Historic WWII Era Film on PTSD

An historic film by John Huston on PTSD is available at: 

http://www.filmpreservation.org/preserved-films/screening-room/let-there-be-light-1946 

This is an actual film of veterans being treated. Very interesting film from an historic and psychiatric perspective. Also interesting from a propaganda perspective. One of my first teachers in psychiatry was a WWII psychiatrist who went through an expedited residency in order to treat combat neurosis.  The attached notes about the making of the films is also interesting in terms of the way it is structured, the total footage shot to get this final cut version and why this particular facility was used. 

As an example Huston comments on the treatment process at the hospital he chose for the film: " The hospital admitted two groups of 75 patients each week, and the goal was to restore these men physically, mentally and emotionally within six to eight weeks, to the point where they could be returned to civilian life in as good condition—or almost as good—as when they came into the Army…  "  Just doing the arithmetic, with what we know about the scale of WWII, that would suggest that most veterans with PTSD never got treated.

He also commented on the goal of the film: "[The purpose] was to show how men who suffered mental damage in the service should not be written off but could be helped by psychiatric treatment….".  That message seems to continuously escape the politicians responsible for war making and repairing the damage afterwards.

The original film was suppressed by the Army and the US Government who suggested that privacy considerations were the reason.  All the men in the film had signed releases for the filming, but at one point those releases disappeared.  During an attempted screening of the film, military police showed up and confiscated a copy.  The author of the Film Notes suggests a few reasons for the suppression of the film as well as discussing the innovative and artistic points.

From a psychiatric standpoint, the use of drug therapy by psychiatrists in film was cutting edge.  According to Gabbard and Gabbard the first film depictions of drug therapy occurred in 1947 (Possessed) and 1949 (The Home of the Brave).  In their book they mention Let There Be Light (1946) as the third depiction of narcosynthesis.  It  also reminded me of The Snake Pit (1948) in that the psychiatrists are portrayed as being generally effective.

From a cultural and political standpoint, the film and Huston’s intentions stand in contrast to the atmosphere today where psychiatrists are portrayed in the media as inept tools of pharmaceutical companies who thrive on prescribing ineffective treatments.  In the film notes section, Huston describes the transformation of some of the patients as “miraculous”.  At some level, there has to be skepticism on the treatment effort and outcomes.  For example, there is an overall lack of aggression and severe depression in the veterans filmed for this project.  In my experience in several different VA facilities those are common problems as a result of combat stress exposure.

As a kid walking 5 blocks to elementary school every day, I encountered veterans with clear problems that were explained to me at the time as being “due to the war.”  In some cases more specific etiologies were suggested like: “he got malaria in the war”.  That was in the late 1950s.

As a civilian, I had no idea what exposure to combat stress could do until I was a psychiatric resident working in a VA hospital.  By that time we had already been through the Vietnam War and any consideration of the impact that war had on veterans was secondary to the over-the-top politics associated with an unnecessary war.

Maybe things would have been a lot different if the Army had allowed a broad release of this film.

George Dawson, MD, DFAPA

Gabbard K, Gabbard GO.  Psychiatry and the Cinema. The University of Chicago Press, Chicago, (1987) p 70-71. 

Adult ADHD treated by Internists

I caught this eye-opening quote in the AMNews the other day: "ADHD is common enough that the average internist has 20-80 patients with this disorder".  The physician interviewed for the article suggest getting collateral data, making the diagnosis over several visits, getting an adequate family history, using a screening instrument and not prescribing stimulants on the first visit.  The final pearl in this column is:"Any patient who gets mad that you are not prescribing a stimulant after one visit should be a red flag."  With about 150,000 internists and another 130,000 family physicians that represents a lot of adults being treated for ADHD.

