Guns Are Not Cooling Off Between Mass Shootings

I have previously posted my concerns about mass shootings and the general paralysis on dealing with this problem.  The gun lobby has unquestionable political power on this issue, but that is also due to judicial interpretation of the Second Amendment as it is written.  Today's New York Times describes a mass shooting at an elementary school in Connecticut.  At the time I am typing this, the death toll is 20 children, 6 adults, and the gunman.  This incident occurs three days after a shopping mall shooting in Oregon.

Most people would think that nothing would be more motivating for major societal changes than children being attacked in this manner.  Unfortunately this is not the first time that children have been victimized by mass shooters.  On October 2, 2006 a gunman shot 10 girls and killed 5 before committing suicide.  According to the Wikipedia article that was the third school shooting that week.  Altogether there have been 31 school shootings since the Columbine incident on April 20, 1999.

My question and the question I have been asking for the past decade is what positive steps are going to be taken to resolve this problem?  How many more lives need to be lost?  How many more children need to be shot while they are attending school?  Some may consider these questions to be provocative, but given the dearth of action and the excuses we hear from public health officials and politicians, I am left in the position of continuing to sound an alarm that should have been heard a couple of decades ago.  After all, the elections are over.  The major parties don't have to worry about alienating the pro-gun or the pro-gun control lobbyists and activists.  This will not be solved as a Second Amendment or political issue.  I have said it before and I will say it again - the basic approach to the problem is a scientific one and a proactive public health one that involves the following sequence of action:

1.  Get the message out that homicidal thoughts - especially thoughts that involve random violence toward strangers are abnormal and treatable.  The public health message should include what to do when the thoughts have been identified.

2.  Provide explanations for changes in thought patterns that lead to homicidal thinking.

3.  Provide a discussion of the emotional, personal and economic costs of this kind of violence.

4.  Emphasize that the precursors to homicidal thinking are generally treatable and provide accessible treatment options and interventions.

5.  The cultural symbol of the lone gunman in our society is a mythical figure that needs to go.  There needs to be a lot of work done on dispelling that myth.  I don't think that this repetitive behavior by individuals with a probable psychosis is an accident.  Delusions do not occur in a vacuum and if there is a mythical explanation out there for righting the wrongs of a delusional person - someone will incorporate it into their belief system.  The lone gunman is a grandiose and delusional solution for too many people.  If I am right it will affect even more.

6.  Study that sequence of events and outcomes locally to figure out what modifications are best in specific areas.

One of the main problems here may be the deterioration in psychiatric services over the past three decades largely as a result of government and managed care manipulations.  Ironically being a danger to yourself or others is considered the main reason for being in an inpatient psychiatric unit these days.  I wonder how much of the inertia in dealing with the problem of mass homicide comes from the same forces that want to restrict access to psychiatric care?  Setting up the remaining inpatient units to deal with a part of this problem would require more resources for infrastructure, staff training, and to recruit the expertise needed to make a difference.

The bottom line here is that the mass homicide epidemic will only be solved by public health measures.  This is not a question of good versus evil.  This is not a question of accepting this as a problem that cannot be solved, grieving, and moving on.  This is a question of identifiable thought patterns changing and leading to homicidal behavior and intervening at that level.

George Dawson, MD, DFAPA

ADHD and Crime

There has been a lot of commentary on the NEJM article on the association between stimulant treatment of Attention Deficit Hyperactivity Disorder (ADHD) and less crime in a cohort of patients with ADHD.  Two of my favorite bloggers have commented on the study on the Neuroskeptic and Evolutionary Psychiatry blogs.  As a psychiatrist who treats mostly patients with addictions who may have ADHD and teaches the subject in lectures - I thought that I would add my opinion.

Much of my time these days is spent seeing adults who are also being treated for alcoholism or addiction. I also teach the neurobiological aspects of these problems to graduate students and physicians.  In the clinical population that I work with - ADHD is common and so is stimulant abuse/dependence and diversion.  Cognitive enhancement is a widely held theory on college campuses and in professional schools.  That theory suggests that you can study longer, harder, and more effectively under the influence of stimulants.  They are easy to obtain.  Stimulants like Adderall are bought, sold, and traded.  It is fairly common to hear that a feeling of enhanced cognitive capacity based on stimulants acquired outside of a prescription is presumptive evidence of ADHD.  It is not.  It turns out that anyone (or at least most people) will have the same experience even without a diagnosis of ADHD.

There is very little good guidance on how to treat ADHD when stimulant abuse or dependence may be a problem.  Some literature suggests that you can treat people in recovery with stimulants - even if they have been previously addicted to stimulants.  Anyone making the diagnosis of ADHD needs to makes sure that there is good evidence of impairment in addition to the requisite symptoms.  Ongoing treatment needs to assure that the stimulants are not being used in an addictive manner.  I would define that as not accelerating the dose, not taking medications for indications other than treating ADHD (cramming for an exam, increased ability to tolerate alcohol, etc), not attempting to extract, smoke, inject, or snort the stimulant, not obtaining additional medication from an illegal source, and not using the stimulant in the presence of another active addiction.  Addressing this problem frequently requires the use of FDA approved non stimulant medication and off-label approaches.

With the risk of addiction that I see in a a population that is selected on that dimension, why treat ADHD and more specifically why treat with medications?  The literature on the treatment of ADHD is vast relative to most other drugs studied in controlled clinical trials.  There have been over 350 trials and the majority of them are not only positive but show very robust effects in terms of treatment response.  The safety of these medications is also well established.

Enter the article from the NEJM on criminality and the observation that stimulants treatment may reduce the criminality rate.  This was a Swedish population where the research team had access to registries containing data on all persons convicted of a crime, diagnosed with ADHD, getting a prescription for a stimulant, and to assign 10 age, sex, and geography matched controls to each case.  Active treatment was rather loosely defined as any time interval between two prescriptions as long as that interval did not exceed six months.  The researchers found statistically significant reductions during the time of active treatment for both men (32%) and women (41%).      

I agree that this is a very high quality article from the standpoint of epidemiological research - but my guess is the editors of the NEJM already knew that.  This study gets several style points from the perspective of epidemiological research.  That includes the large data base and looking for behavioral correlates of another inactive medication for ADHD - serotonin re-uptake inhibitors or SSRIs.  There is a robust correlation with stimulants but not with self discontinued SSRIs.  They also analyzed the data irrespective of the order of medications status to rule out a reverse causation effect (treatment was stopped because of criminal behavior) and found significant correlations independent of order.

Apart from the usual analysis clinical and researchers in the field ranging from neurobiologists to researchers doing long term follow up studies do not find these results very surprising.  The Medline search below gives references of varying quality dating back for decades.  The pharmacological treatment certainly goes back that far.  The accumulating data suggests that where the disorder persists, it requires treatment on an ongoing basis.  A limited number of studies suggest that cognitive behavioral therapy (CBT) may be useful for adults with ADHD but not as useful for children or adolescents.  The practice of "drug holidays" prevalent not so long ago - no longer makes sense when the diagnosis is conceptualized as a chronic condition needing treatment to reduce morbidity ranging from school failure to decreased aggression to better driving performance.

One of the typical criticisms of epidemiological research of this design is that association is not causality, I think it is time to move beyond that to what may be considered causal.  In fact, I think it may be possible at this time to move beyond the double blind placebo controlled trial to an epidemiological standard and I will try to pull together some data about that approach.

George Dawson, MD, DFAPA

Lichtenstein P, Halldner L, Zetterqvist J, Sjölander A, Serlachius E, Fazel S, Långström N, Larsson H. Medication for attention deficit-hyperactivity disorder and criminality. N Engl J Med. 2012 Nov 22;367(21):2006-14. doi: 10.1056/NEJMoa1203241.

