Ten Ways to Improve Post Partum Psychosis Care in the United States

I have two recent posts on the issue and thought I would add this as a better summary.  The media refrains at this point are tiresome and not helpful.  Just yesterday I heard arguments about how the current Clancy case is or is not an indictment of the mental health system.  That was followed by a poll that said most men consider filicide cold blooded murder and most woman are more sympathetic.  There are of course social media influencers amplifying those extremes to get likes and improve their revenue streams and politicians doing the same. All of this occurs in the context of highly publicized incidents of violence perpetrated by persons with obvious severe mental illness on the streets in New York and other large cities. Those incidents have resulted in loss of life of both victims and perpetrators. 

Any consistent reader of this blog over the years should get the strong message that there is no system of care for mental illnesses in the US and that the system of care for physical illnesses is rapidly going down the same tube. Disproportionate rationing of care for mental illnesses started out as a profit maker for the managed care industry and that has expanded to all medical care.  As a result, there has been an explosion in the number of administrators compared with people doing the work and a transfer of a trillion dollars a year to management.  It is more than profit making at this point. It leads to a current lack of quality care for those who can access it and it is unsustainable.

Here are a few thoughts on getting an actual system in place that might be able to address the real problems rather than focusing on all of the non-functional political rhetoric.    There is some overlap between points.  That is intentional to place more of a focus on postpartum care. 

1:  Improve mental health and the care of mental illnesses in general – The first time the federal government took a direct role in the provision of mental health services was the Community Mental Health Act of 1963 signed by President Kennedy.  The goal was to move mental health care out of asylums and back to communities.  It led to the creation of many Community Mental Health Centers.  Even as late as 1988, I was providing care at a rural hospital so they would not default on a grant they obtained though that original Act.  Since then many CMHCs have been closed.  Some have been assimilated by other non-public systems of care.  New certified community behavioral health clinics (CCBHCs), were established under the Protecting Access to Medicare Act of 2014 rather than continuing the CMHC category.  This changing landscape has made facilities a poor proxy for access to mental health care. 

 Better metrics and the current statistics are included in the table below:

Metric	What it measures	Key statistics	References
1. Treatment rate / minimally adequate treatment	Whether care reached the person and met a guideline-based quality threshold	Of 24.9% of US adults with a past-year disorder, 60.7% received any treatment but only 34.0% received minimally adequate treatment (MDPS, SCID-5). Historically ~47.7% of adults with serious conditions received no treatment; only ~44.8% of adults with any mental illness treated in 2019	[1-3]
2. Workforce supply per population (HPSA)	Provider capacity relative to population; shortage-area designation	>1/3 of Americans live in a behavioral health workforce shortage area; majority of counties lack any practicing psychiatrist, psychologist, or social worker; psychiatrists per 100,000 fell ~10% (2003–2013) while PCP/neurology supply grew	[4-5]
3. Timely access (availability & wait times)	Whether providers accept new patients and how long the wait is	Only 18.5% of sampled psychiatrists available to new patients; median wait 67 days (in-person) vs 43 days (telepsychiatry); worse for Medicaid than private insurance	[6]
4. Two-dimensional geographic access (availability + affordability)	County provider supply per 100,000 AND cost of a treatment course vs disposable income, mapped simultaneously	Reveals counties where providers are physically present but financially inaccessible; income was the strongest predictor of both dimensions; rural and Southern counties carry dual burdens	[7-8]
5. Medicaid acceptance & out-of-pocket burden	Whether existing providers accept Medicaid/new patients and cost-sharing faced by patients	~Nearly half of psychiatrists do not accept insurance due to poor reimbursement eliminates SMI patients who hit benefit limits; SMI care is disproportionately publicly financed	[5]
1:  Edlund M, Guyer H, Ringeisen H, Stambaugh L, Dever J, Carpenter L, Olfson M, First M, Geiger P, Liao D, Peytchev A, Carr C, Zangeneh S, Chwastiak L, Dixon L, Monroe-Devita M, Stroup TS, Swanson J, Swartz M, Gibbons R, Bareis N, Kessler RC. Treatment of Mental Disorders Among U.S. Adults: Findings From the Mental and Substance Use Disorders Prevalence Study. Psychiatr Serv. 2026 Jul 22:appips20250398. doi: 10.1176/appi.ps.20250398. Epub ahead of print. PMID: 42482274. 2:  Olfson M, Wang S, Wall M, Marcus SC, Blanco C. Trends in Serious Psychological Distress and Outpatient Mental Health Care of US Adults. JAMA Psychiatry. 2019;76(2):152–161. doi:10.1001/jamapsychiatry.2018.3550 3: Askari, M.S., Mauro, P.M., Kaur, N. et al. Age, Period, and Cohort Trends in Perceived Mental Health Treatment Need and Differences by Mental Health Severity in the United States, 2008–2019. Community Ment Health J 59, 631–640 (2023). https://doi.org/10.1007/s10597-022-01044-3 4:  Substance Abuse and Mental Health Services Administration. Expanding Behavioral Health Teams in Care Deserts With Community Health Workers and Peer Support Specialists. Publication No. PEP26-07-001. Substance Abuse and Mental Health Services Administration. 2026. 5:   Huskamp HA, Iglehart JK. Mental Health and Substance-Use Reforms--Milestones Reached, Challenges Ahead. N Engl J Med. 2016 Aug 18;375(7):688-95. doi: 10.1056/NEJMhpr1601861. PMID: 27532837. 6:  Sun CF, Correll CU, Trestman RL, Lin Y, Xie H, Hankey MS, Uymatiao RP, Patel RT, Metsutnan VL, McDaid EC, Saha A, Kuo C, Lewis P, Bhatt SH, Lipphard LE, Kablinger AS. Low availability, long wait times, and high geographic disparity of psychiatric outpatient care in the US. Gen Hosp Psychiatry. 2023 Sep-Oct;84:12-17. doi: 10.1016/j.genhosppsych.2023.05.012. Epub 2023 May 25. PMID: 37290263. 7:  Park J, Kim HR, Duffy RD, Vogel D, Keum BT, Lee S, Tomé NL. Two dimensions of access: Availability and affordability of mental health care across the United States. Am Psychol. 2026 Jun 4. doi: 10.1037/amp0001735. Epub ahead of print. PMID: 42241094. 8:  Cummings JR, Allen L, Clennon J, Ji X, Druss BG. Geographic Access to Specialty Mental Health Care Across High- and Low-Income US Communities. JAMA Psychiatry. 2017;74(5):476–484. doi:10.1001/jamapsychiatry.2017.0303