The physician suggested approach in this case is fairly comprehensive and includes corroborating symptoms in childhood and adolescence, obtaining collateral information, and using a standardized checklist. There is no mention of screening for addiction, discussing prior exposure to stimulants, or the use of performance based testing as opposed to diagnostic checklists. There is also the frequent scenario of a clinic that is set up to do expensive test batteries referring patients to physicians for the purpose of prescribing stimulants and advising the referred patient that they have in fact made the diagnosis of attention deficit hyperactivity disorder.

These are not insignificant problems given the flood of stimulants available on college campuses these days and at least one cultural viewpoint using stimulants as "cognitive enhancers" rather than medications to treat a specific diagnosis. There is also no accounting for clinician to clinician variability in terms of who is prescribed stimulant medication. The largest dividing point is persons with a history of addiction and the associated politics of believing that a stimulant should not be denied anyone with the appropriate diagnosis as opposed to a person with an addiction being placed at risk by stimulant prescription.

The best approach is a network of interested clinicians who have access to uniform diagnostic and treatment methods and who are dedicated to consistent treatment practices that include not treating at least some people with stimulants and using non-stimulant approaches to the treatment of attention deficit hyperactivity disorder.

George Dawson, MD, DFAPA

Christine S. Moyer.  Orchestrating Drug Management.  American Medical News.  May 21, 2012. 55(10): 12-13.

Sahakian B, Morein-Zamir S. Professor's little helper. Nature. 2007 Dec 20;450(7173):1157-9.

DSM5 - NEJM Commentaries

I highly recommend the two commentaries in the New England Journal of Medicine this week.  The first was written by McHugh and Slavney and the second by  Friedman.  Like Allen Frances they are experienced psychiatrists and researchers and they are likely to have unique insights.  I may have missed it, but I am not aware of any of these authors using the popular press to make typical political remarks about the DSM.  Those remarks can be seen on an almost weekly basis in any major American newspaper.

McHugh and Slavney focus interestingly enough is the issue of comprehensive diagnosis and opposed to checklist diagnoses.  It reminded me immediately that the public really does not have the historical context of the DSM or how it is used.  It also reminded me of the corrosive effect that managed care and the government has had on psychiatric practice with the use of "templates" to meet coding and billing criteria in the shortest amount of time.   Finally it reminded me of the bizarre situation where we have managed care companies and governments combining to validate the concept of a checklist as a psychiatric diagnosis and court testimony by experts suggesting that it is negligent to not use a checklist in the diagnostic process.

McHugh and Slavney summed up in the following three sentences: “Checklist diagnoses cost less in time and money but fail woefully to correspond with diagnoses derived from comprehensive assessments. They deprive psychiatrists of the sense that they know their patients thoroughly. Moreover, a diagnostic category based on checklists can be promoted by industries or persons seeking to profit from marketing its recognition; indeed, pharmaceutical companies have notoriously promoted several DSM diagnoses in the categories of anxiety and depression.” (p. 1854)

In my home state, the PHQ-9 is mandated by the state of Minnesota to screen all primary care patients being treated for depression and follow their progress despite the fact that this was not the intended purpose of this scale and it is not validated as an outcome measure.  The PHQ-9  is copyrighted by Pfizer pharmaceuticals.

The authors go on to talk about the severe limitations of this approach but at some point they seem to have eliminated the psychiatrist from the equation. I would have concerns if psychiatrists were only taught checklist diagnoses and thought that was the best approach, but I really have never seen that. Politicians, managed care companies, and bureaucrats from both are all enamored with checklists but not psychiatrists. They also talk about the issue of causality and how that could add some additional perspective. They give examples of diagnoses clustered by biological, personality, life encounter, and psychological perspectives. Despite its purported atheoretical basis, the DSM comments on many if not all of these etiologies.

Friedman's essay is focused only on the issue of grief and whether or not DSM5 would allow clinicians to characterize bereavement as a depressive disorder. That is currently prevented by a bereavement exclusion and DSM-IV and apparently there was some discussion of removing it. He discusses the consideration that some bereavement is complicated such as in the situation of a bereaved person with a prior episode of major depression and whether the rates of undertreatment in primary care may place those people at risk of no treatment.