Criminality and ADHD:  Medline Search

Paradigm Shift or Typical Rhetoric?

"Humanism and science cannot be based on rhetoric and wishful thinking. They require hard work and dedication to both scientific methodology and humanistic concerns."  - Akiskal and McKinney - 1973  


Well I decided to interrupt a post I was working on to respond to more noise about everything that is wrong with psychiatry - at least according to one blogger and an author that he is reviewing.  The basic argument is that there is a push to "remedicalize" psychiatry because of pressure on psychiatrists from non physician providers.  Apparently psychiatrists are an expensive commodity- especially if they really don't know anything.  That argument is so poorly thought out - it is difficult to know where to start.

The medical basis of psychiatry is well recorded starting in European asylums.  At one point German psychiatry was firmly focused on brain studies and Alzheimer, Nissl and others were searching for the neuroanatomical basis of mental illnesses in the late 19th century.  Psychiatrists were the first physicians responsible for the large scale treatment of epilepsy and neurosyphilis.  Whenever a previously intractable condition became more treatable it seems like it was no longer under the purview of psychiatry.

If anything there was a push to demedicalize psychiatry with the advent of Freudian and later therapies - that for the most part were good literary efforts but seem to offer very little in terms of modern treatment apart from a few very broad guideposts. It probably persisted right up to the heyday of biological psychiatry in the US and I would put that sometime in the early 1980s.  A well read friend of mine suggested that when Freud was waiting for a call from the Nobel committee, it probably should have been the committee on Literature rather than Medicine.  Given Freud's subsequent impact on English literature - I think that was a keen observation.  It certainly had little to do with medicine.

The medical basis of psychiatry is well documented and all I have to do is  spin around in my chair and look at the texts I have on my book shelves.

The original work on delirium by Lipowski.  Three editions of Lishman's Organic Psychiatry.  Countless texts on consultation liaison psychiatry, geriatric psychiatry, addiction psychiatry, sleep medicine, psychosomatic medicine, and specialty volumes on Alzheimer's disease and other brain conditions.  Classic chapters in Lahita's Systemic Lupus Erythematosus on the cognitive and psychiatric aspects of SLE.  Every psychiatrist needs to know if there is a medical cause for the psychiatric problem being evaluated, if it is safe to treat a person given their medical comorbidity, and how to assure the medical and psychological safety of that patient they are treating.  That has always included the ability to make common and rare medical diagnoses, interpret physical findings, and interpret test results.  That last sentence is frequently minimized but it requires the ability to recognize patterns and manage information that is on par with any other specialist.

The idea that psychiatry requires "remedicalization" or has been "remedicalized" is another myth of the ill informed, but it does have a basis.  The basis is in how the managed care cartel has taken over and dumbed down the field.  Managed care companies would like nothing more than psychiatrists sitting in offices doing cursory interviews and handing out antidepressants.  Reviewers from managed care companies have essentially disclosed this to me over the years with comments like: "Psychiatrists are not supposed to manage delirum".   My reply:  "That's funny because the Medicine service transferred me this patient as 'medically stable' and with no delirium diagnosis."  Who in the hell else is going to manage delirious bipolar patients with hepatic or renal failure?

Of course I realize that managed care companies really don't care about my patients and in this case it was fairly explicit that they could save the "behavioral health" cost center a lot if they could shame me into transferring the patient back to Medicine.  My response was basically - you convince them to accept the patient and I will transfer them back.  It never happened.

The only "paradigm shift" required here is to let psychiatrists practice medicine at the level they are competent to provide, rather than rationing their services.  The quality of care will dramatically improve and that includes associated medical care and diagnoses determined based on the ability of psychiatrists to communicate with patients.  What is probably difficult to accept by the "paradigm shifters" no matter who they may be is that psychiatry is a difficult field.  You do have to know plenty of medicine and like all other medical specialties you need to know the theory.  When I trained in in medical school there was plenty of theory that we had to learn that never made it into mainstream practice.  Much of the neuroscience and genetics that applies to psychiatry already exceeds the applicability of what I was taught about theophylline in medical school.

The most difficult part about psychiatry is that you always have to be patient centered and know how to talk to people.  That falls flat if you don't have the expertise to recognize all of their their illnesses and help them get better.  The only real crisis in psychiatry is that it is being starved into non existence by the government and managed care companies.  They don't care what psychiatrists know and what they can do.  They don't want you to see one.

George Dawson, MD, DFAPA

Akiskal HS, McKinney WT Jr.  Psychiatry and pseudopsychiatry.  Arch GenPsychiatry 1973 Mar;28(3):367-73.

Freedom of Information is Not Exactly Free

I am still trying to figure out how to access information from the Freedom of Information Act (FOIA).  Some data acquired through this act  has proven to be valuable from a research standpoint.  I first became aware of this data a a research technique in the excellent studies by Kahn, looking at the issue of suicide in placebo controlled drug trials of antidepressant and antipsychotic medications.  These were excellent studies and I am surprised that they are not widely referred to whenever the issue of suicidal behavior secondary to a medication or suicidal behavior in drug trials is discussed.  Kahn, et al accessed their raw data through FOIA requests through the FDA.

I have been trying for a long time to access data from the FBI on the basis of an FOIA request.  I started out about 10 years ago and asked them for specific data pertaining to their pre-911 role of auditing physicians billing practices and determining whether or not a physician had committed "fraud" based on a mismatch between the billing statement and the document of the clinical visit.  I know that they had specific documents about this practice and even briefly published a journal detailing their strategies and tactics.  At one point that data was online and then it disappeared.  In order to have a closer look at FBI activity in the area of health care fraud I filed the original request that resulted in no data.  This year, I looked at the FBI reading room again and it discussed the wide availability of information in that venue that could also be copied and sent at a cost to the requester.  Using the FBI form and broadening the request to data pertaining to health care fraud, I completed the following form on the FBI web site on September 1, 2012 (click graphic to expand):

   I  think that it is fairly clear that I am interested in activities pertaining to health care fraud.   I received the following reply today (click graphic to expand):

That is quite a price tag.  $66,702.50 for 667,125 pages or $7,985 for 533 CDs.  I can't imagine that there is a lot of relevant data contained in these pages.  The documents I am looking for comprise no more than 200 pages.  Using their rates that is $20 of information.  The result when I specifically ask for information that I am certain they have is a denial.  If I try to broaden the search and look for myself they offer to send me what could be a small directory off a hard drive.  Figuring 14 kB per page that converts to about 8.9 GB.  The fact that they are willing to send CDs suggests to me that it is already sitting on a hard drive.  My point here is that all of this data could be sitting on a hard drive somewhere in a federal building and I could be searching it from home for free.

If data is declassified and available to the public, why jump through all of these hoops to get it?  If the data was available, I don't think it would be too hard to trace the FBI activity in health care fraud against physicians and get all of the facts out on the table.  As it stands both price tags in this FOIA request are too steep for me and that story will have to be written at another time.  As with many problems that occur with our government  that time is usually when anyone who cared about the issue, all of the politicians responsible for it, and the bureaucrats who actually administered it are long gone.

George Dawson, MD, DFAPA

Mayo Clinic Counterpoint to FDA on Citalopram

The Mayo Clinic came out with their recommendations on what to do about the FDA's warning about citalopram.  By their own description they are more liberal with regard to their citalopram recommendations and more conservative regarding escitalopram.  I have previously reviewed the problem here and concluded that there is really a lack of data available on the likelihood of electrocardiogram abnormalities during normal clinical use and if citalopram is as cardiotoxic as the FDA is describing it - we should treat it more like a standard antiarrhythmic drug and used flecanide as an example.