 

The data for postpartum depression in various clinical settings is that only 6.3% of women with the disorder receive adequate treatment and only 3.2% of that cohort achieve remission (1).  Similar rates are not available in those populations for postpartum psychosis, but there is no reason to expect the numbers would be better.  In a study of postpartum psychosis where all of the cases were identified as a cohort treated by the same research group the remission rate was 82-94% (2) illustrating the rates of treatment response with a comprehensive program.

The first metric is the clearest indicator of a non-system.  Less than half of anyone with a serious mental disorder or any mental disorder receives minimally adequate care in this country. For some conditions like depression that number goes as low as 10% when considering effective treatment for depression. With those numbers it should not be surprising that people with acute symptoms are obvious at times. Metrics 2 – 5 explain why the gap exists (capacity, timeliness, geography, and financing).  There are concrete ways to address every one of those problems.

2:  Develop state of the art guidelines for treatment - the existing system has evolved to ration access and shift costs to non-mental health care settings like jails, shelters, and county detox units.  This impedes access to medical providers with the most resources and access to referrals.  The standard crisis approach at most hospitals creates a boarding situation in emergency departments (ED), excessive congestion, and slows access to mental health care.  Many people end up leaving without treatment.

3:  Develop adequate inpatient units for care – bed requirements to produce the same wait time and access to care that medical and surgical patients get have been determined.  States and health care systems have been reluctant to build and staff those adequate numbers and there is some indication that medical and surgical beds are also in short supply.  Granted there is more ambulatory care than in the past – but it clearly has been inadequate at alleviating pressure on both the ED and hospital admissions.  Many outpatient mental health providers use the ED for after hours crisis referral and in many cases it is the only way to access more intensive services like electroconvulsive therapy.  The ED services that I am familiar with do not provide crisis care.  They provide a decision about whether a person should be admitted to the hospital or not and the bias is on the not side.

4: Adequately fund treatment maternal care including replacing the Medicaid funding that has been cut - Medicaid is the largest single payer of maternal care, mental health and substance use treatment – even before additional funding is considered.  The current administration cut this funding source by $1trillion over the next decade.  Even before those cuts directly impact all of those millions of individuals – hundreds of rural and safety net hospitals and other facilities will be closed.  In the process all health care premiums will increase fueling the ongoing cycle rationing and cost-shifting to increase corporate profits.  Safety net hospitals are generally critical components of the treatment of severe mental illnesses and psychiatric emergencies.  Every hospital with a large obstetric component needs mental health consultants that know about perinatal care.   

5:  Educate medical professionals about the disorder – most of the physicians I have discussed this disorder with have encountered some form of maternal mental disorder that compromised the safety of the mother or child at some point in their training and career.  In my experience it first happened during my clinical rotation though obstetrics and gynecology (OBGYN) in medical school.  At that time there was no discussion of the mental disorder or what care was necessary. Even as a psychiatric resident, I saw patients with the disorder but there was no discussion of specific evaluation or treatment.   I did not start to see that information until about a decade into clinical practice.  My next post will have the top groups worldwide studying this disorder as well as some of the top references.   

6:  Promote maternal mental health as a necessary subject in primary care and psychiatric specialties – the full array of psychiatric disorders associated with the peripartum state has become a lot clearer with research. It is a frequent topic at psychiatric research and continuing education conferences.  All primary care specialists need to have a good idea about necessary care and available resources.  The psychopharmacology of these disorders is also a necessary topic and the experts in that area do not necessarily overlap with postpartum psychosis experts (3).

7:   Prioritize prophylactic treatment of severe mental disorders before and during pregnancy – in woman with known preexisting psychiatric disorders there is a lot known about effective prophylaxis that is safe at all stages of pregnancy.  Pregnancy is a known cause of rapidly worsening pre-existing mental disorders and there should be a plan in place to prevent that disruption.  

8:  Educate the general public about the disorder – in one of the studies I referenced in a previous post the partner involved was unaware of pregnancy related mental health disorders and was often concerned about the loss of the relationship or future with the woman involved.  All of that can be addressed in education about peripartum and postpartum care and the appropriate educational materials made available.

Social media is a very poor format for these discussions because of the level of misinformation out there about psychiatric disorders as well as the political posturing involved.  That has resulted in moralistic positions being taken that have no basis in reality.  And yes – I am saying as a psychiatrist that mental conditions can affect consciousness, insight, judgment, and agency to the point that a person will make a decision that they would not otherwise make in the commission of a crime.  And further I am saying that is a qualitative change and not a quantitative one.  In other words it is not getting excessively angry or emotional in the heat of the moment, it is an entirely different state of mind.   