There can be no doubt that reducing a psychiatric diagnosis to a checklist loses a lot of information and probably does not produce the same diagnoses. There is also no doubt that the great majority of grieving persons will recover on their own without any mental health intervention. Both essays seem to minimize the role of psychiatrists who should after all be trained experts in comprehensive diagnoses (the kind without checklists). They should be able to come up with a diagnostic and treatment formulation that is independent of the DSM checklists. They should also be trained in the phenomenology of grief and the psychiatric studies of grief and realize that it is not a psychiatric disorder.  If they were fortunate enough to be trained in Interpersonal Psychotherapy they know the therapeutic goals and treatment strategies of grief counseling and they probably know good resources for the patient.

The critiques by all three authors are legitimate but they are also strong statements for continued comprehensive training of psychiatrists. There really should be no psychiatrist out there using a DSM as a "field guide" for prescribing therapy of any sort based on a checklist diagnosis. Primary care physicians in some states and health plans have been mandated to produce checklist diagnoses.  The public should not accept the idea that a checklist diagnosis is the same as a comprehensive diagnostic interview by psychiatrist.

That is the real issue - not whether or not there is a new DSM.

George Dawson, MD DFAPA

McHugh PR, Slavney PR. Mental illness--comprehensive evaluation or checklist?

N Engl J Med. 2012 May 17;366(20):1853-5.

http://www.nejm.org/doi/full/10.1056/NEJMp1202555?query=TOC 

Friedman RA. Grief, depression, and the DSM-5. N Engl J Med. 2012 May

17;366(20):1855-7.

http://www.nejm.org/doi/full/10.1056/NEJMp1201794?query=TOC

Why Allen Frances has it wrong

Allen Frances has been a public critic of the DSM process and as an expert he frequently gets his opinions out in the media.  Today he has an op-ed piece on the New York Times that is a more general version of a more detailed post on the Health Care blog.  His main contention is the stakeholder argument and that is that there are too many stakeholders both public and professional to allow the American Psychiatric Association to maintain its "monopoly" on psychiatric diagnosis.  I will attempt to deconstruct his argument.

He discusses the earlier DSM versions as revolutionizing the field and the associated neuroscience but then suggests that diagnostic proliferation has become a central problem and the only solution is political arbitration.  What about the issue of diagnostic proliferation?  The number of diagnostic entities per DSM are listed below:

DSM-I, 268 entities

DSM-II, 339 entities 

DSM-III, 322 entities

DSM IIIR, 312 entities

DSM-IV, 374 entities

DSM-V,  370 - 400 entities (depending on final form)

In terms of the total diagnostic entities, I have not seen any stories in the media pointing out that the total number of diagnoses may end being less than DSM-IV.  I have also not seen any discussion of major diagnoses where that is clearly true, such as the elimination of schizophrenia subtypes.   Other issues on diagnostic proliferation that are not discussed are the other required diagnostic system in medicine - the International Classification of Diseases 9th Revision or ICD-9.   The recent modification the ICD-10 has undergone a revision and the total number of diagnoses has increased from 14,000 to 68,000 diagnosis codes.  A fourfold increase.  The number of potential codes for a fractured kneecap has gone from 2 to 480 or more than the total potential codes in DSM5. 

I have also not seen any discussion of the role of psychiatrists in making a psychiatric diagnosis.  Psychiatric diagnosis does not depend on looking up a diagnosis in a catalog of symptoms.  It involves being trained in psychopathology and knowing the patterns of these illnesses.  The patterns of psychotic disorders and the other main diagnostic groupings have basically been unchanged across DSMs.  Psychiatrists make clinical diagnoses based on these major groupings and not the total number of diagnostic entities.