For all practical purposes that would include baseline ECGs, ECGs at the max dose and taking it up one more level from either the Mayo Clinic or the FDA - a stress test looking for QTc prolongation at higher heart rates.  The other elements in the Mayo recommendations based on history and physical examination and expecting some physician knowledge of drug metabolism are fairly standard.  I thought it was interesting that they did not mention checking plasma levels of the drug especially in complex cases (eg. a patient with cirrhosis) who only responds to higher than recommended doses of the drug.  Regarding the statements:  "Selective serotonin reuptake inhibitors cannot simply be substituted for one another, not even escitalopram for citalopram."  That is generally true and where are these guys in the battle against PBMs saying that these drugs are all equivalent?  I have not found any patient that responded selectively to citalopram and not escitalopram.  I have generally been able to convert patients to an equivalent amount of escitalopram the next day.

Both the Mayo Clinic and the FDA are silent on molecular approaches to solving this problem and screening patient for potential risk before they are started on either drug.  The Mayo Clinic offers testing for cytochrome P450 genotypes.  The genetic basis for hereditary prolonged QTc intervals has been a hot topic of research over the past decade.  It is probably time to expand the search for additional genotypes that place people at risk during specific drug therapies.  Until then we have only very approximate methods of determining the at - risk population and keeping them safe and the Mayo recommendations are more reality based than the FDA.

I think it would also be possible to estimate the risk associated with taking citalopram across the entire population.  In fact, at this point the FDA seems to have the data to estimate the risk of any QTc effect at all to the risk of torsade de pointes - the most significant arrhythmia.  I think it is very important for patients making the decision to have this number and if I can provide numbers on rare but serious antidepressant complications like serotonin syndrome, a federal agency with more perfect information and no patient care responsibility can do better.

George Dawson, MD, DFAPA

Sheeler RD, Ackerman MJ, Richelson E, Nelson TK, Staab JP, Tangalos EG, Dieser LM, Cunningham JL. Considerations on safety concerns about citalopram prescribing. Mayo Clin Proc. 2012 Nov;87(11):1042-5.

FDA Drug Safety Communication: Revised recommendations for Celexa (citalopram hydrobromide) related to a potential risk of abnormal heart rhythms with high doses.

Why I No Longer Support NAMI

For the past several years my wife and I have been regular donors to our state branch of the National Alliance on Mental Illness (NAMI).  We decided to do it initially as a memorial to family members who suffered from mental illness.  I just got two letters in the mail encouraging me to donate again.  One was a "Dear Friend" letter from NAMI reminding me of the plight of the mentally ill.  The other was from the Medical Director and CEO of the American Psychiatric Association.  Dr. Scully apparently thinks he is reminding me of how fragmented the system of care is and "The treatment system that confronts families seeking care is too often fragmented, unorganized and, despite the efforts of many, is uneven at best in its quality."  After working in that "system" for over 25 years and witnessing its decimation by the managed care industry - both letters are insulting.

The only time I was impressed with NAMI was during an attempt to secure resources for a patient in another state.  At that time I contacted NAMI in Illinois and was almost immediately faxed, about 50 pages of resources that my social worker and I could use to come up with a discharge plan.  The fragmented system often resulted in us spending long stress filled hours trying to piece together a plan that we hoped would work while we were being pressured to discharge the person to the street.  Managed care companies were not helpful.  I can still recall a patient with complicated problems.  The managed care company did not acknowledge the serious nature of the problem and wanted immediate discharge.  When we tried to get a discharge appointment for the patient the earliest appointment was 6 months away and they refused to give any priority based on the recent hospital discharge.  

A local NAMI walk for fund raising was disappointing.  Psychiatrists tended to walk with their own organizations, but the dimension that was unnerving to me was the corporate presence.  It seems that the no free lunch movement for doctors is not as concerned about corporate sponsorship of NAMI and any conflicts of interest that might arise.  Why would anyone raise the issue of conflict of interest?  There are two obvious issues.  NAMI has long been an advocate for access to psychiatric care and psychiatrists.  The managed care companies listed as sponsors have been the primary drivers in restricting access not just to psychiatric care but any kind of evaluation or treatment for mental illness or addiction.  In the Twin Cities they currently use case managers to control admissions and discharges.  Those case managers make those decisions based on proprietary guidelines that have little to do with the modern practice of psychiatry.

A second issue is pharmaceutical sponsors.  Psychiatry has been singled out for the appearance of conflict of interest whenever there have been sponsorship or payment of researchers or speakers by pharmaceutical companies.  The real effect of this sponsorship is on the public.  There is no clearer example than National Depression Screening Day.   This event began across the country over 20 years ago.  I was the organizer for two years for the Minnesota Psychiatric Society.  The event was sponsored nation wide by the company who had the most expensive and widely known antidepressant on the market.  It was a field day for the idea that antidepressant medications treat depression.  That bias is still present today and is probably one of the single greatest reasons why treatment of mental illness is typically reduced to a cure in a pill.

Despite my reservations, I decided to support NAMI with an annual check and was listed as a professional member of the organization.  NAMI is a politically powerful organization and I often heard that they had interests that were similar to psychiatric professional organizations.  Then a few months ago Minnesota Public Radio came out with a story on the Minnesota Security Hospital.  It is the state facility that is used to house and treat patients with severe mental illnesses who are also dangerous on an ongoing basis.  Most of the patients are there because they have been adjudicated after committing a violent crime or they are there for an evaluation.  There have been severe administrative problems that have resulted in the resignation of most of the psychiatric staff and an increased number of injuries to staff.

According to that report:

"Sue Abderholden, the executive director of the mental health advocacy group NAMI Minnesota, said despite the concerns, she thinks Barry and other officials are doing a good job of addressing serious, long-standing issues at the facility. She said the decrease in the number of psychiatrists is not necessarily a problem, as long as the facility hires qualified nurse practitioners. Ideally, she said, patients would always see the same provider, but she said that's not realistic for most facilities."

The opinion given in that story is certainly at odds with my opinion.  The state and NAMI seem to believe that psychiatrists are there to prescribe medications and can be easily replaced in that department.  I don't see anything that reflects psychiatric training in how to treat aggressive patients (what else is needed besides medication?) and what needs to happen from a systems or administrative standpoint.  Psychiatrists are the only staff with that kind of training and I wonder about whether they can use that training in a system that seems to suggest that an administrator can develop programs to deal with aggression.  The executive director's opinion seems quite consistent with that approach.  Wasn't that the problem in the first place?

I don't expect any support from NAMI.  Psychiatrists should be able to  support their own positions and members.  At the same time, I don't see any benefit to financially supporting an organization that has radically different goals than my professional goals and sees psychiatrists as easily replaced by people with much less training.  As far as the position of administrators dictating clinical care goes, that is a psychiatrist replaced by someone with no training.  If anyone can act like a physician - then physicians become superfluous.  It is tantamount to running the place with a managed care company and creating the illusion that serious care is being done by seeing people for a few minutes and talking about their medications.

The time has come to not renew my professional membership in NAMI.  With mental health parity still in question, any advocacy organization needs to have higher standards than a managed care company.

George Dawson, MD, DFAPA


Madeleine Baran.  More injured employees, fewer doctors at Minnesota Security Hospital.  August 29. 2012.