9:  Adequately fund research on the disorder – like most people reading this I do not have a scorecard on what research programs or scientists were cut doing research on this disorder.  I think there is a general bias with the new political movement against women up to an including the criminalization of pregnancy complications in some states.  Those laws place the lives of women at risk and the careers of professionals trying to treat them at risk. With that level of overt bias against women, I would not be shocked to see research grants in this area defunded.  After reading some of the research from groups with organized research efforts – I do not want to see that happen.  

10:  Add postpartum psychosis and depression to the DSM – this was an ongoing debate in the research I reviewed for my posts on the topics.  As noted in the graphic at the top of this post – ICD has discrete diagnoses for both postpartum depression and postpartum psychosis. The DSM uses a “peripartum” specifier for 11 pre-existing categories most of which are mood disorders.  There is always debate about what codes to include in a DSM – but my reading of the literature suggests that there are clearcut cases that only occur postpartum and that is a critical distinction in terms of whether maintenance medication is required.  The only non-mood disorder diagnosis in the DSM with a peri-partum specifier is brief psychotic disorder. Based on the cases I have seen and treated my speculation is that the group of women in that category who are postpartum is extremely small.

A section on women’s mental health in the DSM listing these disorders and other considerations would be a welcome addition.  It fulfills the goal of mapping onto the ICD codes and could be a valuable source of education about these disorders.

These are a few of the thoughts I have about what is needed to improve mental health care in the US. I am painfully aware of the The Mental Health Parity and Addiction Equity Act (MHPAEA) and its unfulfilled promise. It also illustrates that as long as governments allow for profit businesses to run the healthcare system – the only expectation should be continued deterioration in care and higher expenses.  The current stance of most companies denying care is they will ignore you until you either get a national news organization to look into their care denial or you sue them.

That is not a way to run an ethical healthcare company or have an actual system of care.

 

George Dawson, MD, DFAPA

 

Supplementary 1:  I have posted my experience in his area many times on this blog and therefore did not include it in the above post.  When I started working at a major medical center in 1989, the department heads were all physicians who were doing clinical work, teaching, and research.  The only business people present were business managers who answered to the head of the department. Over the next 20 years – department heads were physicians in name only who mostly did administration.  There was still a business manager.  And now there was an entire tower of executives managing all of us by basically giving us the message that we were not working hard enough.  We were routinely called up to implement bad ideas from management.  When I tried to contact the tower directly I was told: “You should think of a firewall between the clinicians and us”.   Translation: don’t ever call us – just listen to us through your physician/manager and business manager.

Supplementary 2:  I will have a major post out in the next few weeks looking at all of the top research groups in the world on postpartum psychosis and a few of their references.  I will have a separate post on peripartum psychopharmacology since I have attended several of these meetings and have first hand knowledge of many of these researchers.

 

References:

1:  Cox EQ, Sowa NA, Meltzer-Brody SE, Gaynes BN. The Perinatal Depression Treatment Cascade: Baby Steps Toward Improving Outcomes. J Clin Psychiatry. 2016 Sep;77(9):1189-1200. doi: 10.4088/JCP.15r10174. PMID: 27780317.

2: Kamperman AM, Veldman-Hoek MJ, Wesseloo R, Robertson Blackmore E, Bergink V. Phenotypical characteristics of postpartum psychosis: A clinical cohort study. Bipolar Disord. 2017 Sep;19(6):450-457. doi: 10.1111/bdi.12523. Epub 2017 Jul 12. PMID: 28699248.

3:  Bourke CH, Stowe ZN, Owens MJ. Prenatal antidepressant exposure: clinical and preclinical findings. Pharmacol Rev. 2014 Feb 24;66(2):435-65. doi: 10.1124/pr.111.005207. PMID: 24567054; PMCID: PMC3973612.

Photo Credit:  Rick Ziegler - sunset over Panama City, Florida, March 29, 2024.

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The Best Neurosurgery Clinic in the World

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I wrote this editorial in 2010 for the Minnesota Psychiatric Society newsletter Ideas of Reference as part of my role as the President at the time. Since then things continue to go in the wrong direction.  We no longer have insurance that covers the Mayo Clinic. My wife continues to do very well.

 

"We have the best neurosurgery clinic in the world." My wife Linda was in a conversation with a staff person at the Mayo Clinic, and somewhere along the line that statement was made. Just a few weeks earlier she had been diagnosed as having a growth hormone secreting pituitary adenoma and we were in the process of looking for neurosurgeons. I was concerned about that statement and wondered what the motivation was. I have called a lot of clinics and never heard a statement like that. I had talked with a lot of doctors and had never really heard many physicians talk like that.

The pituitary fossa is a dark and dangerous place for even a small tumor. Psychiatrists are generally familiar with the area because of patients with microadenomas that have been discov­ered during evaluations for what is usually hyperprolactinemia secondary to D2 receptor antagonists. In Linda's situation it was a 1.3 cm diameter cystic lesion that involved the cavernous portion of the right carotid artery. The surgery involves a transnasal and transsphenoidal approach to remove the tumor through an endoscope. Cutting into the carotid artery is a potential catastrophe. Damaging the pituitary and needing lifelong hormone supplementation was also a possible outcome. We wanted the best neurosurgeon for the job.

I had just finished reading a NEJM article on robotic surgery that suggested that surgeons need to do 150-200 procedures with this device to be proficient. There was no data available for endoscopic transsphenoidal tumor resections, much less what might be reasonable stratifications like size and type. I figured that the surgeon doing the most was probably the best bet.

At Mayo we were given a timely appointment and met the surgeon. He was confident, detail oriented and personable.

He assured us that his goal was to cure Linda, but that he was not going to trade off safety at any point for a cure. He openly acknowledged the potential problem of the carotid artery being involved with the tumor.