Further evidence that the total number of diagnostic categories is unlikely to have any impact on the number of people diagnosed with mental illness in any given year comes from the distribution of diagnostic codes in an outpatient setting. For 2006-2007, there were approximately 58 million ambulatory care visits for mental disorders. 92% of those visits were for 10 major diagnostic categories that have not changed in recent DSM revisions. It is not likely that new diagnostic categories will significantly impact the remaining 8% or 4.8 million visits per year.

In a study more specific to psychiatry, the number of psychiatric ICD-10 codes used in Danish Psychiatric Central Registry.  The data  represented 1,260,097 diagnoses from 1,041,589 discharges of 653,754 patients from in- and outpatient treatment episodes.  Forty nine of the diagnostic codes accounted for 75% of all the diagnoses (Munk-Jørgensen, et al). 

The "medicalization of normality" is another argument.  The media routinely runs stories about the percentage of the population that is "mentally ill" based on DSM diagnoses.  One of the common stories is the estimate that as many as 50% of the population has a DSM diagnosis over the course of the year.  There is never a critical look at that statistic.  The first dimension is whether any percentage should be too high or too low.  For example, would anyone be surprised to learn that 100% of the population has a medical diagnosis in the previous year?  With a high prevalence of gastroenteritis and respiratory infections - probably not.  The second dimension speaks directly to the issue of threshold for an illness.  One of the key papers in this area shows that although the one year prevalence using DSM criteria may be high, limiting the diagnoses to severe disorders reduces the prevalence to 8%.

The use of high prevalence numbers for mental illness based on DSM diagnoses also ignores the extensive Epidemiological Catchment Area (ECA) work that estimated lifetime prevalence.  Readers are generally not told that the methods used include addictive disorders and neurological disorders that cause cognitive impairment.  Would anyone doubt that 32% of adults would report a psychiatric disorder that included an addiction or cognitive impairment at any point in their lifetime?

Similarly there has been the repeated criticism that psychiatrists were going to start treating grief like clinical depression.  I have never seen that approach anywhere in my career spanning psychopathology seminars, journal articles, and continuing education courses.  Any psychiatrist with a clue knows the difference between grief and depression and at some point they have probably been tested on that difference.  What psychiatrists know that is not public knowledge is that a small number of grieving people actually develop a depression that is indistinguishable from clinical depression and it may have to be treated that way.  Knowing the difference is part of psychiatric expertise and you really cannot write it down as sentences in a manual.  In fact, it is a grave  mistake to equate a manual of diagnostic criteria with the clinical expertise and methods of psychiatry.

Dr. Frances correctly points out that the other common media theory that DSM diagnoses are driven by the pharmaceutical industry is a myth.  He continues on to suggest that the public and other mental health professionals somehow have a stake in the DSM and that organized psychiatry has frozen them out.  He concludes: “Psychiatric diagnosis is too important to be left exclusively in the hands of psychiatrists.”  I don’t understand how the specialty who invented the technology, who is trained and tested on it, and who is focused on a comprehensive view of psychopathology that extends beyond it should somehow give way to political considerations.  As he points out – there are always political considerations – even in science.  I would suggest that there is no such thing as “independent scientific review” of anything that psychiatry does.  There are many ways to address issues of professional bias in terms of including a diagnosis or not.

The arguments against the DSM and psychiatric influence vary across the usual spectrum of there being no such thing as a psychiatric diagnosis to there are too many diagnoses to the fact that psychiatric diagnoses are nonspecific.  There is no practical way to incorporate that spectrum into a diagnostic manual that is designed for psychiatrists to make clinical diagnoses and do research.  The single most important fact that is left out of these debates is that psychiatrists are effective in treating serious mental illness and they are undoubtedly more effective now than they have been in the past.  That is the only reason we need a DSM and that is why it stays squarely in psychiatry.

George Dawson, MD, DFAPA  


Frances A.  Diagnosing the DSM.  New York Times May 11, 2012.

