More Talk on Psychiatry and the Affordable Care Act

I guess the magical thinking about how a purely political initiative with absolutely no grounding in science will affect the practice of medicine will never cease.  The latest speculation is from the Journal of Clinical Psychiatry and commentary from several prominent psychiatrists (see reference) on "The Effects of the Affordable Care Act (ACA) on the Practice of Psychiatry."  I know I have said this before but there is so much wrong with this piece, it is difficult to know where to start.

The centerpiece like most discussions of the Affordable Care Act focuses in integrated care.  I criticized the American Psychiatric Association for backing any proposal that relegates psychiatry to a peripheral supervisory position looking at so-called measurements to determine if the clinic population is "healthy" or if they need more treatment (translation = antidepressants).  There is weak evidence in this article that this model will be the bonus it promises to be.  Care given in the Department of Veteran's Affairs (VA) clinic is given as example of how things might be.  A patient seeing multiple specialists may receive care from multiple specialists without personally having to coordinate that care.  As a patient at the Mayo Clinic - it has been that way for decades.  In fact, if they know you are from out of town they can frequently coordinate that care on the fly so it can all happen the same day!  No patient aligned care teams necessary there.  Just a good system.

There was a statement about how the ACA could hurt psychiatric care of the seriously mentally ill because the states who previously paid for that care will want to bail out.  The discussants point out "although the ACA plans to reimburse certain institutions for emergency inpatient psychiatric care for Medicaid patients, other evidence based practices for treating severe and persistent mental disorders are not usually covered by health insurance."  Let me translate that for you.  That means there will be even fewer inpatient services.  The inpatient care for mental health and severe addictions takes another hit.  After three decades of decimation by the managed care industry and that same industry shifting the treatment cost for these severe mental disorders to the state - we are going to pretend that nobody needs these services and continue to downsize.  After all, there have been no enlightened managed care CEOs to date who decided that these services were actually important enough to adequately fund.  Why would they now that they have the leverage to shift all of the money to the all important Medical Home?

The idea that physicians will be paid by "value rather than volume" had me laughing out loud.  I pictured the Medical Home psychiatric consultant poring over the clinic's latest batch of PHQ-9 scores and deciding which patient's antidepressants needed tweaking based on this checklist and the cryptic note of a primary care provider.  Will we need more checklists for side effects and unexpected effects on the patient's conscious state?  Will we need checklists for neuroleptic malignant syndrome or serotonin syndrome?  What about the FDA's recent concern about arrhythmias?  Cardiovascular review of systems or electrocardiogram?  That will be a lot of paperwork to look over.  I wonder what the consultant will be paid for delivering that level of "value".   Of course all of the discussants were aware of the fact that most psychiatrists will be employees of some sort or another.  Those who have not been assimilated may be in concierge practices or private practice, but good luck interfacing with the ACO.

The all important technology card was played and how that should cause us all to swoon.  Online or computerized therapy was mentioned.  That modality has been available for over 20 years and not a single insurance company or managed care company has implemented it.  Any cost benefit analysis favors an inexpensive assessment (PHQ-9 + low intensity primary care visit) and even less expensive medications prescribed as quickly as possible.  The unmentioned tragedy of the electronic health record is how much psychiatric assessments have been dumbed down.  The loss of information and intelligence due to the electronic health record is absolutely stunning.  Phenomenological elements that require a substantial narrative or interpretation by a thinking psychiatrist are totally gone.  All that is left is a template of binary elements  that are important only for billing and business purposes.  I suppose the lawyers might like the fact that you check the "Not suicidal" box before a patient is hurriedly discharged.

Psychiatry without a narrative or a formulation or a rationale is not psychiatry at all.  In the end that is what the ACA leaves us with.

George Dawson, MD, DFAPA

Ebert MH, Findling RL, Gelenberg AJ, Kane JM, Nierenberg AA, Tariot PN. The effects of the Affordable Care Act on the practice of psychiatry. J Clin Psychiatry. 2013 Apr;74(4):357-61; quiz 362. doi: 10.4088/JCP.12128co1c. PubMed PMID: 23656840.

The Lancet's Illogical Digression

The latest editorial in the Lancet has an illogical digression.  The brief note starts out by stating that there will soon be a revolution in psychiatry based on a genomics study published in the Lancet.  It concludes with a digression to a discussion of about the provision of mental health services across the lifespan with a pejorative connotation:

"The child with ADHD at 7 years could be seen by a child psychiatrist, but at the age of 18 often loses access to mental health services altogether, until he presents with a so-called adult mental health problem. Substance misuse and personality disorders may complicate the picture."

It seems to me that practically all adult psychiatrists would not have any difficulty at all in getting a history of an earlier diagnosis of ADHD and deciding how that would be treated.  I wonder if the Lancet's editors would make the same commentary on childhood asthma presenting to an Internal Medicine clinic.  Would that be "so-called adult asthma"?  The asthma example is instructive because it turns out that what physicians have been calling asthma for decades is more complicated than that.  Recent research has adopted the endophenotype/endotype methodology that has been used to study schizophrenia.  The reason why adults are seen by adult psychiatrists rather than child psychiatrists is the same reason why people stop seeing their pediatricians as adults.  Treating cormorbid substance misuse and personality disorders is just a part of that reason.

As far as the idea that the future of psychiatry is set to change any more than the future of the rest of medicine consider the statement:

"The future of psychiatry looks set to change from the current model, in which ADHD, bipolar disorder, or schizophrenia are considered as totally different illnesses, to a model in which the underlying cause of a spectrum of symptoms determines the treatment."

If that were true, psychiatry would have suddenly catapulted into the most scientifically advanced medical specialty because currently there is no other medical specialty that treats illness based on an underlying genetic cause.   The Lancet's attached paragraph on access to services across the lifespan is accurate, but it really has nothing to do with the possible genetic revolution in psychiatric diagnosis.  If the services are anywhere near as bad in the UK as they are in the United States (Is public health rationing as bad as rationing done by corporations?) there is a widespread lack of services and disproportionate rationing relative to the rest of medicine.

Until psychiatrists, psychiatric services, and mental illness are destigmatized there is no reason to think that a genetic revolution will mean more access to services.

George Dawson, MD, DFAPA

The Lancet.  A revolution in psychiatry.  The Lancet - 1 June 2013 ( Vol. 381, Issue 9881, Page 1878 ) DOI: 10.1016/S0140-6736(13)61143-5.

Cross-Disorder Group of the Psychiatric Genomics Consortium.  Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysis.  The Lancet - 20 April 2013 ( Vol. 381, Issue 9875, Pages 1371-1379 ) DOI: 10.1016/S0140-6736(12)62129-1

Hamshere ML, Stergiakouli E, Langley K, Martin J, Holmans P, Kent L, Owen MJ, Gill M, Thapar A, O'Donovan M, Craddock N. A shared polygenic contribution between childhood ADHD and adult schizophrenia. Br J Psychiatry. 2013 May 23.  [Epub ahead of print] PubMed PMID: 23703318.

Larsson H, Rydén E, Boman M, Långström N, Lichtenstein P, Landén M. Risk of bipolar disorder and schizophrenia in relatives of people with attention-deficit hyperactivity disorder.  Br J Psychiatry. 2013 May 23. [Epub ahead of print] PubMed PMID: 23703314.

Preference for Psychotherapy or General Dislike of Medication?

I haven't see the study mentioned in many places yet, but there was a meta-analysis of patient preference for psychological versus pharmacological treatment of psychiatric disorders in the Journal of Clinical Psychiatry.  It contained all of the usual buzzwords about evidence based medicine and why this is a hot topic to study because of the possible cost savings and potential for better outcomes if preferences were matched to actual treatments.  Interestingly, in the same month a more high tech approach to matching depressed patients with pharmacotherapy versus psychotherapy came out in JAMA Psychiatry where the independent variable was a brain imaging result rather than patient preference.