He performed the surgery and the next day came by to explain the results. They were uniformly good but would need confirmatory IGF levels at 3 months. He carefully explained the possible post op complications, how long we had to look for them, and exactly what to do about them. He told me that if any­thing happened during recovery and I was not at the hospital, I would be called immediately. At the time of discharge, he said that he was available through the hospital operator, and that if we called from a cell phone we might have to pull over and wait for him to call back.

While all of this was going on, I learned from other health care providers in the state that the "Mayo Clinic option" was being eliminated from some employee health plans. I had just spoken with a local expert in health economics who said that this suggestion had been made in the past and plan subscribers had rejected it. I thought about the implications for all of the free market and "quality" hyperbole that we hear from politi­cians and business leaders. If we have the best neurosurgical service in the country, why are health plans limiting access to it? If it is the best on a competitive quality basis, why aren't they rewarded rather than being penalized by the market? Most of all, what are the implications for the most heavily rationed health care, namely mental health care?

From a quality perspective, I was hard pressed to think of the best psychiatric service in the state, and not because we lack great psychiatrists. Most of the ·inpatient units I know of are pretty intolerable places. The emphasis is largely to put the patient on medications and discharge them as soon as pos­sible, even when many are highly symptomatic. By comparison with medicine and surgery services, it is difficult to consider this as even a minimal standard of care. Imagine the patient with congestive heart failure being placed on medications and discharged, and making it the family's responsibility to monitor the response and adjust cardiac medications. Imagine me doing post operative neuro checks and monitoring urine volumes, labs, and pain medications on my wife in a Rochester hotel room. In either example, medicine and surgery patients are more likely to follow recommended discharge instructions compared with over half of discharged psychiatric patients not recognizing that they are ill.

What about actual time spent with a psychiatrist? The time that my wife and I spent with her neurosurgeon probably exceeded the time that many hospitalized patients see their psychiatrist. Inpatient settings are usually very poor work environments for psychiatrists because the central fact is that it is no longer an environment where high quality work can be done. Unlike our neurosurgeon, psychiatrists have been mar­ginalized to the role of medication prescribers in both inpatient and outpatient settings. In many inpatient settings psychiatrists no longer control crucial discharge decisions.

When I walked out of the hospital with Linda, we were hope­ful that she had been cured. We knew what we needed to look out for and that there were future options. I noticed that the hospital looked like most of the teaching hospitals I had worked at in the past. There was no valet parking, massage or aroma therapy, harpsichord player, or high-end coffee shop. There were 19 plaques on the wall showing that Mayo Clinic Neurology and Neurosurgery was ranked #1 in the country for each of the past 19 years by US News and World Report. But most of all, we knew that we had just encountered medical and hospital staff with a high degree of expertise and professionalism and that there was an administration supportive of their efforts.

We need to get that back in psychiatry.

 

George Dawson, MD, DFAPA

 

Supplementary 1:

Since writing this I read Neurosurgeon Henry Marsh’s book Do No Harm. In it he describes how modern technology has reduced the risk of neurosurgery but not eliminated it and how even operations that seem to have gone well can have catastrophic results.

 

Treatment Setting Mismatches - The Implications

Most physicians first experience with treatment setting mismatches occur when they are medical students and residents.  The ethos of medical training fosters an attitude of being put upon by the trainees - partly because they are or at least they were.  There was a history in American medicine as using the trainees in particular as inexpensive labor - doing all of the admissions to training hospitals and staffing them all night long.  In many if not most cases that meant long hours and minimal staff supervision.  The staff typically would hear about late night admissions only if they gave their resident team specific parameters to call them.

That work flow created tension in the system of care.  Depending on the institution teams could negotiate for admissions but typical the emergency department (ED) physicians had veto power in getting people in the hospital.  They were in the highest risk situation because they were responsible for what happened with discharges from the ED and they were responsible for getting patients out of the ED in a timely manner.  This led medical and surgical teams to view some of the admissions pejoratively as weak or dumps.  Many of these admissions were discharged as soon as possible - partly due to circumstances and partly self-fulfilling prophecy.  The treatment setting mismatches in these case could occur in both the ED and the hospital if the patient did not need to be there.  These problems has bee addressed over the part 15 years with the advent of hospitalists.  Hospitalists have a more enduring relationship with their colleagues in the ED.  There is more consensus on admissions and hospitals are staffed 24/7 by hospitalists rather than trainees.  That does not mean that the treatment setting mismatch has been solved.  You start to notice the issues involved with treatment setting mismatches after you are practicing medicine and you are no longer a trainee.  A few examples will illustrate this point.    


Hospital to Home

A 75 year old woman with diabetes mellitus Type 2, hypertension, and new onset atrial fibrillation is discharged home after two days in the hospital. She came in taking 5 medications but is leaving with 8.  She lives alone and during the nursing review at the time of discharge she knows how to set up the medications out of the bottles every day and the basics of what she needs to avoid in her diet.  There are some red flags with her medications in terms of potential interactions and symptoms that she needs to quickly report to her physician.  She currently has no primary care physician.  Her physician quit the practice and moved to a different clinic.  She tried making appointments with the other physicians in the clinic and had the feeling that "none of them like old people".  She is discharged with a bundle of medication side effect sheets highlighted by the nursing staff.  She is advised to review the highlights and report those symptoms to the clinic. 