Frances A.  DSM5 begins its belated and necessary retreat.  Health Care Blog May 10, 2012.

Kessler RC, Avenevoli S, Costello J, Green JG, Gruber MJ, McLaughlin KA,

Petukhova M, Sampson NA, Zaslavsky AM, Merikangas KR. Severity of 12-month DSM-IV disorders in the national comorbidity survey replication adolescent supplement

Arch Gen Psychiatry. 2012 Apr;69(4):381-9.

Munk-Jørgensen P, Najarraq Lund M, Bertelsen A. Use of ICD-10 diagnoses in Danish psychiatric hospital-based services in 2001-2007. World Psychiatry. 2010 Oct;9(3):183-4.

Regier D, Kaelber CT.  The Epidemiological Catchment Area Program:  Studying the Prevalence and Incidence of Psychopathology. in  Textbook in Psychiatric Epidemiology eds.  Ming T Tsuang, Mauricio Tohen, and Gwnedolyn EP Zahner.  John Wiley and Sons, 1995. p141.

Schappert SM, Rechtsteiner EA. Ambulatory medical care utilization estimates for 2007. National Center for Health Statistics. Vital Health Stat 13(169). 2011. (see Table 7.)

Radicals and Reformers for Managed Care

I was struck by a post on the Critical Psychiatry blog this AM.  Duncan Double discusses his experience at a meeting of the radical caucus at the APA on Sunday.  His main argument was the need to abolish psychiatric diagnostic systems - specifically the DSM, but he mentions that you can apparently provide psychiatric services without an ICD diagnosis in the UK.  But then he makes this astonishing comment: " The American psychiatric system has become very dependent on DSM for billing purposes, but I'm sure the insurance companies could develop an alternative system unrelated to DSM. "


I am positive that the American insurance industry would like nothing better than to establish their own "alternative system unrelated to the DSM'.  In fact, they are doing it already with a host of measures that they can use to basically deny care or dismantle systems of care.  The managed care industry in the US has selectively discriminated against psychiatric services for the past 20 years to the point that most states have little service availability.  The motivation for managed care is clear - shift hundreds of billions of dollars away from providing care to persons with mental health and chemical dependency problems and into the pockets of the insurance industry.  We are talking about an industry where the CEOs can make an annual salary of millions of dollars and in a famous case the CEO received a $1 billion dollar bonus.


Stated in another way, the "American psychiatric system" is no system at all.  There is hardly any availability of psychotherapy services.  Most people are restricted to a handful or less of 15 minute visits with a psychiatrist every year.  The length of stay in hospitals is appallingly short by UK or European standards and people are asked to leave if they are no longer "suicidal".  It is psychiatrists on the one hand being severely restricted in attempting to provide care and a predatory insurance industry trying to make disproportionately more money off policy holders with mental health problems on the other.   The government is not a passive player in this effort with most state governments abdicating their role in caring for the indigent and the uninsured often by using managed care tactics.  All of this happens independent of any DSM or ICD diagnosis.  At the national level, there is a long list of interests who favor the same tactics in order to maintain leverage over doctors and the clinical care advocated by doctors.


Critical psychiatry would rather "Occupy American Psychiatric Association" rather than "Occupy Wall Street" .    I guess we can add them to the managed care  list.  That is exactly the type of reform that the politicians want.

Vision Quest "6 minutes" - Why We Watch Sports

Another clip that goes a long way toward explaining why we watch sports, go to concerts, read good books:

https://www.youtube.com/watch?v=TZeaZ3rZumg

In this clip Louden Swain, a high school wrestler preparing for the match of his career goes to see why Elmo the cook who he works with took the evening off of work to go to his wrestling match.  Elmo's soliloquy here about sports still strikes me as the best single reason why I watch sports.