ADHD - The Scientific Evidence versus the Political Hype

I attended a day long seminar by Russell Barkley, PhD.  It is part of my ongoing mission of seeing the experts in person who I have read and collected in my library over the past 30 years.  My earliest exposure to Dr. Barkley's work was the book Hyperactive Children that I acquired while I was in Medical School and used when I was treating children in the first clinic I worked in as a psychiatrist.  Interestingly he was working at the same medical school I had attended.  Dr. Barkley has an impressive surveillance system for current literature and in the seminar was presenting work that had literally been published or put into prepublication the day before.  His scholarship is impressive and he is one of the most widely published authors in the field.  He has a clear scientific approach and does not recommend treatments that have not gone through randomized and blinded clinical trials.  He gave many examples of ADHD treatments that seemed effective until the raters were blinded to the treatment or the methods were used by researchers who had no vested interest in the outcome.

All of his information was presented on PowerPoint as is the standard.  His PowerPoint slides were information dense, frequently presenting dimensions and data points from several studies on the same line.

A few of the highlights that you will not read in the New York Times:

1.  On the "overdiagnosis" issue - at this time about 40% of kids and 10% of adults with the disorder are treated.
2.  On the DSM issue - the categories of ADHD are going away.  Like categories of schizophrenia and autism spectrum disorder they are not unique entities.   This of course runs counter to the usual DSM criticism that there is a proliferation of diagnostic categories   Another positive was that the age of onset criteria is changing from age 7 to age 12.  Barkley points out that an age cutoff for a developmental process is arbitrary and suggested a further change to "onset in childhood or adolescence".  On the other hand, it does appear that the committee in charge is responding to political pressure from the government and insurance companies to not make any changes that would increase the prevalence of the disorder.  He presented clear criteria that would improve the diagnosis of ADHD in adults that will apparently not be included or possibly on a parenthetical basis.
3.  The problem with the treatment of children is not overtreatment, but that fact that most children who need treatment discontinue their medications as teenagers.
4.  The resulting complications of untreated ADHD are significant from an educational, public health, and psychiatric perspective.  As one example, untreated ADHD is associated with high risk of dropping out of school.  Every person who drops out and does not complete school represents a cost of $450K to the community.
5.  Stimulant medications have a 40 year record of use and there have been over 350 studies documenting the efficacy and safety.  They have the greatest effect size of any psychiatric medications and that includes up to 90% response rates across all stimulants.
6.  Response to treatment is robust and the best of any psychiatric disorder.  Evidence based studies show that patients treated with stimulants show improved outcomes across 20 parameters and that treatment with atomoxetine is associated with improvement across 23 parameters.
7.  These medications have an unprecedented safety record.
8.  There is a potential steep cost in many areas of not adequately treating the disorder.

It is very disappointing to hear that the DSM committee may be yielding to political pressure when it comes to implementing new evidence based DSM criteria particularly give the poor quality of these arguments.  A professional organization should be above political influence when it comes to scientific findings and this revision of criteria was supposed to be based on science.  The APA does have a long history of not providing any resistance to the managed care industry or government initiatives to reduce the quality of psychiatric care in favor of the managed care industry.  If true it will be ironic that the ADHD section of the DSM5 will be be directly influenced by the usual managed care forces and that they are aligned with all of the media rhetoric about the proliferation diagnoses and increased prevalence.

So the usual media hype is wrong - psychiatrists and pharmaceutical companies are not plotting to put more people on medication.  The government, managed care companies, and the anti-biological antipsychiatrists are trying to keep them off even when they are indicated.  In that political divide - the science is left out.

George Dawson, MD, DFAPA

Dr. Russell A. Barkley, PhD.  Official Web Site.

Dr. Russel A. Barkley, PhD.  Professional Workshop on ADHD.  ADHD Across the Life Span: Diagnosis, Life Course, Management, and Comorbidity.  Minnetonka, Minnesota.  Thursday November 15, 2012.

International Consensus Statement on ADHD (excerpt) - read this statement signed by scientists explaining that this diagnosis is not controversial and that the percentage of patients treated is about the same in the past decade.

Being Flynn - Another Cinematic Portrayal of Alcoholism

My previous post looked at the accurate portrayal of alcoholism in the film Flight.  I recently saw Being Flynn starring Robert De Niro in the role of an alcoholic father and self proclaimed novelist.  This film is also a study of alcoholism.

Like Denzel Washington, De Niro accurately portrays the ways that alcoholism impacts the lives of some men.  In this case we meet De Niro's character Jonathan Flynn in a downward spiral.  We first meet his son Nick Flynn and learn through a series of flashbacks that the elder Flynn abandoned Nick and his mother for unclear reasons and he has not seen his father in about 18 years.   We first see Jonathan Flynn when he is driving a taxi.  He is drinking vodka on a regular basis.  We see him lose his job and then his housing and end up at a homeless shelter.  Nick is floundering as a poet and author.  He lacks direction and the flashbacks suggest that childhood adversity has played a big role.  He comes to be employed at a homeless shelter where his father eventually seeks shelter.

The trajectory of that story line is impacted by the fact that Jonathan is a very volatile and generally unlikable character.  Although it is certainly dangerous to live on the street, he has an aggressive attitude at times that is not warranted.  It is the reason he was evicted.  At other times he is able to keep quiet when he witnesses some street thugs beating one of his drinking buddies.  He uses a lot of expletives and at times seems incoherent.  In his interaction with Nick he is unapologetic and grandiose - describing himself as one of America's greatest authors.  When he allows Nick to read his manuscript, the first chapter shows some promise but the rest is incoherent.

Nick is on his own parallel journey.  He is lucky to get the job at the homeless shelter and initially blends in seamlessly with the staff.  The shelter staff and the environment at the shelter is expertly portrayed and very realistic.   The tension at the shelter between caring for desperate and sometimes disagreeable men and the required altruism is palpable.  Eventually Jonathan's disagreeable temperament creates a situation where Nick has to vote on whether to expel him.   He does despite a staff person trying to convince him not to send his father out on one of the coldest days of the year.  Jonathan predictably acts like he relishes the thought and that living on the street is nothing.  When we see what actually happens out there it is clear that his attitude is another manifestation of his pathology.  There is a time when we are not sure whether Jonathan will survive or not.

There are a number of fascinating articles available that look at the process of making this film.  The gold standard for any film is the book and many critics suggest reading that as a starting point.  The real Nick Flynn has some fascinating interviews talking about the evolution of homelessness in America.  When did it become acceptable?  The motion picture business is averse to producing any films that portray characters or themes that the general public would find to be distressing and the main reason is how that translates into box office numbers.

As I contemplated the Flynns' predicament I naturally thought about all of the homeless alcoholic men I have seen in the past 25 years.  At some point in time they all create the anger, frustration, and hopelessness portrayed in this film.  Many of them are not only grandiose and paranoid, but permanently delusional or amnestic.  The good news is that they are also a stimulus for the altruism apparent in the shelter staff in this film and eventually Nick Flynn himself.  This film is similar to Flight in that there are no proposed solutions.  The are no public policy statements.  It is an accurate depiction of real people dealing the the problem of addiction in their daily lives.  Despite those significant problems there are hopeful messages everywhere.  After reading an interview with the author, I am skeptical of the origins of those messages, but based on my experience they seem real.

I also had associations to what I consider to be some of the most important work in alcoholism.  The first was a study of inner city alcoholics by George Vaillant in the 1980s and several subsequent studies by the same author.  Most of the original articles online are available only with steep fees for a one time read.  It is probably easier to look at The Natural History of Alcoholism - Revisited in your local library.  It contains most of the important graphics from the research articles and Dr. Vaillant's views circa 1995.  The summary section looks at seven very important questions about the nature of alcoholism and the answers provided by prospective research on the problem.  In looking at this research, Jonathan Flynn probably most closely resembles the follow up study of 100 consecutive admissions to a detoxification unit in Boston.  At the end of 8 years of follow up, about 32% were abstinent, about 30 % were still drinking and 32% were dead or institutionalized.  One of Dr. Vaillant's characterizations of the recovery process in alcoholism:  "... alcoholics recover not because we treat them, but because they heal themselves.  Staying sober is not a process of simply becoming detoxified, but often becomes the work of several years or in a few cases even of a lifetime.  Our task is to provide emergency medical care, shelter, detoxification, and understanding until self healing takes place." (p384).  Self healing was evident in this film.