Hospital to Facility

An 82 year old man with dementia and agitation is admitted to an acute care psychiatric unit.  He comes in with the message that his current facility will not take him back because he is too aggressive.  The initial assessment shows that he is barely mobile due to osteoarthritis but that he requires intensive nursing care for diabetes mellitus Type 2, wound care for foot ulcers, nebulizer treatments for asthma/COPD, and careful attention to his input and output each day because of moderate renal failure and a tendency to take inadequate amounts of fluids.  After two weeks of working with medical consultants, the attending psychiatrist realizes that there is no Skilled Nursing Facilities where the patient will get the level of care he is currently getting.  Without that level of care the patient will be dead in a few months. 

ED to Home

Patient X is a 50 year old man with alcoholism, alcoholic liver disease, and mild emphysema.  For the past three months he has been drinking 750 ml of vodka per day.  After an intervention with his friends and family he was referred to a substance use treatment facility.  The family was told at that time that he should be admitted to a detox facility because detox was not available at the treatment facility.  The patient decided to go to the ED.  He was given IV fluids and discharged 3 hours later with a prescription for lorazepam and told to go home and detoxify himself of go directly to the treatment setting.  He took all of the lorazepam on the first day and resumed drinking vodka.  He tried to get in to the original treatment facility and was turned down again because he still needed detox.

ED to Treatment Facility

The patient is at a local drug and alcohol treatment facility when he experiences a sudden acute mental status change.  He is confused and starts to experience auditory hallucinations part way through a detoxification protocol.  He asks to leave the treatment facility.  The facility and the patient's family convince him to go to the ED.  While there the staff treat him with benzodiazepines and IV fluids and tell him to return to treatment.  He tries that but the treatment facility disagrees with the ED and see his mental status and being too compromised to participate in treat.  He goes home and resumes drinking instead.

Hospital/ED to Jail

Patient Y a 29 year old man is detained by the police in a local shopping mall for creating a public disturbance.  He was panhandling. When none of the shoppers responded favorably he got very close to them and made loud threatening noises until the police were called.  When the police asked him to leave the mall, he shouted at them and threatened to kill them.  He was arrested but because the police suspected a mental illness he was taken to the emergency department for evaluation.  The arresting officers were hoping he would be admitted for further observation and treatment.  After the ED evaluation was completed as social worker came out and asked about what would happened if the patient was discharged to the street.  The officers responded that he would be arrested and taken to the local county jail.  At that point the patient was released on the basis that he was not dangerous and transported to county jail.   

These scenarios are all hypotheticals based on my experience.  Any physician with similar experience can cite hundreds of these examples and many, many catastrophic endings.  The common biases are that alcohol is not that much of a problem and that most people with chronic mental health and medical problems can continue to plug along with minimal assistance.  The error is to ignore the real dangers and not be focused on quality care that by definition solves and addresses clear health problems.

These scenarios all have some common dimensions.  First, the receiving setting is easily exceeded by the patient's medical needs.  In some cases the receiving setting is not medical oriented at all and is ill equipped to address medical problems.  Obvious examples are people who are discharged to jail or care facilities that are funded on the basis that they provide little to no medical care.  The scenario where the man with chronic (or in some cases acute) mental illness being sent to jail rather than hospitalized for effective treatment is one of the reasons why county jails have become the largest psychiatric hospitals in the USA.  It is one thing to recognize that fact but it is another to think about how that is happening.  In most cases hospitals have little to no bed capacity for psychiatric patients.  If they do - they are inadequately funded to provide complex care with inadequate staffing, length of stay, and in some cases inadequate medical and psychiatric coverage. At some point the politicians and bureaucrats decided to align the incentives so that level of care would be best provided in jail. 

Second, the discharge to inadequate facilities are driven by rationing of acute care facilities as "expensive and possibly unnecessary facilities".   That determination is complicated by the fact that receiving facilities have also been depleted by the same rationing mechanisms.  The reality of American healthcare at this point is that it is almost all rationed by a middleman who are incentivized to make as much profit as possible by rationing.  A great example is detoxification from drugs and alcohol.  Despite the fact that this process is potentially life threatening, at the minimum is associated with a high degree of distress, has significant psychiatric morbidity including suicide risk, and needs to be properly done in order to facilitate sobriety very few people in the USA are admitted for appropriate detoxification.  Like people with severe mental illnesses they are mostly sent home or to a facility with minimal to no medical coverage and then sent home.  In cases where a person is incarcerated they often go through acute detoxification with no medical assistance.  In many cases they suddenly stop opioids, benzodiazepines, or opioid agonist treatment (methadone or buprenorphine) and go through severe withdrawal in jail. 

Third, leaving a medical facility where there is intensive nursing care is like falling off a cliff for a lot of people.  There is no transition or assurance that many people can manage their own care in their own homes.  There used to be more options.  Public health nursing comes to mind.  Twenty years ago the attending physician could write an order and a public health nurse would see the patient in their own home and make sure that the transition was occurring properly and if not stay in contact with the patient and provide ongoing assistance.  That service was eliminated along time ago in order to reduce costs.

Fourth, an entire system of shadow care has evolved to make it seem like care is being provided when it is not.  Typical examples include health club discounts or a life style coach that calls you up on the phone and encourages you to be more physically active or eat less.  The ultimate advertising these days is a plan where you get a very modest health insurance discount through your employer if you sign up for one of these options and demonstrate compliance.  It makes it seem like both your employer and your health plan care about your health.  In the larger scope of things, it is nothing compared to the lack of care that happens in the above scenarios.

The final point to be made here is the irony of spending more money on health care than any other country in the world and having a large portion of it go up in smoke.  The source of that smoke is the huge administrative costs and profits of rationing health care under the guise that it is more "cost effective" or "efficient".

There is nothing cost effective or efficient about rationing poor quality care to patients.  The best evidence is during care transitions and the resulting treatment setting mismatches.


George Dawson, MD, DFAPA

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).