The authors here looked at a final sample of 34 studies out of 644 studies that were screened.  They end up with a chart of effect sizes with confidence intervals for each of the 34 studies.  There were a total of 90,483 participants but 78,753 were included in one study.  All of the studies are of depression and anxiety.  They had tried to include studies on schizophrenia and bipolar disorder and found that they were not published.  The authors conclude that their meta-analysis was valid and that there was a consistent preference for psychological treatment in the treatment seeking and non-treatment seeking or recruited patients.  From this the authors suggest that patient prefernce should trump other considerations if the efficacy of both treatments are equivalent.  They question why medication related treatments have increased and psychological therapies have dimished over the past decade.  They suggest that the patients who prefer medication related therapies are non adherent.

In their discussion of the limitations of the study they find there was not enough data to compare combination therapy as a choice, they excluded non-published studies and therefore included potential publication bias, and they were not able to address the question about why psychological treatments were preferred over medication based therapies by a factor of 3:1.

These and other important questions have already been answered on this blog, but don't expect to see any publications on this anytime soon.  Managed care has taken the very evidence based treatments that these authors emphasize and stood them on their head.  I have written many times about the diagnosis of depression using rating scales and the preferred treatment of antidepressants.  If you are using a primary care physician follow up code and a PHQ-9 score result to diagnose depression in ten minutes and treat all of these patients with a generic antidepressant ($4/month) - there is no psychotherapy that compares to that low cost.

All psychiatrists who are actively looking for psychotherapists to treat anxiety and depression encounter the problems of a lack of qualified therapists and more specifically a lack of therapist time in managed care systems.  Managed care systems especially those that are actively managed to reduce outpatient mental health treatment has reduced available therapy in many systems to 2 or 3 sessions of crisis management and essentially limited or eliminated additional services like psychological testing that some therapists require to do their work.  It is no accident that patients seeking psychological therapy can't get it.  It is a conscious business decision.

The second problem is the lack of availability to research proven psychotherapies.  Any psychiatrist doing patient evaluations will hear the story that therapy sessions are often very non-specific, lack goals, and often result in the patient losing faith in the process and stopping the therapy.  Being seen in a psychological therapy is no assurance of a good outcome.  Many patients who are provided with excellent research proven therapy are frustrated with the time commitment and stop because of the cost or number of sessions.  Psychotherapy may look a lot better on paper than the reality of the relationship with the therapist and the logistics of getting to and paying for the sessions.

What can be done to improve the situation right now?  The decision to take a medication for any reason is never a casual one.  Taking that medication reliably is even more significant.  Non medication alternatives and combination therapies to reduce exposure to medications should be available in every clinic.  Instead of screening everyone for a medication on day one, non-medication alternatives should be presented at that time.  There are innovative non-medication therapies such as computer delivered psychotherapy for depression, anxiety and obsessive compulsive disorder.  No clinic appointments.  The therapy is delivered online or by phone any time of the day or night.  With the appropriate implementation, these therapies could be offered as first line treatment to massive numbers of patients.  The human cost is so low they could essentially be made available across an entire health plan for free.  There is no reason why networks of therapy clinics cannot be linked to primary care clinics who see the majority of patients with depression and anxiety.  Any medication alternative can be discussed if the psychotherapy or non-medication intervention works.

From a research perspective if only 34 of 644 studies were suitable for inclusion in a meta-analysis, the problem is clearly not being studied very well.  I think it is important to ascertain patient preference for psychological, combination, pharmacological and other (eg. lifestyle change) therapies in all registered clinical trials.  In clinical practice, it is all part of informed consent for treatment.  I think it is the universal experience of physicians that most people prefer to not take medications.  The negative treatment of psychiatry and  psychiatric medications in the press create an understandable bias against psychiatric medications relative to others as a potential source  of the described phenomenon.   There is some evidence that the advertising of these medications is different and potentially stigmatizing.  We also need better design of clinical trials.  If therapies are in fact equivalent, they need to be tested in actual clinical populations where psychiatrists work.  That includes severely ill patients with comorbidity, patients who are acutely agitated and suicidal, women and children and adolescents.  Much of the discussion of equivalent therapies is based on extrapolation from populations of people who are mildly depressed and in some cases who have enrolled in a number of studies.

This study highlights the current weaknesses in studying how people actually receive psychiatric treatment and how to best approach that from a research perspective.  It points out that we need much better research designs and better patient selection in order to answer even basic questions about the treatment process.  It should be apparent that a research design that is not adequate to describe clinical practice is not a commentary on clinical practice.

George Dawson, MD, DFAPA

McHugh RK, Whitton SW, Peckham AD, Welge JA, Otto MW.  Patient preference of psychological vs pharmacological treatment of psychiatric disorders: a meta-analytic review.  J Clin Psychiatry 2013; 74:6: 595-602.

To the Left and the Right of Dr. Frances

Allen Frances continues to erect his wall of criticism of DSM-5.  He shows no sign of slowing down even after the DSM-5 was released.  He has written a list of 18 problems in the Psychiatric Times that he characterizes as "glaring mistakes in wording and coding."  He believes that there were "egregious mistakes on almost every page I read."  That is a curious counterpoint to the opinion I heard recently from Jon Grant, MD when he presented the history, process, and details of the development of DSM-5. While Dr. Frances has undeniable DSM-IV experience there is always plenty of room for disagreement.  He comments that he has limited time for a detailed read of DSM and I have even less, so I will concentrate on 2 of his 18 points to illustrate what I mean.

Intermittent Explosive Disorder - Dr. Frances main complaint about this diagnosis is that is "lacks the needed exclusions to exclude the other more common causes of violent behavior."   The diagnostic criteria actually contains the exclusion:

F.  The recurrent aggressive outbursts are not better explained by another mental disorder.....and are not attributable to another medical condition.....or to the physiological effects of a substance.

Specific examples are given and there is also an exclusion for adjustment disorders in children.  The actual number of exclusionary diagnoses listed are essentially the same as DSM-IV and the discussion in the differential diagnosis is more extensive (p 612-613).  My problem is that I don't think this diagnosis actually exists.  That statement comes from over two decades of experience in acute care inpatient psychiatry, community psychiatry, and hospital psychiatry.  These are all settings on the front lines of aggressive behavior.  When the police encounter aggression and there is any question of an intoxication, medical problem, or mental disorder associated with that behavior - those people are brought in to settings where acute care psychiatrists are  involved.  In my experience of assessing extreme aggression up to and including homicide I have never seen a single case where the outbursts were not better explained by another mental disorder.  I don't agree that the exclusion criteria are any different.  I don't believe that this disorder exists.  If it does, the prevalence is so low that this acute care psychiatrist has not seen it in thousands of evaluations of aggressive behavior.

Mild Neurocognitive Disorder - Dr. Frances complaint about this diagnosis is "so impossibly vague that it includes me, my wife and most of our friends.  It will cause unnecessary worry and a rush to useless and expensive testing."

As I read through these criteria I have a much different perspective.  For about 10 years I ran a Geriatric Psychiatry and Memory Disorders Clinic where we did comprehensive assessments of patients with cognitive problems.  I worked with a nurse who would collect detailed information on patient's functional and cognitive capacity before they came into the clinic for my assessment.   A significant number of those patients had a strictly subjective complaint about their memory or cognition.      A large percentage of these patients did not have any insight into the severity of their problem and their typical assessment was: "My memory is no different than any other 60 or 70 year old."  Even though we had generally spent about three hours of assessment time with each patient, at the end of my evaluation we often did not have a clear diagnosis.  We would stick with that person until we did and often times the outcomes were surprising.  We had striking examples of chronic delirious states where the patient was given a diagnosis of dementia based on on neuropsychological testing, and with treatment and reassurance we observed their cognition to clear completely and they were restored to normal cognitive function.