I have never seen it studied, but it seems that there are several reason for why sports play a central role in society.  The social elements are apparent and many people see themselves as a larger community tied to a particular team.  I used to be  New York Yankee fan, despite the fact that I did not set foot in New York City (or the state of New York) until I was about 26 years old.  My father was a Yankee fan and so was I, so identification is important.  Somewhere in my late 20's I realized that a certain team winning was no longer important.  I started watching "This Week in Baseball" just to watch all of the best plays.  I tuned in to see Nolan Ryan pitch.  I watched the Tour de France and the Olympics to see the best athletes in the world compete.  I can still remember my excitement as I watched Johann Olav Koss in the 1,500, 5,000, and 10,000 meter events at Lillehammer. It was the first time that they had a motorized camera following the speedskaters. We learned that he had some last minute technical problems with the blade angle on his skates but Koss's form was perfect.  I was ecstatic.  I had become Elmo.

I have never seen a study that looked at the percentages of people who watch sports for the purposes of seeing a certain team win versus those who are looking for the best possible human performances.  But for the later - there is no better explanation than Elmo's soliloquy in this clip.

George Dawson, MD. DFAPA

A Consciousness Based Model

One of the criticisms of psychiatric treatment in particular drug therapies is that essentially nothing is known about psychopathology, neurobiology, or human genetics and therefore claiming that drug therapy is treating a pathological state is erroneous (1). "Chemical imbalance" can be used as a red herring along the way and I will try to address that in a later post.  In that post, I also hope to address the issue of disease states and whether or not they need to be strictly measurable.

For now, I want to discuss a model that I have used in clinical practice for the past decade that addresses both the issues of recovery and whether or not the drug altered state or treating an underlying pathological state is really the issue.  Let me start by saying I think it is irrelevant for the purposes of treatment.  I am first and foremost a clinical psychiatrist and not a researcher and my priority is at all times patient care.   My goal is to treat alterations in a person’s conscious state and restore their level of functioning with medications and/or psychotherapy that have been shown to work.   My goal is also not to introduce any new problems such as sedation, mood changes, rage, perceptual problems, ataxia, false memories, vertigo, or any number of subjective changes commonly seen as "side effects".

I found that the best way to proceed is to have an explicit discussion of the person’s conscious state and whether it has undergone any transformation associated with the reasons why they are seeing me.  I focus on the typical stream of consciousness that occurs each and every day and how it may have changed over the previous weeks or months or years.   I ask about whether or not getting back to that conscious state is a reasonable goal.  I point out that the phenomenology associated with a person's cognitive and emotional changes (2) can be followed in at least two dimensions at once - the psychopathological and the normal.

There are obviously problems with my approach. The subjective assessment of a psychopathological state and the subjective assessment of the baseline conscious state are difficult to do and they take time.  There are a large number of markers of psychopathological states but not so many for normal conscious states.  I often end up discussing broad outlines that include the typical stream of consciousness, fantasies, daydreams, defense mechanisms, distracting thoughts and typical thought patterns in certain situations such as driving into work each day.   I also ask about a global assessment and whether at any point during treatment the person feels like their original conscious state has been restored.   It adds another goal to treatment that is focused on restoring the self rather than just treating symptoms.

George Dawson, MD, DFAPA

1: Moncrieff J, Cohen D.  How do psychiatric drugs work?  BMJ. 2009 May 29;338:b1963.

2: Andreasen NC. DSM and the death of phenomenology in america: an example of unintended consequences. Schizophr Bull. 2007 Jan;33(1):108-12. Epub 2006 Dec 7.

Does the FDA discriminate against antidepressants?

The FDA came out with a new warning on citalopram on 3/28/2012.  The main point of the warning is that citalopram may lead to electrocardiogram changes that can be associated with an abnormal heart rhythm or arrhythmia that is potentially fatal.  The specific change is prolongation of the QTc interval or the interval that correlates with the total duration of ventricular activation and recovery.

