absurdly short length of stay.  It is a clash of paradigms and as far as I can tell the administrators have won.  You cannot possibly address complex problems when someone is telling you that the only reason a patients should be in the hospital is that they are "suicidal" or "homicidal" - both very loosely defined business terms for getting the patient out in time to capture about a 20% profit on the DRG payment.  Let's suspend the reality that this person is just  too ill to function or that their illness has created an impossible situation at home or they are not able to care for their new medical diagnoses until they have recovered their cognition to some extent.

If you are really interested in a rigorous approach to tough problems these days you will run afoul of a huge managed care infrastructure that is there to process patients in and out of hospitals based almost entirely on business decisions.  That makes life a lot less interesting for physicians and a lot more frustrating for patients.  Patients coming out of the managed care environment have an almost universal experience that they were hardly seen in the hospital and when they were, there was not a lot of interest in solving their problems.  They end up saying what they think people want to hear in order to be released and after they have been discharged realize that nothing has changed.

In the final analysis these are contrasting models but nobody pays much attention to the contrast.  An academic full spectrum of care model versus a severely rationed model where care is based on an administrators notion of "dangerousness".  Clinicians aware of the full spectrum of illness, grappling with all of the nuances and offering the necessary care versus a doctor sitting in an office prescribing pills as fast as they can.

That is what we are talking about and in that context - I will take the Renal Service any day.

George Dawson, MD, DFAPA