I see the diagnosis of Mild Neurocognitive Disorder as a portal to that level of care.  Based on the list of 10 brain diseases and other medical conditions listed as specifiers the authors of this criteria clearly had that intent.  It is clear to me that any clinic with a high standard of care for patients with cognitive disorders like my clinic had can use this diagnosis both as part of the continuum to more Major Neurocognitive Disorders associated with progressive neurodegenerative dementias and to provide high quality assessments for patients with concerns about any cognitive changes.  Keep in mind that the typical managed care model would use a crude screening test and possibly refer for other psychological testing.  There might not be a physician in the loop who can make the necessary assessments and diagnoses.  Current research in this area also points to the need to identify patients as early as possible, especially as treatments become available.

On these two points I guess I am to the right of Dr. Frances on Intermittent Explosive Disorder and to the left on Mild Neurocognitive Disorder.  But I think the entire argument misses the mark if we think about the issue of psychiatric diagnosis and where the DSM fits in.  Any DSM cannot be used like a phone book to classify hundreds of different presentations to a Memory Disorder and Geriatric Psychiatry Clinic.  The unique conscious states of those individuals and their relative levels of impairment can only be determined by a comprehensive evaluation by a physician who is knowledgeable in all of the possible brain diseases that are suggested as etiologies.  Apart from the obvious increase in complexity for anything that is determined by a central nervous system, getting a diagnosis of Mild Neurocognitive Disorder is no different than getting a diagnosis of "Neck pain" or "Ankle pain" from a primary care physician.  And yes - those primary care diagnoses are very common.

The idea that there are precise criteria that can be written down and applied to make definitive diagnoses is a common misconception of the DSM and other diagnostic schemes.  To emphasize that point, I will end with a quote from Harold Merskey, FRCP, FRCPsych:

"Medical classification lacks the rigor either of the telephone directory or the periodic table."

That is all medical classification and not just the DSM-5.   A good starting point toward realizing the truth in this quote is to stop looking at the DSM-5 like it is a phone book.  You don't get a psychiatric diagnosis from the DSM-5.

You get a psychiatric diagnosis from a psychiatrist.

George Dawson, MD, DFAPA

Merskey H. The taxonomy of pain. Med Clin North Am. 2007 Jan;91(1):13-20, vii. PubMed PMID: 17164101

The Real Problem With Managed Care Research

You know the kind of research I am talking about.  The research that shows that managed care is more cost effective and higher quality than fee for service.  This stuff has been out there since the 1990s.  Is there really research like that out there or is it little more than a political exercise?  We have more than a few clues thanks to recent analysis of a Health Affairs article by Kip Sullivan.  The article is titled: "The ‘Alternative Quality Contract,’ Based On A Global Budget, Lowered Medical Spending And Improved Quality"  Sullivan points out that the title of this article is misleading because it suggests that the managed care intervention here "lowered medical spending and improved quality" in the title, but in the body of the work the authors state:

"Our findings do not imply that overall spending fell for Blue Cross Blue Shield of Massachusetts in 2009-2010."  

and a paragraph later:

"This result makes it likely that total Blue Cross Blue Shield payments to groups in 2010 exceeded medical savings achieved by the group that year."  

Sullivan's analysis here is dead-on, especially the idea that "medical savings" can be parsed from overall savings when there is suddenly a large managed care infrastructure.  From some of the places where I have worked, this means bringing in a raft of middle managers who provide no service and generate no income to "manage' the people who are actually providing the care.  In some settings that could mean a "manager" for every 5 - 10 physicians.   If your goal is to cut reimbursement to the providers by just paying them less or sending them fewer referrals while adding a costly overhead of a number of managers who think they can translate their ideas about business into better clinical care - that seems like a recipe for higher costs, record physician dissatisfaction, and disregard for professional quality based guidelines.  Sullivan points out that this specific problem in managed care research has been around since the 1990's

The "higher quality" issue is as interesting.     I encourage anyone interested to download the paper because it is only free until Sunday June 30.  As you read it, take a look at the table labeled "Exhibit 4".  It is a table of quality care measures across both the control groups and the intervention groups.  Although many of the variables are easily defined a couple of issues appear to be clear.  Many seem to be process variables.  In other words, just keeping track of variables and making sure that you are ticking them off gives you more credit.  This is standard procedure in a managed care environment with more case managers.  They can literally be assigned to remind physicians or ward teams to do tasks on a time frame that gives them credit for the process variable.  More administrative manpower should equate to a larger percentage of process variables.

I note that within the quality variables there are two that apply to psychiatry - Depression: Short Term Rx and Depression: Long Term Rx.  There are no significant differences across that study period at the P<0.05 level.  This is interesting at a couple of levels.  First, if this is actually the number of depressed people treated the change after the managed care intervention is not significant.  Secondly, what measures are used to make this determination.  Are these actually depressed people or are they patients scoring above a certain cutoff on a PHQ-9 rating scale?  Third, is the change in percentage of patients treated a legitimate quality marker?  Aren't we more interested in retention in treatment and actual treatment of individual patients treated into remission rather than a cross sectional look at the percentage of patients treated?

The scientific concerns about this paper are numerous.  Like all research (and I mean all research) there are political implications.  The defined intervention here of the Alternate Quality Contract, is basically a primary care physician as gatekeeper model that consumers rejected over a decade ago.  At that point in time, managed care organizations realized that they would need to compete on the basis of providing direct access to specialty care without primary care referrals.  The adaption of the MCOs was to hire their own specialists and build speciality clinics.  The article describes this as basically the "patient centered medical home" (p 1886).   I wonder if the average consumer realizes that the medical home is really a primary care gatekeeper system from the past?

I can't help stressing the importance of article like this one and all research that purports to save money with larger administrative structures that are there in a large part to supervise physicians rather than create administrative efficiencies.  There is no better example than the non-existent mental health system for what this kind of rationing and administrative excess can create.  Diverting money from the direct provision of clinical care into complicated forms of administrative overhead needs to be measured accurately in all of these studies.

George Dawson, MD, DFAPA

DSM-5 and Primary Care

In the pre-DSM-5 hysteria, I posted the observation that primary care physicians were not "avid readers" of the DSM and therefore the idea that they would be likely to be influenced by it was erroneous.  Of course I was responding to the propaganda that the DSM-5 was basically a tool for psychiatric hegemony and that upstanding physicians everywhere would be mere pawns of organized psychiatry.  Tens of millions of people would be overmedicated.  There would be total chaos while Big Pharma, the APA, and psychiatrists everywhere lined their pockets with the proceeds of inappropriate prescribing.  In that atmosphere some considered my statement controversial.

From this week's American Medical News:

"....Perry A. Pugno, MD, MPH, vice president for education for the American Academy of Family Physicians, is not surprised that he hasn't heard about DSM-5 from the organization's members.

'From a pragmatic perspective, we don't use (the manual) very much,' he said. 'Most of the things we see we already know the diagnostic criteria for them.' " (page 12, AMEDNEWS, June 17, 2013).

Remember I also said that psychiatrists are not memorizing the DSM-5 either, for a similar reason.

As I think about what happened in the press before the release of DSM-5, mass hysteria is not a bad phrase.  Mass psychogenic illness is probably more politically correct these days but some experts consider an anxious form and a somatic form.  There are numerous examples of each and some references suggest that it is compounded by the presence of social media.  At any rate, the dynamic is very similar to the critical DSM-5 frenzy prior to the release.  In both cases, it can start as a rumor or speculative theory.  If that speculation sounds plausible to a larger group it is accepted and built upon.  At some point the response to the speculation is critical.  Will some experts step in and confirm the original speculation or introduce their own shocking hypotheses?  The reaction of the authorities takes it to the next level.  Will they seem to take the problem seriously. Media coverage makes things worse.  Will additional systems be activated to broaden the response?  Momentum builds and before you know it the anxiety or somatic symptoms are linked with a totally implausible hypothesis.  Some reviews suggest that treatment involves separating the affected individuals and keeping them out of the limelight for a while until the symptoms fade away.   As a psychiatrist who has treated many cases of conversion disorders with neurological symptoms using psychotherapy, I can't imagine competing with several "experts" in the media all having their own theories about the problem.  My guess is that my therapy would be either neutralized or severely protracted.