Citalopram is a widely used antidepressant medication and it widely used for three reasons.  It is not likely to have a lot of interactions with other drugs.  Citalopram figured prominently in the STAR*D algorithm from the largest study done on enhancing antidepressant effectiveness.  A third reason is that it is a generic medication and it is very inexpensive.  Psychiatrists have broad experience with the drug and the general experience is that it is well tolerated with little toxicity.

Flecainide is a Type IC antiarrhythmic agent indicated for the prevention of paroxysmal atrial fibrillation (AF), paroxysmal supraventricular tachycardia (PSVT), and the prevention of life-threatening ventricular  arrhythmias like sustained ventricular tachycardia. The FDA warnings on the drug include proarrhytmic effects and excess mortality.  The excess mortality was directly observed in a clinical trial done to suppress ventricular arrhythmias.

The black box warnings for each drug listed below are directly from Medline:

Looking at the safety concerns for both medications - important differences emerge.  First, the FDA recommends maximum doses for the citalopram not just for the a maximum dose for adults but in specific conditions including aging.  Searching the FDA web site shows exactly 25 references for safety concerns of flecainide and none of them contain that level of information.  Second, the citalopram warning shows a table of QTc interval changes by dose for both citalopram and escitalopram.  There is no information in FDA documents (that I could find) for flecainide even though it is widely accepted that flecainide causes dose related changes in not just the QTc interval but also the QRS and PR intervals  along with a host of additional effects on cardiac pacemakers and conduction.  The  overall tone of the release is  that citalopram is a potentially cardiotoxic drug.  Third, the ECG monitoring recommendations are not internally consistent.  The absolute cut off of a QTc interval of 500 ms is highly unlikely - even in cases where the patient is taking 60 mg per day or more of citalopram.  It is also unlikely that the QTc intervals in the citalopram warning will lead to a QTc interval of greater than 500 ms.  This will result in tens of thousands of ECGs done because that is the only way that the QTc interval can be determined.

The black box warnings and the recently issued warning all considered, serious questions are raised relative to drugs with known cardiotoxicity and the whole issue of QTc warnings in all psychiatric drugs.  Certainly nobody wants a rare severe complication as a result of a prescription medication but can it really be avoided?  What good would ECG screening do?  There have not been any trials to address that issue of whether all patients taking citalopram need baseline ECGs.  All the patients taking flecainide have probably had multiple ECGs done that indicate a possible need for treatment but there is little guidance on the ECG issue.  In many patients taking flecainide, patients get serial ECGs and they do exercise stress tests to rule out proarrhythmic effects.  Are the same precautions needed for patients on citalopram?

Are the thresholds for treatment different given the fact that flecainide caused increased mortality during clinical trials and citalopram did not?  There would be an argument that flecainide is used to treat life-threatening arrhythmias, but the other indication is for prevention of atrial fibrillation and atrial fibrillation is not a life threatening arrhythmia.  With regard to the seriousness of the diagnosis, major depression carries a lifetime mortality of 10%.  Finally, where is the table on the relationship between flecainide dose and QTc prolongation like we see for both citalopram and escitalopram?  Is it possible that flecainide has more of an effect throughout the dosage range than citalopram?

These are serious questions given that I have already established that there is a significant bias in the media against psychiatry, psychiatrists and psychiatric medications.  The most recent FDA warning has created a lot of anxiety for psychiatrists and any patient taking citalopram.  The majority of those patients are being seen by primary care physicians.

  

If citalopram is that cardiotoxic, let's see the evidence and let's see how it compares to a medication with known cardiotoxicity.  Let's have the same level of warning for both medications and some concrete ideas about what needs to be done to manage that risk.

George Dawson, MD, DFAPA

The $40 Call

One of  the local HMOs has been heavily advertising their nurse practitioner diagnostic line. It caught my attention because the radio ad was focused on wood tick season, and it suggested the diagnosis and treatment of Lyme disease could be rapidly made over the phone and that it could require e-mailing in a picture of the rash or tick.