The other work that I routinely discuss with people I have seen for alcoholism and the associated comorbidity is the work of Markku Linnoila.  Dr. Linnoila was a prolific researcher in both basic and clinical alcoholism research.  He did some of the early studies looking at cerebrospinal fluid metabolites, especially serotonin metabolites and how they correlate with depression, aggression, and impulsivity over time when men consume alcohol.  These studies continue to provide a scientific basis for advising patients on basic dietary changes and in some cases pharmacological interventions that may assist in recovery.  An important aspect of the work of shelters like the one depicted in this movie is getting protein back into the diet of the homeless with alcoholism.

This film is harder to watch than Flight but it is no less accurate a depiction of how alcoholism can impact the person and their family.  It speaks to the spectrum of intervention necessary to provide safety and assist with recovery.

George Dawson, MD, DFAPA

Vaillant GE. Alcoholics Anonymous: cult or cure? Aust N Z J Psychiatry. 2005 Jun;39(6):431-6. PubMed PMID: 15943643.

Zemeckis portrayal of addiction in "Flight"

I went to see Robert Zemeckis film Flight starring Denzel Washington as pilot Whip Whitaker yesterday.  Spoiler alert - if you are a person who likes to see new films knowing nothing about the plot - stop reading this post right here.  I work at a large residential addiction facility and ran into one of my colleagues in the lobby.  He told me he was there to see the film because it was a good film about addiction.  I was completely surprised.  Robert Zemeckis made the film that I have seen more times than any other - Forrest Gump.  I generally see anything that Denzel Washington does.  Like everybody else, I like his work and he does not make any bad movies.  His last transportation themed movie Unstoppable cast him the role of a wise engineer trying to stop a runaway train.  The trailers I had seen for Flight suggested a similar role.  I expected a heroic pilot with a similar outcome.

From the outset, it is obvious that Whip Whitaker has a tremendous problem.  He wakes up hung over, snorts some cocaine, drinks what is left of a beer and heads out the door with his pilots uniform on.  Almost incredibly he proceeds to inspect his commercial airliner, fly it through extreme turbulence, drinks some additional vodka in flight and takes a 26 minute nap before the critical scene in the movie where he performs a complicated series of maneuvers to save most of the crew and passengers from a mechanical failure.  Subsequent analysis proves that he is the only pilot who could have saved the plane.  But even those facts are not enough to preserve his fleeting hero status.

Throughout the film we see Whip drinking in an uncontrolled manner.  There is some ambivalence.  He gets out of the hospital post crash and goes to the family farm where he proceeds to dump out all of the beer and hard liquor.  He dumps out his stash of marijuana.  There is the implicit recognition that somewhere there are toxicology results that he is going to have to deal with.  As that part of the plot unfolds, he resumes drinking, smoking marijuana, and snorting cocaine with a vengeance.  In one scene he walks out of a liquor store with a case of beer and what appears to be a three liter bottle of vodka.  As soon as he gets into the car he is drinking the vodka like water and drives around with an open can of beer.  There are several scenes where the interpersonal toll of alcoholism is evident with his potential love interests, his son and ex-wife, and friends and business associates who are rooting for him.  The business associates have a common interest in seeing that he is exonerated for any crimes related to substance abuse.

This film succeeds in its depiction of alcoholism and how it hijacks the life of an otherwise highly successful pilot.  On the surface he is a "functional alcoholic."  His friend and former fellow Navy pilot describes him as a "heavy drinker" rather than an alcoholic   He appears to be successful in one aspect of his life but it does not take long to figure out even that is a charade.  He can't tolerate even the suggestion that he has a problem on the one hand and on the other makes the promise that he will stop and he can stop at any time.  He walks out of an AA meeting when the speaker asks people to raise their hand if they are an alcoholic.  There is a contrast between Whip and his girlfriend Nicole illustrating that addiction has no socioeconomic boundaries.  There were so many scenes in this film that captured the problems of addiction.

As an audience member you cannot help getting caught up in his fight with alcohol.  He is after-all the hero of this film and that is firmly established in the first 20 minutes.  You are hoping that he will not pick up another drink.  You are left with a situation where the hero will be dealt with according to technicalities.  His heroism does not count.  The only thing that matters is that he has an addiction.

This is a compelling film about addiction for families who deal with this problem on a daily basis and for those who do not.  It accurately portrays the central problems of addiction and recovery as not just avoiding punishment or making a conscious decision to stop.  It is a lot more than that and hopefully that message will be clear from watching this film.

George Dawson, MD, DFAPA


References (Doug Sellman has done a great job of distilling out the scientific points of addiction):

1. Sellman D. Ten things the alcohol industry won't tell you about alcohol. Drug Alcohol Rev. 2010 May;29(3):301-3. PubMed PMID: 20565523.

2. Sellman D. The 10 most important things known about addiction. Addiction. 2010 Jan;105(1):6-13. Epub 2009 Aug 27. PubMed PMID: 19712126.

3.  Alcohol Action New Zealand web site (various resources)

4.  Alcoholics Anonymous.  Grounded.  Alcoholics Anonymous World Services, New York City, 2001.

Who Runs My Drug Plan?

The real issue in pharmaceuticals used to treat mental illness is the business practices that looms as an obstacle between the psychiatrist prescribing the medication and the patient who wants to receive the medication.  I have posted about the managed care practices - specifically pharmacy benefit managers (PBMs) that get in between physicians and patients. That previous post shows a diagram from an internal memo that reveals some perspective on the PBM attitude.  The goal for them is to come up with a business argument that will either improve profits for the managed care company or justify the billions of dollars in costs that PBMs add to the health care system every year.

The National Community Pharmacists Association fights back against PBMs from this web site.  A lot of what you find is relevant for pharmacists also applies to physicians - especially wasting physician time, indirectly affecting reimbursement, and disrupting the patient-physician relationship by dictating medications that need to be prescribed that are financially advantageous to the PBM.

Some of the details provided on this site are very interesting.  One example is a $10 price spread on up to 4 billion prescriptions per year.  I once read that PBMs made up an $80 billion per year industry and it is easy to see how they can get there.  In fact, the volume strategies that they use are very similar to the financial services industry.  In both cases, political advantage has added businesses that levy another tax on consumers and do not provide any added efficiency.  It is easy to see how managed care strategies fail to contain health care inflation when the intermediaries with government advantages are set up to maximize profits and waste the time of physicians and pharmacists.  

If you are a physician, watch the "Fed Up With Phil" video and ask yourself if it isn't time to get rid of health care middlemen that are increasing costs and in many cases detracting from the quality of health care?  If you are a physician, isn't it time that you or your professional organization starting putting up web sites like this one to educate the public about managed care and all of its problems?  Isn't it time that we stopped wasting our time and money with politicians?

George Dawson, MD, DFAPA

The diagnosis of anosognosia

Follow up on another blog today where the author proclaims "It is not possible to diagnose anosognosia in schizophrenic patients on brain scan."