A lot of these things happened in the run up to the DSM-5.  So I am using mass hysteria here as a metaphor and not a "diagnosis".  I thought I should clarify that because I fully expect  that somebody would accuse me of that and go on to suggest that I am a control agent for somebody (?)

It is also not a diagnosis because it is not in DSM-5 or DSM-IV for that matter.

Hopefully cooler heads will prevail in the next big public controversy about psychiatry.  But I doubt it.

George Dawson, MD, DFAPA

Collaborative Care Model - Even Worse Than I Imagined

I wrote a previous post about the APA backing the so-called collaborative care model and provided a link to the actual diagram about how that was supposed to work.  I noted a more elaborate model with specific descriptions of roles in the model in this week's JAMA.  The actual roles described on this diagram are even more depressing and more predictive of why this model is doomed to fail in terms of clinical care.  It does succeed in the decades long trend in marginalizing psychiatry to practically nothing and providing the fastest route to antidepressant prescriptions.

Wait a minute - I thought psychiatrists were the Big Pharma stooges who wanted to over prescribe antidepressants and get everyone on them?  Well no - it turns out that there are many government and insurance company incentives to assure that you have ultra rapid access to antidepressants even when psychiatry is out of the loop.  You don't need a DSM-5 diagnosis.  You don't need to see a psychiatrist.  If you pulled up the diagram in JAMA, you would discover that the consulting psychiatrist here has no direct contact with the patient.  In fact, about all that you need to do is complete a checklist.

Copyright restrictions prevent me from posting the diagram here even though I am a long time member of both organizations publishing them.  I do think that listing the specific roles of the psychiatrist, the care manager and the primary care physician in this model is fair and that is contained in the table below:

Roles in Collaborative Care Model

Care Manager	Monitors all patients in the practice Provides education Tracks treatment response May offer brief psychotherapy Describes patient symptoms and response to treatment to psychiatrist. Informs Primary care Physician of treatment recommendations from the psychiatrist
Primary Care Physician	Makes initial diagnosis and prescribes medication Modifies treatment based on recommendations from psychiatrist
Psychiatrist	Makes treatment (medication) recommendations. Provides regular psychiatric supervision. Has no direct contact with the patient.

  

see JAMA, June 19, 2013-Vol 309, No. 23, p2426.

As predicted in my original post, the psychiatrist here is so marginalized they are close to falling off the page.  And let's talk about what is really happening here.  This is all about a patient coming in and being given a PHQ-9 depression screening inventory.  For those of you not familiar with this instrument you can click on it here.  It generally takes most patients anywhere from 1 - 3 minutes to check off the boxes.  Conceivably that could lead to a diagnosis of depression in a few more minutes in the primary care clinic.  At that point the patient enters the antidepressant algorithm and they are they are officially being treated.  The care manager reports the PHQ-9 scores of those who do not improve to the "supervising" psychiatrist and gets a recommendation to modify treatment.

This is the model that the APA has apparently signed off on and of course it is ideal for the Affordable Care Act.  It is the ultimate in affordability.  The psychiatrist doesn't even see the patient - so in whatever grand billing scheme the ACA comes up with - they won't even submit a billing statement.  The government and the insurance industry have finally achieved what they could only come close to in the past - psychiatrists working for free.  Of course we will probably have to endure a decade or so of rhetoric on cost effectiveness and efficiency, etc. before anyone will admit that.

Keep in mind what the original government backed model for treating depression was over 20 years ago and you will end up shaking your head like I do every day.  Quality has left the building.

George Dawson, MD, DFAPA

Why reform of the mental health system is hopeless.

I debated putting "reform" in quotes.  The term has essentially become meaningless.  I have been hearing about health care reform for over 20 years and things continue to get worse and worse.  They get worse at a much faster rate whenever mental health care reform is considered.  I won't belabor the facts that I have already listed here before, but I witnessed an event yesterday to highlight why any reform of the mental health system is completely hopeless at this point.

The event was a panel discussion entitled "Many Perspectives on Patient-Centered Care and Building a Stronger Mental Health System".  There were 5 panelists including two psychiatrists, a local celebrity, a reporter, and a mental health advocate.  It was scheduled as a one hour event and I left at about the 1:05 point.  The hour began with the panelists disclosing their personal experiences with the system and what that seemed to imply for reform.  There were stories about a system that is fairly refractory to input.  Psychiatrists can't get people hospitalized when it is a true emergency, the family can't get input into the clinicians treating their loved ones, and there is minimal if any cross talk among physicians.  There were two stories of misdiagnosis, in one case over a period of 20-30 years.  The problem of documentation came up and the fact that there seems to be "no narrative" any more about the patient's diagnosis and problems - only check lists and electronic health record forms.

After the initial presentations the audience got involved.  The audience was essentially all psychiatrists and the solutions were predictably more infuriating anecdotes, workarounds, and tales of the one unique person who might be able to save the day.  From the panel, the advocacy standpoint seemed to be that progress was being made and that no more hospital beds were necessary or at least they should be discussed as an absolute last resort since they are the most expensive treatment option.  That discussion focused on a point by an audience member who I would consider to be one of the top experts in child and adolescent mental health in the state when he mentioned there were only "2.5 acute care beds in the State" available for children in crisis.  I may have missed the actual solutions because I had to leave the meeting.  I have seen meetings and panels like this before and they go nowhere.

So what is the problem and what can be done about it?

The problem is quite simply managed care and all of its permutations.  I waited for 65 minutes and nobody uttered the word.  Managed care and all of its special interests is directly responsible for the ridiculous time constraints on clinicians.  There is no time for a complex diagnostic evaluation much less time to talk with the family.  It is responsible for the rationed inpatient beds and the lack of bed capacity.  It is responsible the fact that systems of care are set up to optimize cash flow to large health care organizations rather than the quality of care.  There is perhaps no better example than what currently passes for inpatient psychiatric care.  We currently have case managers running the care of hospitalized patients and telling their psychiatrists when to discharge them.  I talked directly with an inpatient psychiatrist the other day who told me that case managers and social workers at his hospital frequently have the discharge plan set up before he sees and assesses the patient.  They simply tell him that the patient can be discharged.  All in the service of making sure that nobody extends beyond the DRG payment and the hospital continues to make money.  Inpatient units seem to have become holding tanks for people to sit around until they are "cleared" for discharge.  That typically involves sitting around on a secure psychiatric unit and answering questions about whether or not you might be "suicidal" until you can be released.   All of this flows from the ridiculous managed care concept that "dangerousness" is the only reason people need to be on a psychiatric unit.  All of that occurring at a time when mental health advocates are concerned about stigmatizing the mentally ill as violent.  Is it possible that psychiatrists have become so hopeless about reversing the trend of business friendly but otherwise irrational rationing that they avoid even talking about it anymore?  I think that is more than likely.

Outpatient care is not much better.  Some of the panelists were talking about the virtues of outpatient care where there is a team that knows the patient and everything is idyllic.  There is no reason to expect that an outpatient case manager is any more virtuous than an inpatient one.  I have talked with many psychiatrists who notice that their care is basically completely marginalized by low to mid level bureaucrats who have no professional responsibility to the patient.  I have be pointing this out for 20 years and recently other physicians are also  talking about the problem.

As long as you pretend that making money off rationing your care and treating you is not a conflict of interest - the system will continue to deteriorate.  As long as nobody acknowledges that psychiatrists have been looking at "cost effective" care in the rear view mirror for the past 20 years - reasonable change is impossible.  As long as nobody in the room can clearly say "First of all there is no system and second, managed care and the associated rationing and low quality are the real problems here" - reform will remain meaningless political rhetoric.