Happy Labor Day III

This is the third Labor Day of this blog.  I usually take the opportunity to mark the lack of progress in the physician work environment and this year is not much different.  All of the usual corporate and government buzzwords being promoted to suggest why physicians need to be managed by somebody who knows nothing about medicine.  All of the hype about computerization and how the grossly overpriced electronic health record will save us all, even as the printout from that record looks less and less coherent.  I just read a copy of The Institute from the IEEE on Big Data.  From that report:

"It's is estimated that the health care industry could save billions by using big-data health analytics to mine the treasure trove of information in electronic health records, insurance claims, prescription orders, clinical studies, government reports, and laboratory results.

Analytics could be used to systematically review clinical data so that treatment decisions could be based on the best available data instead of on physicians' judgment alone...."

The state of current electronic health records as the worst value in the information technology sector is is probably not too surprising given the above observations or the following:

"Instead of seeing only 20 patients a day, doctors are able to see 75 to 100 people and get ahead of the wave..."

I don't know what kind of doctor sees 75-100 patients a day or what the quality of these visits is, but I have never met a physician who wanted to see that many people in a day and wonder if it would not trip a billing fraud flag somewhere in the CMS data base.  I have talked with many physicians who were overwhelmed by coming into the office and having 200 tests to review and sign an additional 30-50 orders in addition to seeing 20 patients that day.  We are decades away from any machine intelligence being incorporated into the medical record.  The current EHR has destroyed the narrative, especially in psychiatry and converted the basis of care to a checklist.  Instead of higher order machine assisted decision making the electronic health record has not resulted in the expected savings or utilization of technology.  Paying tens of millions of dollars in licensing fees per year and larger IT departments with thousands of PCs running 24/7 to access the sever farm has not produced a nickel of savings and has added large recurring costs.

So I have not noticed any striking improvements in the practice environment.  At the same time, it is at such a low level that it is difficult for me to say that it has deteriorated any further.  The American Psychiatric Association (APA) the largest professional organization for psychiatrists still supports collaborative care - a managed care model of psychiatric care that in some cases eliminates any direct access to psychiatrists.  The American Medical Association also seems managed care friendly largely due to their support of the PPACA.  Both organizations support the onerous recertification process mandated by the American Board of Medical Specialties.

The only bright spot I can think of this year was being seated at the same table with 3 younger colleagues at at a Minnesota Psychiatric Society CME event.  They had all been practicing for 10 years or less.  They were all in private practice to one degree or another.  They were all women and although I haven't seen it studied I think that women may have a greater skill level (at least relative to men of my generation) in setting up and managing a private practice.  I was quite interested in their experiences and they listed all of the positives.  The overwhelming positive that I took away from that meeting was that their practice environment was very positive because they ran it and had eliminated all of the toxic administrators along the way who were supposed to manage them.  They did not have to tolerate the notion that just because they were an employee that they suddenly needed supervision from somebody who was not qualified to supervise them.  Near the end of our conversation they tried to talk me into going into private practice myself.  I have always been an employee, but my current vocational trajectory has been predicated on fleeing toxic administrators.  I gave the usual excuses about being one bad cold away from retirement and an old dog not being able to learn new tricks.

If I was starting out today - I would only be working for myself and I would try to design the practice to reflect my interests in neuropsychiatry and severe mental illnesses.   Any resident reading this should consider this career path.  The decision may be as easy as contemplating seeing 75-100 patients a day and meeting with an administrator who suggests that you could see more.

Happy Labor Day to any physician reading this whether you are in private practice or on the assembly line in a clinic or hospital somewhere.  And good luck to physicians everywhere in avoiding unnecessary administration.


George Dawson, MD, DFAPA

Kathy Pretz.  Better Health Care Through Data.  The Institute September 2014.  p 6 - 7.

The Fifth Inconvenient Truth

Thomas Insel, MD the current head of NIMH captured a few sound bites in a recent edition of Psychiatric News.  In it the following Inconvenient Truths were mentioned:

1.  The field has failed to “bend the curve” in the prevalence and cost of mental illness;

2.  More people are getting more treatment, but outcomes are not getting better.

3.  The current knowledge base is insufficient to ensure prevention, recovery, or cure for too many people with serious mental illness.

4.  A transformation of diagnostics and therapeutics is necessary to make significant progress in treating mental illness.

Any head of a politically funded agency has to carefully parse his or her rhetoric in a manner consistent with his main goals.  I would see his main goal as getting funding for NIMH and in that role he needs to speak to the politicians who hold the purse strings.  That is really the only reason why cost is included in his first sentence.  The cost estimates both within the United States and world wide have been calculated many times and they are staggering.  There are well known estimates of disability that show the disability due to mental illness and addictions are routinely in the top ten causes.  But what  about the cost of treatment?  The cost of treatment has been flat to decreased for about three decades now largely as a result of managed care rationing with a disproportionate hit being absorbed by psychiatric services.  I have argued repeatedly that cost needs to be taken off the table in these discussions at least until the mental health infrastructure gets on even par with cardiology or oncology.  The whole idea that you can produce equivalent results with practically no resources strikes me as absurd.  The only thing more absurd is that we are supposed to be even more cost effective.  Compared with the rest of medicine we are looking at cost effective in the rear view mirror.  We crossed into the "on the cheap" zone a long time ago.  As expected, cost effective is synonymous with low quality.  Since we have abandoned quality reviews with managed care we have abandoned that word.  A more appropriate observation would have been:

The field has failed to “bend the curve” in the prevalence and quality of care of mental illness.