No kidding.  Here is another shocker and you can quote me on this - it is not possible to diagnose anosognosia in stroke patients based on a brain scan.  Quoting an expert: "Anosognosia refers to the lack of awareness, misbelief, or explicit denial of their illness that patients may show following brain damage or dysfunction.  Anosognosia may involve a variety of neurological impairment of sensorimotor, visual, cognitive, or behavioral functions, as well as non-neurological diseases."  I  encourage anyone who is interested in this topic to find a copy of this book chapter listed in the references below.  The author thoroughly discusses the fascinating history of this disorder, specific protocols used to make the diagnosis, various neurological subtypes with heterogeneous lesions and the fact that no specific mechanism has been determined.

In a more recent article available online, Starkstein, et al provide an updated discussion in the case of stroke.  They discuss it as a potential model of human awareness, but also point out the transient nature and difficulty in developing research diagnostic criteria.  They provide a more extensive review of instruments used to diagnose anosognosia and conclude: "Taken together, these findings suggest that lesion location is neither necessary nor sufficient to produce anosognosia, although lesions in some specific brain areas may lower the threshold for anosognosia. Strokes in other regions may need additional factors to produce anosognosia, such as specific cognitive deficits, older age, and previous strokes."

The experts here clearly do not base the diagnosis of this syndrome on imaging.  It is based on clinical findings.  For anyone interested in looking at the actual complexity in the area of anosognosia in schizophrenia I recommend reading these free online papers in the Schizophrenia Bulletin in an issue that dedicated a section to the topic in 2011.  You will learn a lot more about it than reading an anti-biological antipsychiatry blog.  But of course you need to be able to appreciate that this is science and not an all or none political argument.

George Dawson, MD, DFAPA.

Patrik Vuilleumier. Anosognosia in Behavior and mood disorders in focal brain lesions.  Julien Bogousslavsky and Jeffrey L. Cummings (eds), Cambridge University Press 2000, pp. 465-519.

E. Fuller Torrey on the New Anti-biological Antipsychiatry

This post by E. Fuller Torrey was noted on another blog especially the phrase "the new anti-biological antipsychiatry".  Torrey explains anosognosia both as a biological phenomenon and why it may be "deeply disturbing" to the new antipsychiatrists.  Basically it represents the difference between social behavior based on choice versus social behavior based on brain damage.  The former  might be a civil rights issue but the latter is a medical problem that benefits from identification, study, and treatment.  Torrey is also clear about the consequences of no treatment, facts that the antipsychiatrists conveniently often leave out of their arguments or more conveniently blame on treatment.

There is a lot of technical information apart from the data on anosognosia that is ignored by the new anti-biological antipsychiatry.  There are studies on the prefrontal cortex that go back for decades and the implications for social behavior and the neurobiology of everything from addiction to dementia.

Here is a link to the original blog post by Duncan Double entitled: "E. Fuller Torrey attacks 'The new antipsychiatry.'"  Defending against attacks by the new antipsychiatry is more like it.  Dr. Double laments the fact that at times he is seen as an antipsychiatrist, even though he essentially maintains many of the positions of mainstream antipsychiatry.   He includes a variation of the old antipsychiatry argument that if you don't have a specific test for a disease - the disease does not exist.  That opinion fails to take into account studies about what is or is not a disease as well as a massive literature of biological psychiatry.  It also fails to take into account the fact that these arguments are political in nature and have very little to do with science.

A good example is the chemical imbalance red herring.  Any psychiatrist trained since the 1970s is aware of the complex neurobiology of human behavior.  I can recall reading Axelrod's paper in Science over 30 years ago.  Since then there have been eight editions of The Biochemical Basis of Neuropharmacology and five editions of the ACNP text Neuropsychopharmacology.  Since then a psychiatrist has won the Noble Prize for contributions in neuroplasticity and wrote a seminal article on neuroplasticity and learning in psychotherapy.  That is apparently ignored by the anti-biological antipsychiatry crowd and those who would characterize the field as prescribers versus therapists.  The Internet is currently full of diagrams of cell signalling pathways with the associated proteins and genetics.  The idea that chemical imbalance reflects some central central theory of biological psychiatry or represents anything beyond pharmaceutical company marketing hype reflects a gross misunderstanding of the field.

Any psychiatrist who tries to respond to these crude arguments is at a disadvantage for a couple of reasons.  It is certainly seems true that the antipsychiatrists political stance is really not conducive to scientific discourse.  Suggesting that the appearance of conflict of interest invalidates psychiatry is an obvious example.  Discounting the amassed research on the neurobiology of mental illness is another.  A political argument is well outside the scope of hypothesis generation and testing.  Dismissing the science by attributing it to the "worldview" of a single person is consistent with that political approach.  

Conflict of interest and psychiatry - what's missing?

A new article looking at conflict of interest in psychiatry was presented on another blog to suggest that new rules are required to improve transparency. The article takes a look at six cases and the process used by Sen. Charles Grassley to publicize these cases. The article suggests that the reason for publicizing these cases was in order to support Grassley legislation (Physician Payment Sunshine Provision).  According to the article it was attached to the Patient Protection and Affordable Care Act and was never voted on alone. 

These cases were repeatedly publicized in the popular media and some of the problems with these cases and Grassley's analysis were never adequately discussed.  The clearest example is the case of Alan F. Schatzberg, MD of Stanford University. He was the chairman of the Department of psychiatry and when Grassley investigated the matter at the level of Stanford University and several pharmaceutical companies. You can read the exact details in this paper but the bottom line is that Stanford University has always maintained that it handled potential conflicts of interest in an appropriate manner consistent with their policies. They actually published a statement on their web page at the time.  He remained the department head and although he was apparently temporarily removed as the principal investigator on a federal grant but he was later reinstated. The authors of the article in this case suggest that exposing the conflict of interest had negligible effect on the outcomes in this case, but the fact is the case was handled according to university policy.

There are really two key elements in this paper that are critical. The first is why Grassley went after psychiatry in the first place. The article suggests this occurs because his aide Paul Thacker "Combed  the media for stories of influential physicians with industry ties. He then requested the physicians conflict of interest disclosures from their AMCs and compared them to payment schedules obtained from companies."  I had always wondered why physicians from other specialties were never mentioned or consultants from other departments. It is fairly well known that scientists and engineers can make substantial incomes to supplement their university salaries based on their expertise. So why was the "media combing" restricted to psychiatry?

If I had to speculate, I would suggest that media bias against psychiatry is a well known fact. It has actually been investigated and the frequency of negative press that psychiatry receives relative to other specialties is well known. (see paragraph 4)  The popular press has an automatic media bias against psychiatry and it should come as no surprise that prominent psychiatrists are investigated and reported more frequently than other specialists. This is why “combing the media” is really not a legitimate research method. It should be fairly obvious that prominent university affiliated physicians of all specialties have similar conflicts of interest and that the business stake in other specialties is probably significantly higher.

The second element that should be obvious to anyone skeptical of Congress is Grassley's quote in the article "The whole field of medicine is connected by a tangled web of drug company money. For the sake of transparency and accountability should the American public know who their doctor is taking money from?"  That sounds like there is an obvious answer in there somewhere but the U.S. Congress is the best case in point that transparency is essentially meaningless. There is probably no better example than Sen. Grassley himself.  You don't have to look too far to find campaign donations that align with the votes and the Senator's denial (see paragraph 8) that there is any connection.

These simple facts are left out of the Journal article and that represents a serious flaw to me. Is the U.S. Congress is a shining example of disclosure becoming a license to do whatever you want to do? If that is the case you really don't have the basis to suggest that transparency will allow the "power of sunlight to disinfect". It clearly does not have that effect in Congress.  That is at the minimum an appearance of a conflict of interest on par with any scenario described in this article.  When I point this out - the usual rebuttal is that doctors should have a higher standard when it comes to the appearance of conflict of interest.  Is that really true?  Should a doctor who already has a fiduciary responsibility to a patient and the patient's well being have a higher conflict of interest standard than one of the 100 most important law makers in the country?