George Dawson, MD, DFAPA

Jerry A. Singer, MD.  How Government Killed the Medical Profession Reason May 2013.

DSM-5.0

I finally saw a copy of the DSM-5 today.  It was sitting on a table at a course on the DSM put on by the Minnesota Psychiatric Society.  The DSM-5 portion of the course was about 3 1/4 hours of lectures (98 information dense PowerPoint slides) by Jon Grant, MD.    Dr. Grant explained that he was in a unique position to provide the information because he and Donald Black, MD had been asked by the American Psychiatric Association (APA) to write the DSM-5 Guidebook.  In this unique position they were privy to all of the notes, minutes, e-mails and documents of the DSM Work Groups.  In the intro it was noted that Dr. Grant had written over 150 papers and 5 books.  He was probably one of the best lecturers I have ever seen with a knack to keep the audience engaged in some very dry material.  There were times that he seemed to be riffing like a stand up comedian.  The content was equally good.  I thought I would summarize a few of the high points that I think are relevant to this blog.

The first section was an overview of the history.  The original DSM was published in 1952, but before that there were several efforts to classify mental disorders dating back to ancient times.  Some of the systems persisted for hundreds of years.  He credited Jean-Etienne Esquirol (1772-1840) as one of the innovators of modern classification.  The philosophical approaches to the subsequent DSMs were reviewed and they generally correlate with the theories of the day.

The development of DSM-5 began in 1999.  The original goals included the definition of mental illness, dimensional criteria, addressing mental illness across the lifespan, and to possibly address how mental disorders were affected by various contexts such as sex and culture.  Darrel Regier, MD was recruited from the NIMH to coordinate the development of DSM-5 in the year 2000.  Between 2003 and 2008 there were 13 international conferences where the researchers wrote about specific diagnostic issues and developed a research agenda.  This produced over 100 scientific papers that were compiled for use as reference volumes.  As far as I can tell the people on the ground on this issue was the DSM Task Force and the Work Groups.  The Task Force addressed conceptual issues like spectrum disorders, the interface with general medicine, functional impairment, measurement and assessment, gender and culture and developmental issues.  The Work Groups met weekly or in some cases twice a week by conference call and twice a year in person.  The work groups had several goals including revising the diagnostic criteria according to a  review of the research, expert consensus and "targeted research analyses".  No cost estimate of this multi-year infrastructure was given.

Like any volume of this nature the originators had some guiding principles including a focus on utility to clinicians, maintaining historical continuity with previous editions, and the changes needed to be guided by the research evidence. The most interesting political aspect of this process was the elimination of people closely involved in the development of DSM-IV in order to encourage "out of the box" thinking.  This was a conscious decision and I have not seen it disclosed by some of the professional critics out there.

Final approval of the DSM occurred after feedback was received through the DSM-5 web site.  There were thousands of comments from individuals, clinicians and advocacy organizations.  Field trial data was analyzed and discussed.  A scientific committee reviewed the actual data behind the diagnostic revisions and confirmed it.  Hundreds of expert reviewers considered the risks in revising the diagnoses.  The APA Assembly voted to approve in November 2012.

Some of the criticisms of the DSM-5 were discussed in about 4 slides.  Dr. Grant was aware of all of the major criticisms and I have reviewed most of them here on this blog such as the issue of diagnostic proliferation.  Dr. Grant's lecture contained this graphic for comparison:

Rather than repeat what I have already said, it should be apparent to anyone who knows about this process that it was open, transparent and involved a massive effort of the part of the psychiatrists and psychologists involved.  It should also be apparent that the DSM process was clinically focused and that safeguards were in place to consider the risk of diagnostic changes.  I have not seen any of that discussed in the press and don't expect it to be.  For all of you DSM-5 conspiracy theorists, more than enough people involved without a sworn oath to assure that no secret would ever be kept.

What about the final product?  The DSM-5 ends up including 19 major diagnostic classes.  Some of the highlights include moving some disorders around.  Obsessive-compulsive disorder and Post Traumatic Stress Disorder were moved out of the Anxiety Disorders section to their own separate categories.  Bipolar and Depressive Disorders each have their own diagnostic class instead of both being placed in a Mood Disorders class.  Adjustment Disorders have been moved into the Trauma and Stress Related Disorders class and there are two new subtypes.  As previously noted here, all of the Schizophrenia subtypes have been eliminated.  The Multiaxial System of diagnosis has been scrapped.  One of the changes impacting the practice of addiction psychiatry is the elimination of the categories of Substance Abuse and Substance Dependence and collapsing them into a Substance Use Disorder.  Panic attacks can now be used as a symptom of another disorder without having to specify that the person has panic disorder and that is a pattern I have observed over the course of my career.  The controversial Personality Disorders section is unchanged but there is a hybrid diagnostic system that includes dimensional symptoms, the details of which (I think) are in the Appendix.  Mapped onto all of the diagnostic classification and criteria changes are a number of subtypes and specifiers as well as a number of ways to specify diagnostic certainty.  As with previous editions since DSM-III there is a mental disorder definition that indicates that behavior or criteria are not enough.  There must be functional impairment or distress.  The definition specifies that socially deviant behavior or conflicts between the individual and society do not constitute a mental illness unless that was the actual source of the conflict.

The overall impression at the end of these lectures was that this was a massive 18 year effort by the APA and hundreds and possibly thousands of volunteer psychiatrists and psychologists.  None of those volunteers has a financial stake in the final product.  Many of the criticisms were addressed in the process and many of the critics have a financial stake in the DSM-5 criticism industry.  The criticisms of the DSM-5 seem trivial compared with the process and built in safeguards.  The DSM-5 was also designed to be updated online instead of waiting for another massive effort to start to make modifications, hence this is not DSM-5 but DSM-5.0.

If Dr. Grant is lecturing in your area and you are a psychiatrist or a psychiatrist in training, these lectures are well worth attending.  If you have a chance to look at his Guidebook, I think that it will be a very interesting read.

George Dawson, MD, DFAPA

Supplementary 1:  The DSM-5 Guidebook by Donald W. Black, MD and Jon E. Grant, MD came out in March 2014.  Table 1.  (p.  xxiii) lists the total diagnoses is DSM-5 as 157 excluding "other specified and unspecified disorders". 

A Valentine from the President

I caught the link to this fact sheet from President Obama a couple of days ago on the APA's Facebook feed.  In the post immediately before it, the current President of the APA is seen rubbing elbows with Bradley Cooper.  My first thought is that these initiatives are always a mile wide and an inch deep.  They provide a lot of cover for politicians who have enacted some of the worst possible mental health policy, but also for professional organizations who have really not done much to change mental health policy in this country.  These are basically non-events as in we applaud the President and he applauds us.  In the meantime, patients and psychiatrists are never given enough resources for the job and the necessary social resources keep drying up.

Since the 1970s, the political climate in the US has focused on being as pro-business as possible.  Congress practically invented the credit reporting industry and in turn that industry made it easy for businesses to change your fees based on a credit report number.  What you have to pay for home and auto insurance can be based solely on your credit rating and independent of whether or not you have ever missed a payment.  It turns out that competitiveness is little more than political hyperbole.  But the politicians in Washington did not stop there.  The financial services industry is currently a multi-trillion dollar enterprise with little regulation or oversight that has essentially placed all Americans at financial risk.  There is no better proof than the fact that there are currently no safe investments and that some advisors are suggesting that prospective retirees need as least $1 million dollars in savings and $240,000 for medical expenses in addition to whatever is available in Medicare and Social Security.   Congress's retirement invention the 401K has surprisingly few accounts with that kind of money.