The second issue is a brief lapse into rhetoric of vagueness.  Who is "the field" here?  Are we referring to psychiatry, other mental health professionals, primary care physicians who do 80% of the psychopharmacology,  or the managed care systems and systems with the same techniques that rigorously ration mental health care?   The meaning of the sentence changes dramatically by substituting each of those words.

To the second point on more treatment not leading to better outcomes it is fairly easy to show why this is the logical outcome of rationing.  I have posted many times about how inpatient psychiatry has become sham treatment based on dangerousness criteria and corporate priorities.  You don't need any research to show that if you are cycling people with serious mental illnesses in and out of short stay psychiatric units in 3 - 5 days and basing their stay there on whether or not they are "dangerous" and using treatments that take weeks to work that by definition you are appearing to treat many more patients but providing adequate treatment to very few.  You don't need any research to show that when you shift mental health care from psychiatric units run by psychiatrists to county jails that the outcomes will be worse.  You don't need any research to show that when people do not get research based psychotherapies in the manner that they were designed and instead get a few crisis oriented sessions that do not address their basic problems that outcomes cannot hope to be better.  When your attitude is that all mental health treatment can proceed by treating common problems with definite social etiologies with medications as fast as possible and not having an intelligent conversation or working alliance with the person affected - it is logical that treatment outcomes will not improve.  Treatment outcomes do not improve if you do not provide effective treatment and that is the mental health landscape at this time.

Dr. Insel's third point should read:

The current knowledge base is not used to ensure prevention, recovery, or cure for too many people with serious mental illness.

I am not by any means suggesting that it cannot be improved upon.  There is no place in medicine where that is not the case.  When services are globally rationed and we are still beating the drum about "cost-effectiveness" we cannot expect inmates to have access to DBT or GPM to treat their borderline personality disorder.  We cannot expect them to get exposure therapy to treat PTSD from psychological trauma.  We can also not expect managed care patients to get this from 2 or 3 sessions of crisis counseling when they need a more specific research based psychotherapy.

The fourth statement is the only one that I have no issue with.  It is a statement that is generally true for most chronic illnesses.  I have many posts here about asthma for example.  Asthma is an illness that many primary care physicians believe that they really have made inroads in treating.  It is a great comparison for mental illness and even chronic mental illness because the fact is that most asthmatics are chronically symptomatic despite treatment.  The reason is a combination of a biologically complex disease, partially understood disease mechanisms, and a medical treatment model that involves seeing the patient every 3-6 months and prescribing them medications that are often partially effective at best.  There is really minimal medical intervention beyond that except for acute hospitalizations.  That is the exact level of care that we provide for mental illness in this country.

A lot of people fault Dr. Insel for being an advocate of neuroscience.  I may be one of the few who does not.  As a student of the brain and brain plasticity things are incredibly complex.  As politics get projected onto that complex system - science is often left in the lurch.  People see the results of a complex situation simplified as a meta-analysis and see the results as supporting both ends of a political argument.  I would go back to the asthma example.  The signaling in that disease is much less complex than signaling in the brain and there are far fewer cell types involved.  Asthma endophenotypes followed the elaboration of endophenotypes in schizophrenia and so far nether has resulted in clinical innovation.  I would argue that the treatment outcomes in most mental illnesses are on par or better than the treatment of asthma.  And yet there is no national research administrator of Dr. Insel's stature talking about the lack of progress.  I think the reason is clear - there are not nearly as many political arguments projected onto asthmatics.

If I fault Dr. Insel for anything it is for not knowing what has happened to the mental health system of care in the USA.  It is not due to a lack of technology, but an obstruction of current technology transfer.  He is not alone in routinely ignoring this as the central problem with psychiatric services today.  Any number of people do and in the process usually promote their own theories of why we are mired in the current environement.

That Fifth Inconvenient Truth?  Must be obvious by now but in the event that it is not:

Ration mental health and addiction treatment, ignore current research proven treatments, and reduce treatment to the prescription of medications and poor outcomes will follow.

You can take that to the bank.


George Dawson, MD, DFAPA

APA Continues to Hype Managed Care

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

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

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

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

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

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

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

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

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

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

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


George Dawson, MD, DFAPA

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

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

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

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

National Behavioral Health Quality Framework - Ultimate Oxymoron?

As I pointed out in a previous post, the Substance Abuse and Mental Health Services Administration (SAMHSA) a branch of the U.S. Department of Health and Human Services is currently working with the managed care industry.  They are also the object of criticism by E. Fuller Torrey in his recent editorial and upcoming book for promoting non evidence based care of people with severe mental illnesses and in fact at many levels dismantling existing care.   With that kind of a backdrop, their e-mail to me this morning suggesting that I should review the National Behavioral Health Quality Framework (NBHQF) and provide comments as an interested member of the public should not have been very surprising.  I thought I would put that commentary here rather than letting it be buried on a government website that nobody would read.

To set the appropriate tone for my comments, the introduction section of this document identifies the major entity that the government is working with here as the managed care industry.  I consider the NCQA (or NQF) to be a proxy for the managed care industry.  That is their history as I recall it and I am not aware of any physician professional group that says otherwise.  In fact, I cannot find the American Psychiatric Association as a member of the NQF, but I am fairly certain that they used to be a member of NCQA..