The other issue here of course is that psychiatrists are conveniently thrown under the bus. Despite the qualifier in this paper is that "Nor did Grassley ever assert that psychiatry was more problematic than other specialties." (p 5).  You really don't have to make an assertion when psychiatry is apparently the only field you are investigating. That bias is totally consistent with one of the themes of this blog. 

When all else fails you can more easily scapegoat psychiatrists.  So why look for anybody else?

George Dawson, MD. DFAPA

Chimonas S, Stahl F, Rothman DJ. Exposing conflict of interest in psychiatry:
Does transparency matter? Int J Law Psychiatry.
2012 Oct 1. pii: S0160-2527(12)00072-6. doi: 10.1016/j.ijlp.2012.09.009.

[Epub ahead of print] PubMed PMID: 23036364.

The Besieged Minority

October 25 marks the 10th anniversary of the death of Senator Paul Wellstone.  There was an article commemorating this date  in the St. Paul Pioneer Press today.  Senator Wellstone was a favorite and perhaps my only favorite politician after he voted against HJ Res 114: "To Authorize the Use of the United States Armed Forces against Iraq."  His actual statements about the logic of going to war that are linked to this page is the best example of a rational analysis at a time when there was near mass hysteria to go to war.  And compared to all of the evidence that Iraq had weapons of mass destruction that they were somehow going to use against the US, only his analysis has stood the test of time.  Senator Wellstone is always recognized for his fighting for social causes but I think he also deserves a great deal of recognition for this analysis on the appropriate threshold for the use of force in a high degree of uncertainty.  His analysis in favor of peace.

The article describes the Paul Wellstone Mental Health and Addiction Equity Act of 2007 as his signature legislative accomplishment.  His son Dave lobbied for five years to pass this bill after his father's death and the title of this post is excerpted from a quote from his son:"My dad said that folks with mental illness and addiction were a besieged minority."

Paul Wellstone was certainly right about that.  Anyone who comes from a family with mentally ill or addicted members can attest to the lack of resources and assistance to address those problems.  Those same people can also attest to the uneven insurance coverage or in many cases a complete lack of insurance coverage.  When managed care arrived on the scene about 20 years ago a lot of people had the appearance of mental health and addiction coverage only to see it disappeared when needed based on the managed care company's tactics.  An example would be discharging a person with severe mental illness or addiction in a few days because the "acute" symptoms had resolved and they were no longer "dangerous".

Unfortunately these practices have really not changed.  In many cases they are worse.  Each managed care company has what it calls "medical necessity" criteria.  The best example is acute inpatient care.  A reviewer or case manager reads the chart and decides that the person is no longer suicidal or potentially aggressive to other and decides that they can be discharged.  The discharges occur at a convenient time that allows for somebody to make a profit.  The person's overall stability in terms of their ability to function or whether their personality function has been restored is never taken into account.   The likelihood that they will immediately relapse to a life threatening addiction that has only partially been addressed is not taken into account.  The issue of co-occurring addictions and mental illnesses are not taken into account.  The issue of whether that person is capable of managing any associated medical problems like diabetes is not taken into account.  People are frequently discharged with as many symptoms and problems as they were admitted with.

Practically every outpatient psychiatrist I have talked and corresponded with about this problem has given me the opinion that inpatient psychiatry is for all practical purposes - worthless.  In the meantime, one of the country's largest managed care companies reported last week that their profits were up 26%.

Apart from the loss of Paul Wellstone and the activity of Wellstone Action as far as I can tell there is no current politician out there to make sure that the intent of this legislation will ever be realized.   There is no doubt that federal and state law is extremely business friendly and overtly hostile toward physicians working in the health care system.  The deck is clearly stacked in the direction of health care businesses and the new legislation promoted by President Obama will make things even worse.  Unless there are some valid protections at the level of patient and physician interaction - business decisions based on health company profits will  always trump clinical decisions.  There is no better example than what has happened and continues to happen to psychiatric care over the past two decades.

In the meantime I will remember Paul Wellstone on October 25 and wish that he was still the most unique guy in the US Senate.

George Dawson, MD, DFAPA

Bill Salisbury.  Living On In Those He Inspired.  Pioneer Press. Sunday October 21, 2012.

Why Psychiatrists Should Agree with David Healy

One of the big media stories today is about David Healy's address to the American Psychiatric Association's Psychiatric Services meeting.  Like many of the psychiatrists turned critic his celebrity and notoriety status depend a lot of the amount of controversy that he is associated with and he comments on that in the opening remark.  If you carefully read through this article, you will find that the financial conflicts of interest alluded to in the article are largely historical at this point.  The elephant in the room for these critics is that practically all antidepressants are generics these days and they are no longer marketed by pharmaceutical companies.

I was an early adopter of maintaining  clear boundaries with pharmaceutical companies and for the past 20 years or so - did not see detail salespeople, did not accept food and did not accept any gifts.  On the other hand, I have always found pharmaceutical companies to be a rich source of data in addition to the usual FDA approved package insert.  As an example, I am looking at a disc sitting on my desk right now entitled "Iloperidone unsolicited slides - for education use only."  I gave a lecture on newer atypical anti psychotics several years ago and contacted the scientific divisions of three pharmaceutical companies looking for basic science data on the new drugs and they all supplied me with complete clinical trials data and basic science information on the receptor profiles that I wanted.  I will also call them up with possible adverse events and get detailed information about that frequently via fax the same day.

Healy appeared to have made a controversial remark about psychiatrists committing "professional suicide" by their affiliation with pharmaceutical companies.  In his previous remarks he make the comment about professional suicide as a preface to the second paragraph below:


"Healy noted further that when data surfaced showing a link between antidepressant use and risk of suicide in children, the APA issued a statement proclaiming that “we believe that antidepressants save lives.”

“What I believe they should have said is that the APA believes that psychiatrists can save lives because it takes expertise to manage the risks of risky pills,” he said; if psychiatrists’ only role were to dole out drugs, then less-trained physician’s assistants could easily replace them, he noted."

I have seen the comment on his blog at least 6 months ago and there should be complete agreement with this statement.  Just in the past month I have had to diagnose and address drug induced liver disease, serotonin syndrome, eosinophilia, antidepressant associated hypertension, and spent a considerable larger amount of time making sure that antidepressants could be safely prescribed and that they were not making pre-existing medical problems worse.   Recognizing those problems goes beyond the diagnostic process to coming up with a plan to monitor and treat it.  A considerable amount of my time is, if not most of my time is spent managing side effects and protecting the health of my patients.

Although Healy takes positions that I would consider to be inaccurate, in this case he is dead on.  It is professional suicide to collude with the idea that the treatment of any mental illness resides in a pill.  Marketing genius maybe, but certainly not reality.  Drugs don't treat and cure depression, psychiatrists do and it goes far beyond selecting a medication.  Monitoring the patient for these complications and recognizing rare complications takes time and that time needs to be available - even in visits that are supposed to be focused on "medication management".

George Dawson, MD, DFAPA

Confusion about Capitation versus Fee-For-Service versus National Health Care

This is from the Shrink Rap blog this morning the consensus is that capitated care is better than fee-for-service care.  What is wrong with that picture?

Starting out with the much maligned fee-for-service (FFS) -  most medical and psychiatric services are not delivered in that context.  You can safely say that FFS, disappeared a long time ago.  According to a 2012 Medscape survey of 24,216 physicians across 25 specialties only 4% worked in cash only or concierge style practices. That means that everyone else is subject to varying degrees of insurance company discounting.  From my years of providing inpatient care for example,  there is a standard DRG payment based on a global discharge or admission diagnosis.  For the most common psychosis DRGs the standard payment is $4,500 no matter how long a person is stays in the hospital.