How can a government that puts all of its citizens at financial risk all of the time manage the health care of those same citizens?  It is a loaded question and the answer is it cannot.  The idea that an administration has an initiative to "increase understanding and awareness of mental illness"  at this point in time is mind numbing in many ways.  We  have had over two decades of National Depression Screening Day, we have Mental Illness Awareness Week, and we have had the Decade of the Brain.  There seem to be endless awareness initiatives.  I don't think the problem with mental health care is the lack of awareness or screening initiatives.  From what you can see posted on this blog so far, it might be interesting and productive to have some media awareness events that look at the issue of media bias against psychiatry and the provision of psychiatric services.  I don't think it is possible to destigmatize mental illness, when the providers of mental health care are constantly stigmatized.

What about the issue of screening at either a national level or at the level of a health plan?  A fairly recent analysis commented that there have been no clinical trials to show that patients who have been screened have better outcomes than those who are not.  Further, that weak treatment effects, false positive screenings, current rates of treatment and poor quality of treatment may contribute to the lack of a positive effect of the screening.  The authors also refer to a study that suggests that more consistent treatment to reduce symptoms and reduce relapse would lead to a greater treatment effect than screening.  A subsequent guideline by the Canadian Task Force on Preventive Health Care agreed and recommended no depression screening for adults at average or increased risk in primary care setting, based on the lack of evidence that screening is effective.  Why in the President's fact sheet are the AMA and APA recommending screening?  Why are there people advocating for "measurement based care" and the widespread use of rating scales and screening instruments?  Why does the State of Minnesota demand that anyone treating depression in the state send them PHQ-9 scores of all of the patient they treat?

The answer to that is the same reason we have political events that add no resources to the problem and make it seem like something is happening.  Screening everywhere makes it seem like somebody is concerned about assessing and treating your depression.   It makes it seem like we are destigmatizing mental illness and making diagnosis and treatment widely available.  The Canadian papers noted above suggest otherwise.  Nothing is happening, except people are being put on antidepressants at a faster rate than at any time in history.  In a primary care clinic, medications are the first line treatment and psychotherapies - even psychotherapies that are potentially much more cost effective than medications are rarely offered.

My professional organization here - the APA has chosen to advocate for an "integrated care" model that is managed care friendly.  A model like this can use checklist screening and essentially have consulting psychiatrists suggesting medication changes on patients who do not respond to the first medication.  I obviously do not agree with that position.  Only a grassroots change here will make a difference.

If you are concerned that you might have significant depression, you can't depend on your health plan or the government when they are both advocating for a screening procedure that has no demonstrated positive effect.  If somebody hands you a screening form for depression or anxiety or sleep or any other mental health symptom, tell them that you want  to be interviewed and diagnosed by an expert.  Tell them that you want the same approach used if you come to a clinic with a heart problem.  Nobody is going to hand you a screening form that you can complete in 2 minutes.  You are going to see a doctor.  Tell them that you want that expert to discuss the differential diagnoses, the likely diagnoses and the medical and non-medical approaches to treatment including counseling or psychotherapy.

Do not accept a cosmetic or public relations approach to your mental health and spread that word.

George Dawson, MD. DFAPA

Two Undergrad Experiments to Illustrate - What Is Science?

I have always been somewhat of a science nerd and had what I consider to be a first rate science education at a liberal arts college.  I had gone to this school on a football scholarship with the intention of becoming a phy ed teacher and a football coach, but the science education there was too compelling to ignore.  I ended up being a biology and chemistry major and rapidly forgot about football.  Brook's essay of what is science, what is the most compelling science and how that  makes psychiatry as far from science as possible led me to think about memorable experiments from my undergrad days.

Experiment 1:  The Limnology experiment:   For a while in my undergrad career, I considered being a limnologist or fresh water biologist.  My undergrad college was one of the first to emphasize the environment and ecology.  A lot of the work involved doing population estimates of plankton and aquatic invertebrates.  We spent hours classifying and counting thousands of organisms  that are unknown to most people. We used various sampling techniques and statistics to determine populations of these organisms and whether they seemed to be influenced by any environmental variables.  At one point I had equations from an journal article to calculate the probability that a specific species would be in contact with another one - called the "probability of inter species interaction."  This is biological science.

Experiment 2:  The PChem experiment:  Physical Chemistry was the undergrad chemist's dream course when I was in college.  You dreamed that you would be able to pass it.  We had a text that was not very accessible, but a professor who was brilliant, very accessible and an excellent lecturer.  I liked it a lot after we finished thermodynamics and moved on to other topics.  Back in the 1970s we had very primitive computing power. Our lab had an old HP calculator that was as big as a current desktop with less computing power than a modern day scientific calculator.  One of our tasks was to estimate electron densities around carbon atoms in aromatic hydrocarbons.  In an afternoon in the lab we ran the numbers.  This was the science of physical chemistry.

I have intentionally left out all of the details of the experiments because for the purpose of comparison with Brooks thesis they are unnecessary.  From his essay we learn that biology and chemistry are real sciences with a "distinctive model of credibility".  The examples I have given are from those fields.   We learn that psychiatry is a "semi-science" because "the underlying reality they describe is just not as regularized as the underlying reality of say, a solar system".  I will stop at that point because Brooks further examples rapidly degenerate.  What do we have so far?

Looking at my experiments, #2 clearly has the regularity of a solar system.  What could be more regular than the electron density for a specific molecule?  It fits Brooks definition of science to a tee.  What about experiment #1, the biological experiment?  Here we have a number of organisms.  Some have nervous systems and the others (eg. phytoplankton) do not.  I did a series of calculations to look at the probability of one species encountering another.  There were certain assumptions to those calculations about randomness to make the calculation much easier to do.  But what if I wanted for a moment to be a "behavioral limnologist" and attempt to predict the behavior of a specific stoneflies in the sample?  What if I wanted to determine the 5%  of stoneflies that exhibited behavioral characteristics, that differentiated them from the other 95%?  Suddenly we have a problem.  The source of that problem is a nervous system.  The underlying reality of most even slightly complicated nervous systems is that they will never have the regularity of a physical system.  They have evolved not to.  Regularity in a nervous system locking it into a physically predictable system is not in any way adaptive for any animal that needs to forage and reproduce.  It is the kiss of death.

But is gets complicated at additional levels.  The human brain is highly evolved to have significant processing power.  At another level, there are theoretical concerns about whether it is possible to ever to map behaviors and psychiatric symptoms directly onto some neurobiological system.  Unlike my experiment 1 above we are rarely interested in looking at only life or death as the outcome variable.  The variables that will allow us to study different populations are going to be much more complex than grossly observed behaviors.  There is a complicated nervous system between those behaviors and the environment.

Is psychiatry really not a science because it is complex and attempts to deal with the complicated phenomena associated with the human brain?   Should we ever be concerned about 1:1 mappings of psychiatric disorders onto a specific genetic or neurobiological defect?  Is it possible that a human nervous system is so complex that it is unrealistic to expect that this might happen?

Unlike Brook's theme nobody is a "Hero of Uncertainty".  Uncertainty is the expected condition and one that every psychiatrist should be comfortable with.  Psychiatry and the associated neurosciences will never be reduced to the predictable calculation of a physical system and that has nothing to do with one being a more prestigious science.  It has to do with evolution and complexity.  It has to do with what philosophers call the "demarcation problem" between what is and what is not science.  More to come on that in the near future.

George Dawson, MD, DFAPA

Brooks on Psychiatrists As "Heroes of Uncertainty"

Well I suppose it is slightly better than the usual characterizations that we see in the New York Times, but David Brooks recent column on the "improvisation, knowledge and artistry" involved in psychiatry is little more than damning with faint praise.  His flaws include using the term "technical expertise" and comparing psychiatry to "physics and biology".  Psychiatry is certainly comparable to biology but not to physics.   And what is it about psychiatry that is unscientific?  The idea that psychiatry seeks to legitimize itself by appearing to be scientific is a popular antipsychiatry theme.  It is probably why many authors seek to equate psychiatry with the DSM.  The science of psychiatry is out there in many technical journals that are scarcely ever mentioned in the public commentary about psychiatry.  The idea that the science of psychiatry is collapsed into a modest (at best) diagnostic manual is a convenient way to deny that fact and portray psychiatrists as unscientific and perhaps not very much like physicians either.  