Getting back to the document - six goals are identified with a page each dedicated to currently available measures and a second page that is described as "future targeted measures that are deemed important to advancing the behavioral health quality measurement."  An example of what that involves is illustrated in "NBHQF Goal 1: Effective - Promote the most effective prevention, treatment, and recovery practices for behavioral health disorders."  Not to be too much of a stickler here, but I don't really know what a "behavioral health disorder" is.  The most precise definition would be "whatever mental or psychiatric disorder that a managed care company has decided that they will pay for".  Behavioral health is basically a business term with no medical or psychological meaning.  As far as I can tell, it was designed to disenfranchise psychiatrists and other mental health providers and yet the rationale for denying treatment was always proprietary "medical necessity" criteria.   Moving beyond that we basically see a number of screening interventions for "Provider/Practitioners", a number of completely unproven interventions and quality markers, and at least 30% of the cells in the matrix are left "intentionally blank".  What exactly is there to comment on?  In the second page "payers using payment incentives to increase the use of EBP (evidence based practices)" is actually considered a quality marker.  That is a conflict of interest much greater than any pharmaceutical company scandal.  To translate, that means that managed care companies nation wide have another way to deny payment and save money based on what they consider to be an "evidence based practice." but they are rationalizing it as a quality marker.

Let me suggest how the depression assessment and screening should be done in this matrix.  First of all the screening test in this case the PHQ-9 does need to be validated as a diagnostic and outcome measure in populations.  The  current literature is extremely limited and there is no evidence that population screening for depression accomplished anything other than exposing a lot of people to antidepressants that the FDA has identified as potentially arrhythmogenic.  The cost of prescribing SSRIs to a large population as well as the electrocardiogram abnormalities is unknown.

I will briefly comment on the additional goals.  "Goal 2: Person-Centered Care".  As previously explained, this is the goal of every physician who has ever been trained in medical school.  It appears here basically as rhetoric that is designed to disenfranchise professionals and make it seem like managed care companies invented individualized care.  "Goal 3: Encourage effective coordination within behavioral health".  What jumps out of the page at me under this sparsely populated matrix is "Ratio of detox to outpatient admissions".  It is well known that managed care tactics have essentially destroyed the availability of medical detox in most communities.  I can recall being told that medical detox was not "medically necessary" by managed care reviewers.  I guess the hope was that the cost of detox could be transferred from managed care companies to non-medical county facilities.  Quality care for addictions means that there needs to be a spectrum of care.  I don't know what ratio is implied by this quality marker but I can assure you that it will favor managed care companies.

"Goal 5: SAFE - make behavioral health care safer."  Suicide, injury and death, treatment for overdoses after hospitalization, and discharges on multiple antipsychotic drugs are suggested as quality markers.  There is no evidence of what it takes to make the assessment and treatment.  To capture any problems in these areas you need a quality process, not a piecemeal check box that can be gamed so that it appears that you are providing quality care.  Measuring these variables in the absence of defining a quality process is meaningless.

"Goal 6: Affordable/Accessible: Foster affordable high quality behavioral health care...".  This continues to be an absurd priority of the partnership between the government and the managed care system. There is no more "cost effective" approach than what passes for behavioral health care.  Mental health treatment in the US has been decimated by 20 years of managed care to the point it is practically non-existent.  During that same time there has been an addition of trillions of dollars in Cardiology, Intensive Care, and Oncology infrastructure.  Even if that were not true, what is the evidence that cost effectiveness has to do with quality?  It is certainly not reflected in the previous specialties that I just listed.

Are there problems with this approach?  It turns out there are major problems and here are just a couple:

1.  Administrative data - administrators have significant biases that seem to impact on so called quality markers across the board.  They don't seem to understand their biases and the major biases include not really knowing anything about medical quality,  thinking that medical quality can be derived from what is basically administrative data (length of stay, readmissions, etc.) and at this point in time having so much political leverage from government backing that they don't really have to pay attention to the considerable number of people out there who know a lot more about quality.  As I have documented on this blog this is a thirty year trend and all of that is captured in the NBHQF.  Any who has followed quality markers over the last two decades will probably have made the observation that business heavy entities like managed care systems are information averse.  By that - I mean that they collect a large amount of data  but it is really not enough data or the right data.  Great examples are HEDIS data and PHQ-9 scores.  Is it really possible to collapse medical quality in to what are really simplified demographic parameters?  No more than knowing that 50% of 85 year old men have coronary artery disease.

2.  Business practices trumping medical practice -  on this blog I have also reviewed these practices and will focus on one this glares in this report - "person-centered care".  For years HMOs and their administrators were focused on "population based care".  They scoffed at the notion that people or patients needed to be treated on an individual basis.  This was at the peak time when they were deciding that everyone with a certain condition should be hospitalized for a the same number of days and it was a "quality problem" if the length of stay in the hospital was too long.  Nobody ever complained if the length of stay was too short.  Many of the thought leaders in managed care go to that position by basically promoting these ideas.  Why is the managed care industry suddenly behind "person centered care".  You won't see the history recorded anywhere but a lot of it goes back to the primary care physician as gatekeeper.  If you assume that you can managed populations of people with the same interventions, you can tell your subscribers that they have to get "referrals" from their primary care physician for any tests or consultations that are viewed outside of the population norm.  This was happening on a large scale in the 1980s and 1990s but subscribers rebelled against it.  After all they were paying good money for insurance coverage and not seeing it back in what they were interested in for health care.  The gatekeeper function disappeared and suddenly even managed care subscribers could directly seek consultations and referrals that they were interested in.  Patient centered care from the managed care industry was basically determined by the market and the failed theory of their thought leaders about managing populations rather than treating individual people.

Physicians have always been taught that patient care is highly individualized.  The question is will they continue to let the government, business entities, and non-evidence based practices masquerade as quality.  Looking at the quality of physician commentary in the media, in journals, and on blogs is not very hopeful.  It is clear that physicians would prefer to blame themselves or one up one another rather than look at the true problems with the health care system and what bureaucrats and businessmen are calling quality.

George Dawson, MD, DFAPA

SAMHSA.  National Behavioral Health Quality Framework (NBHQF)