The same thing happens on the outpatient side.  I have discussed this more extensively is a previous post.  Looking at the commonest outpatient billing code - actual reimbursement for providing services can be as little as $22.45 per visit.  In the case where bills are submitted with CPT codes (common to all of medicine) Medicare pays 50% of the usual and customary charge for psychiatry compared with 80% for the rest of Medicine.  A lot depends on contracting arrangements since a contract can limit a psychiatrist to billing only a 90862 code and the company can also decide that they disagree that services were provided and either deny payment or demand repayment of a significant amount of money based on a review of the documentation.

The business adaptation to this on the hospital and managed care side (if they own the hospital) is to hire case managers to get patients out of the hospital within 3 or 4 days.  Some of these systems have confabulated their own "guidelines" that allow them to do this that are totally independent of any professional standards.  So if you are a managed care business and you own the hospital you are winning at two levels - you already shift the risk to the providers and hospitals by the Medicare style DRG payment and you do it a second time by insisting that they go along with the business decision to discharge the patient from the hospital.

Strictly speaking, the examples of discounted fees are technically not capitation.  Discounted fees still allow for some elasticity within the system because there is still a fee paid per service event.  Capitated systems of care like behavioral health carve outs can be set up to pay a set fee for managing a specific population.  For example, a system of care is under contract for providing all services to a specific group of employees for a rate that is negotiated irrespective of actual patient visits.

The best way to understand capitated care is that it is designed to provide insurance companies a significant financial incentive for rationing care.  That incentive comes directly out of the total amount of money available for health care spending   Psychiatry, mental health, and addiction services were the easiest targets due to insitutionalized stigma, lack of a vocal constituency, and the political ineptness of psychiatrists.  It is anybody's guess about how much a managed care company can make for denying or rationing care but some estimates of the margins have been as high as 20-40%.

One thing is for certain.  Capitated care is not a comprehensive national health system.  It takes hundreds of billions of dollars out of the health care system and diverts it to CEOs and stockholders.  Contrary to the political opinion it does not contain the cost of health care inflation.  One of the readers of the Shrink Rap blog pointed out that in a national system of health care you might be able to get an expensive medication like aripiprazole but you would have to wait longer.  In our current system of capitated care if your managed care company decides - you will not be able to get it at all.

That is probably the best example of the difference.

George Dawson, MD, DFAPA

"Doctors don't label"

In a rare statement of clarity amid the usual sensational spin this comment jumped out at me:

"Doctors don't label...Doctors diagnose, take care of, and treat.  That's not to say that something cannot be stigmatizing, but 'labeling' kind of gets right into the antipsychiatry component of it."  William T. Carpenter, MD  - Clinical Psychiatry News September 2012; p 3.

Dr. Carpenter is right and every psychiatrist knows it.  Psychiatrists don't label.  Psychiatrists diagnose.  Psychiatrists are very aware of the limitations of diagnosis given the the sociocultural and medical  contexts.  The psychiatric orientation is to be helpful to patients and the diagnosis is the focus of that treatment.  Furthermore, all psychiatric diagnosis and treatment is supposed to be confidential and there is no group of physicians who has tried to hold the line more against government and insurance companies eroding patient-physician confidentiality than psychiatrists. 

A significant part of this article about the content of a letter from the Society for Humanistic Psychology (Division 32 of the American Psychological Association).  Read the letter and draw your own conclusions.  The points of contention listed in the letter have been exposed in several other media contexts.  As I read through the letter there are several problems:

"This document was composed in recognition of, and with sensitivity to, the longstanding and congenial relationship between American psychologists and our psychiatrist colleagues."

I don't think that this is an accurate statement.  When I started out in psychiatry and was in my third year of residency the American Psychological Association decided to get more aggressive politically and their target was basically American psychiatry.   I won't rehash all of that ugliness but simply point out that things were far from congenial and in many areas remain problematic.   Much of those political efforts were based on the idea that organized psychiatry had an inordinate amount of control  over the treatment of mental illness.  Any observer - biased or unbiased should recognize that psychiatrists and physicians in general have been marginalized and the American Psychiatric Association is politically ineffective and weak.  Of course any other group of mental health providers is in the same boat. 

"Given lack of consensus as to the “primary” causes of mental distress, this proposed change may result in the labeling of sociopolitical deviance as mental disorder."

This is a comment on the new DSM5 definition of a mental illness, specifically that the new definition does not explicitly say that deviant behavior and conflicts with society are not mental disorders.  The current version states that these conflicts need to be the result of dysfunction within the individual.  It is hard for me to see a situation where this is relevant to the practice of psychiatry.  Is there really a case where I am going to diagnose a person in this situation with a mental disorder?  Definitely not and the reason is that I have been confronted with the situation many times before and pointed out that the conflict was not the product of a mental illness.  The authors here have focused primarily  on a lower threshold for diagnosis and how they are not confident about the clinical decision making skills of practitioners - but do not comment on the threshold part of the definition.  

"Increasing the number of people who qualify for a diagnosis may lead to excessive medicalization and stigmatization of transitive, even normative distress."

The risk of "medicalization" needs to be considered for a moment.  What is "medicalization"?  The implication of this letter at a practical level is that it involves an excessive use of medications.  Suspending the poor quality of many of those studies for a moment, what is the real driver of medication use in today's practice environment?  The minority of people taking any kind of psychiatric medication see psychiatrists.  The managed care industry and the government are clearly the driving force.  Current "evidence based" approaches are linked directly to medication use.  A checklist diagnosis and rating scale approach has been used to rapidly treat patients with antidepressants in primary care settings.  That approach alone has easily outpaced any DSM5 modifications.  Direct to consumer drug advertising compounds the issue of getting as many people on medications as possible.  You don't even have to read the DSM5 to see that medicalization has little to do with medical doctors.  In fact, managed care companies would clearly like to replace as many doctors as possible with "prescribers" who can fill prescriptions according to these protocols.  The pharmaceutical and managed care industries are far more interested in distilling psychiatric treatment down to a pill or a capsule than psychiatrists are.

The associated idea that psychiatrists may be the initiators of this medicalization or at least collude with it ignores psychiatric innovation that does not involve the prescription of medications.  On this blog alone, I have posted excellent examples of work done by Greist and Gunderson on innovative and highly successful non medication approaches to significant problems.  Dr. Greist's ideas have been presented to a wide audience that includes pharmaceutical companies.  His ideas about how to make effective psychotherapy widely available have been successfully applied in other countries.  Ignoring psychiatric innovation outside  of psychopharmacology is a curious phenomena, but it definitely makes it easier to see psychiatrists as the "medicalizers".  I am sure that both Greist and Gunderson would not see medications as the primary treatment for anxiety disorders or borderline personality disorder.

Once again, the focus on problems in the DSM5 leading to medicalization and stigmatization is clearly overemphasized.  There is no group of people more aware of the limitations of the current diagnostic system than psychiatrists.  There is no group of people better equipped to compensate for these deficiencies.  There is no group of people more aware of the stigma of mental illness and addiction.  Psychiatrists have a unique perspective in observing first hand how health care systems institutionalize stigma and use it to reduce the resources dedicated to treat these problems.  There should be no doubt that the DSM5 is being produced in what is considered the best interest of the American Psychiatric Association.  There should also be no doubt that the critiques of the process have their own interests and their opinions should be evaluated in that context.

George Dawson, MD, DFAPA