Brooks characterization of the DSM shows a continued lack of understanding of this manual by  every journalist who writes about it.  There is practically no psychiatrist I know of who considers it to be authoritative.  Very few psychiatrists  actually go about their diagnostic business by reading through DSM criteria.  That activity would be limited to novices and medical students.    It is well known that only a fraction of the diagnoses listed are ever used in clinical practice.  After familiarizing themselves with the major changes, few psychiatrists will every open it again.   Like most physicians, psychiatrists are looking for patterns of illness that are based more on their clinical experience than criteria listed in a manual.  The idea that this text has "an impressive aura of scientific authority" is certainly consistent with Brook's thesis, but that is not what a psychiatrist experiences when looking at it.  Despite all of the concern about the public impact - psychiatrists are the target audience here.  Psychiatrists are much more aware of the limitations of the approach than the media critics who write about it.  I guess a lay person might be impressed, but I never met a psychiatrist who was.  

Brooks is also confused about the nature of the DSM when he states that it contains "a vast body of technical knowledge that will allow her (your psychiatrist) to solve your problems".  That vast body of technical knowledge is firmly outside of the DSM and it is in the form of training and ongoing education of a psychiatrist.   That technical knowledge is contained in a vast literature, much of it written by psychiatrists.  It is the reason that ongoing training and education of physicians is a career long commitment.  In the general scope of things, the DSM would contribute a percentage point or two at most to that body of knowledge.

There is the associated question about whether physicians are scientists or not.  I have seen Kandel himself interviewed about this issue and he states quite definitely that they are not.  That is quite different from suggesting that physicians are unscientific.  There are certainly not many physicians who are performing scientific experiments and publishing papers.  I suppose that you have to do that to be a professional scientist.  On the other hand, physicians are certainly accountable for learning immense amounts of of scientific principles and data that can be applied in clinical situations and used in critical thinking about patients and teaching it to successive generations of physicians..  I teach Dr. Kandel's plasticity concept and how it applies to addictions in about 30 lectures a year.  Reducing scientific knowledge to "artistry" is really inconsistent with "technical expertise".  There really is no art in medicine.  The most technically competent doctors know the science, have seen more patterns of illness and can recognize those patterns.  They can apply that knowledge to patient care.  In complex medical (and psychiatric) care, a special plan can be designed for each individual patient and most aspects of that plan are rooted in science.

This essay strains under the weight of needing to place psychiatry outside of the scope of science and mainstream medicine.  My study of psychiatry finds it in neither of those locations.  There is a reason that psychiatrists need to go to medical school.  The cross section of basic science and clinical science that all physicians are exposed to is necessary to be a psychiatrist.  Using Brooks reasoning, I suppose he could say that this is just an effort to "legitimize" psychiatry by making it seem like it is on scientific par with the other fields of medicine.   When I am face to face with a severely ill patient who has liver disease, heart disease, diabetes, alcoholism and a refractory psychiatric disorder - the science involved is much more than a political exercise.   

Like every other branch of medicine, psychiatry is an amalgam of the clinical and basic sciences.  Biology especially neuroscience but also the anatomy and physiology of the human body is the central focus.  I will give Brooks partial credit when he writes about the DSM.  Unlike many of his colleagues at the NY Times - he does not refer to it as a "Bible".  When it comes to the issue of whether I am a scientist or not, I certainly realize that I am no Eric Kandel.   But I also know that I am not rolling the dice or taking a leap of faith.   I am  doctor seeing people, trying to understand their unique set of problems, and applying medical science to help them get better.

George Dawson, MD. DFAPA

David Brooks.  Heroes of Uncertainty.  NYTimes May 27, 2013.

Suggested Changes to Psychiatric Residency Programs

I received an e-mail two weeks ago that asked for my suggestions on immediately reforming residency programs for psychiatry.  I had the experience of completing my residency in two different university based programs.  My residency occurred at the height of the controversy between the self described biological psychiatrists and the psychotherapists and psychoanalysts.  Although I have never seen it written about there was open animosity between the groups at times.  A biological psychiatrist back in the day might make a statement like: "I don't do talk therapy".  A psychotherapy oriented psychiatrist might refer to the biological types as "Dial twisters" referring to an approach that suggested excessive biological reductionism.  Apparently neither group had read Kandel's seminal article in the New England Journal of Medicine four years earlier and how plasticity can be affected by talking, medications, and of course other experiences.

Several years ago, I attended an anniversary of the University of Wisconsin Department of Psychiatry, the program I eventually completed my residency at.  Thomas Insel, MD was one of the invited speakers.   He outlined a revolutionary approach to educating psychiatry residents that involved a joint 2 year neuroscience internship with residents from neurology and neurosurgery.  He did not provide any details.  When I sent him a follow up e-mail two years later, he said it would probably not happen on his watch.  I can easily build on that theme.  I think that a two year program focused on basic and clinical neuroscience remains a good approach.  The current approach to getting the relevant information is haphazard at best.  It depends on lectures in neuroscience being interspersed with clinical rotations of varying quality and to a large extent it depends on the faculty.  How many faculty are there and how many of them are expected to produce managed care style billings or "productivity" rather than high quality teaching.

A comprehensive and integrated approach that will teach state of the art neuroscience and provide the relevant training in neurology and medicine is possible.  There are many obvious areas for improvement.  Residents often spend their time on clinical rotations of minimal relevance for psychiatrists.  I can recall learning ICU medicine and needing to familiarize myself with various tasks (Swan-Ganz catheters, central lines, ventilator settings, dopamine drips, balloon pumps) that I would never use again.  I needed to be seeing hundreds of people with heart disease, arrhythmias, hypertension, diabetes, other endocrine disorders and neurological disorders.  I saw many of those people when they were hospitalized, but seeing these folks in ambulatory care settings designed to enhance the learning experience for a psychiatrist would provide a better experience.   The process should probably start earlier in the fourth year of medical school.  Prospective psychiatrists should be focused on electives in neurology, medicine, and neurosurgery rather than psychiatry.

The teaching of psychiatry needs to address the practical concerns about diagnosis and treatment but also philosophical concerns.  Residents need to be familiar with the antipsychiatry philosophy and the existing literature that refutes it.  Residents need to know about the issue of the validity and reliability of psychiatric diagnoses and how that is established.  There is actually a rich history of how that came about but it could easily be summarized in one seminar.  One of the features that I was interested in when I was interviewing for residency positions was whether or not the program supplied a reading list.  There were surprisingly few that did.  This subject area would be a good example of required reading that is necessary to bring any prospective resident up to speed.

A good model to illustrate the difference between a neuroscience based approach as opposed to a symptoms based approach is American Society of Addiction Medicine (ASAM) definition of addiction on their web site.  Unlike the DSM collection of symptoms designed to pick a group of statistical outliers,  the ASAM definition correlates known addictive behaviors with brain substrates or systems.  Both of the standard texts in the field by Lowinson and Ruiz and the ASAM text by Ries, Feillin, Miller, and Saitz are chock full of neuroscience as it applies to addiction.  When I teach those lectures, I generally am talking about how medications work in addiction at that level but also how psychological and social factors work at the level of neurobiology.  I have not seen the DSM5 at this time, but I do think that it is time to move past defining every possible substance of abuse and associated syndrome and incorporating neuroscience.  Especially when the neuroscience in this case has been around for 50 years.   Residency programs need to teach that level of detail.

Psychiatrists need to maintain superior communication skills relative to other physicians and that means getting a good basic experience in interviewing and psychotherapy techniques.  At the same time - the psychiatrist of the future needs to be able to order and interpret tests including ECGs and MRI scans.  That wide skill base taxes every faculty except the very largest academic departments.  In the Internet age, there is really no reason that every residency program should not have access to the same standardized PowerPoints, lectures, and didactic material.  The ASCP Model Psychopharmacology Program is an excellent example of what is possible.  I would go a step beyond that and say that there should be a culture within organized psychiatry so that every psychiatrist should have access to the same material.  Establishing a culture where everyone (trainees and practicing psychiatrists alike) is up to speed and competent across the broad array of topics that psychiatrists need to be familiar with is a proven approach that is rarely used in medical education.

Psychiatry also needs to be focused on old school quality.  Not the kind of quality that depends on a customer satisfaction survey.  The issues of diagnostic assessment and appropriate prescribing at at the top of the list.  How do we make sure that every person consulting with a psychiatrist gets a high quality evaluation and treatment plan and not a plan dictated by a managed care company?  The University of Wisconsin has a paradigm for networking with all physicians in their collaborative Memory Clinics program.  I see no reason why that could not be extended to different diagnostic groups across the state.  The focus would be on quality assessment and to prevent outliers in terms of treatment.  It could be open to any psychiatrist who wanted to join and it could have additional benefits of providing university resources like online access to the medical library to clinicians in the field.

An interested, excited, and technically competent psychiatrist is the ultimate goal of residency and it should continue throughout the career of a psychiatrist.  That can only happen with a focus on professionalism at all levels.  My definition of professionalism does not include managing costs so that  a managed care organization can make more money.  Psychiatrists need to forget about being cost effective and get back to defining and providing the best possible care.   

George Dawson, MD. DFAPA

The Real Role of Biological Tests in Psychiatry

The idea of a "biological test" in psychiatry has appeared on the internet recently, primarily as a way to deny that psychiatric disorders exist.  The contention is that because there is no medical test for a psychiatric disorder - it must not exist.   Time to add a balanced view.

As a backdrop, most people do not understand the concept of "tests" in medicine until they have a problem and realize that the problem is not reflected in the tests ordered by their doctor.  That is a very common experience.  Some studies show that up to 30% of patients presenting to a clinic for investigation of a symptom never find out what the cause of that symptom was.  That is true even after they were given the usual panel of blood tests, imaging studies, and electrophysiological studies.  The assumption that symptoms and disorders in medicine are all diagnosable by a "test" is incorrect.

The second problem occurs at the level of test interpretation.  When a doctor orders a test they have to interpret it correctly and in many cases the idea of an "abnormal" test is blurred by biological variation.  The evaluation of back pain using imaging studies like MRI scans is a good case in point.  As people age there is a greater likelihood that an abnormal MRI scan of the spine is not necessarily the cause of their back pain.  That has very important implications for treatment and the physician interpreting the test may will definitely be influenced by their specialty training, their own personal experience, their knowledge and examination of the patient, and possibly treatment guidelines that they may be mandated to follow.  There is also the question of false positive and false negative testing.  The recent controversy about the utility of prostate specific antigen (PSA) testing for prostate cancer is another good example.  The current guideline says that this test has too many false positive results to use for treatment planning and further invasive procedures.  Even in the case where the diagnosis is made by a specific number there is always the question of whether the test number is accurate or not.  I have frequently repeated thyroid function tests that seemed to show hyperthyroidism only to see them in the normal range on repeat testing.  It is obvious to physicians that the so-called biological tests in medicine have their limitations and  always need to be interpreted in the context of a comprehensive evaluation of the patient.

How are biological tests currently used in psychiatry?  It turns out that there are a lot of applications similar to the rest of medicine.

1.  To detect a medical cause of a psychiatric disorder.  The DSM classification has an entire set of disorders that are caused by underlying neurological illnesses, endocrine disorders, and infectious diseases that need to be recognized and treated.  They often present as psychiatric disorders.  In my experience of treating people with severe problems, up to 15% of the psychiatric presentations had an underlying medical illness that either was a direct cause of the "psychiatric" symptoms or it made a psychiatric disorder worse.  In that case the psychiatrist has to be trained to order the appropriate tests, make the diagnosis and refer the patient for treatment of the underlying disorder.

2.  To screen for medical illnesses that complicate the psychiatric disorder or its treatment.  A good example here is screening blood tests and electrocardiograms based on the clinical assessment of the patient and the likelihood that a disease is present.  At times patients present with significant problems that require urgent treatment that they are unaware of.  A good example would be detecting complete heart block on an ECG because of a patient's responses to the cardiovascular review of systems and the fact that an antidepressant was going to be prescribed.

3.  To monitor the safety of biological treatments.  There is probably no better example than the FDA focus on cardiac conduction and how that can be affected by medications.  The most recent warning occurred with citalopram.  This antidepressant has been used for over a decade by psychiatrists and was widely considered to be a very safe medication. Both the FDA and the Mayo Clinic have guidelines about how this problem needs to be assessed and that is a combination of clinical assessment and electrocardiograms.  In some cases electrocardiograms and referrals to electrophysiologists are required.  In light of this information psychiatrists need to have access to these ECGs and a plan to address any abnormalities.  As specialists, it is common to see patients who are referred taking doses of citalopram that exceed current FDA guidelines and that may involve testing and a plan to modify the dose of antidepressant.

4.  To identify medical emergencies in patients who are being followed for a psychiatric disorder.  Many patients who see psychiatrists either do not have primary care physicians or are very reluctant to see them.  A psychiatrist in this position needs to make every effort possible to encourage the patient to establish primary care, but even then medical emergencies need to be recognized and appropriately triaged.  That can happen more quickly if testing is available to facilitate the referral.  If a patient presents with jaundice, medical consultants are more likely to see him quickly if some basic testing is done that can be discussed with the consultant.

5.  To identify neurobiological correlates of psychiatric disorders.  A common example is an abnormal brain imaging or electrophysiological study that was ordered because of an acute or progressive behavioral change.

6.  For heuristic purposes.  The classic example of a test done for heuristic purposes was the dexamethasone suppression test.  At various times it was suggested as a test for various forms of severe depression and suicide risk.  The test is rarely done today because of the false positive errors but it helped generate a couple of decades of research on the neuroendocrinology associated with psychiatric disorders.

Some of the articles currently out there on the internet deny the existence of psychiatric disorders because there is no biological test for these disorders like depression or schizophrenia.  That really does not differentiate psychiatric disorders from neurological or rheumatic disorders that may have some supporting markers but that in general depend more on pattern recognition and less on a gold standard or pathognomonic test.   From a paper that addresses that subject (1):

"Although the results are often useful, they can be misleading. Few tests yield results that are pathognomonic for particular diseases. For these reasons, test results for autoantibodies alone are insufficient to establish the diagnosis of a systemic rheumatic disease; they must always be interpreted in the clinical context. Positive results for tests such as the ANA test are seen quite commonly in patients with nonrheumatic diseases and even among normal, healthy persons..."

The key sentence here is:  "Few tests yield results that are pathognomonic for particular diseases."  That would mean that in fact there are few so-called gold standard medical tests that confirm or deny the existence of a diagnosis.  Up to 30% of people presenting to a medical clinic for an evaluation of symptoms will never have a diagnosis to explain their symptoms no matter how many tests they have.  People with real illnesses often are frustrated by the fact that the test results they get are often equivocal.  Obvious conditions that have no biomarkers range from migraine headaches to Alzheimer's Disease.  I don't think that any rational person would suggest that neither of these conditions exist.  People who have first hand experience with severe mental disorders know that the profound emotional and cognitive changes that they see in their friend of family member is real - whether there is a biomarker or not.

George Dawson, MD, DFAPA

Reference:

1:  Arthur Kavanaugh, Russell Tomar, John Reveille, Daniel H. Solomon, Henry A. Homburger; Guidelines for Clinical Use of the Antinuclear Antibody Test and Tests for Specific Autoantibodies to Nuclear Antigens. Arch Pathol Lab Med 1 January 2000; 124 (1): 71–81. doi: https://doi.org/10.5858/2000-124-0071-GFCUOT