I used to teach a course in medical diagnostics and diagnostic reasoning and one of the examples I used in that course involved expert diagnosis of rashes from photographs.  An important part of medical diagnostics is pattern recognition. There is probably no better example than the diagnosis of rashes and it should not come as a surprise that experts in rashes or dermatologists do a much better than physicians who are not experts. That is true both in terms of making the actual diagnosis and in the total amount of time that it takes to arrive at that diagnosis.

When I heard about this new service to diagnose Lyme disease based on photographs I went to Medline to see if I could find anything written about it. Managed care organizations and HMOs frequently advertise the fact that they are evidence-based organizations. I really cannot find any studies done on using the Internet or telephone consultation for the diagnosis of rashes or Lyme disease.

I think that this new service has implications for how the business models are impacting the practice of medicine. With all the talk about transparency it would be useful for the public to know the false positive and false negative rates for this diagnostic service. That certainly would be consistent with the literature on the misdiagnosis of Lyme disease.

From a purely economic perspective, it is interesting that the cash charge for this service is on par with the most common cash charge for seeing a psychiatrist in person. As I have previously posted, there is a wide range for the psychiatric charge and it is conceivable that this telephone service generates considerably more cash than a psychiatrist does sitting in a clinic, seeing patients, and doing all of the associated administrative work.

The next logical step for this telephone service is to have patient's complete a number of rating scales and be treated for depression. Whether it is Lyme disease or depression the diagnosticians with the greatest pattern matching and pattern completion capabilities are taken out of the loop.

George Dawson, MD, DFAPA

Health Care Complexity, Politicians, and Judges

There is so much wrong with the Affordable Care Act it is difficult to know where to start. According to a recent article in JAMA, I learned that Accountable Care Organizations (ACOs) are charged with improving the quality of care for Medicare patients at less cost. Any psychiatrist in the country who has witnessed the decimation of mental health care justified by that same rhetoric should be skeptical. 

So far the government has been again engaged in a highly coordinated effort to get the ACO initiative up and running. On October 20, 2011 the final rules for ACOs were released and on that same day the Federal Trade Commission and Department of Justice provided guidelines to address the antitrust issues of ACOs.  The JAMA article discusses five major issues related to the creation of ACO's many of which are unrealistic. As an example the antitrust guidelines suggest that ACOs that have a less than 30% market share are "highly unlikely to raise antitrust concerns".  In that landscape, the government expects that ACO's will develop and use quality measures, avoid exclusive relationships with hospitals and specialists, avoid cost shifting via the leverage of large physician groups to private payers, and be monitored to avoid gaming the risk-adjustment scheme. All of these dimensions are highly problematic.

The most problematic aspect of the Affordable Care Act is the same problem that every major piece of legislation in the United States has and that is that nobody reads it. I have seen quotes on how large the actual bill is ranging from 1000 pages to 2700 pages.  I first became aware of the fact that hardly anyone in Congress reads large bills in 2003. At that time I was following the progress of HR 1 (The Medicare Prescription Drug Bill).  I was watching C-SPAN and Sen. Harkin commented that the 1000 page bill was delivered to members of Congress on Thursday morning so that they could debate it on the weekend and vote on Monday morning. He was the first of many senators to acknowledge the fact that nobody would ever read the bill.

At the time I thought that disclosure was astounding. Here we have members of Congress whose full-time job is to design legislation and they are not actually reading and debating a bill that regulates a huge part of the economy and most people's healthcare. I won't even go into the fact that the pharmaceutical lobby was so satisfied with the final result that most of them left town on Friday.

The Affordable Care Act provides us with a new insight into how our government operates. In this case the constitutionality of the bill is also being debated and that was presented to the Supreme Court about two weeks ago. In the Wall Street Journal article it is official that Supreme Court justices are no more likely to read the bill than members of Congress. Justice Scalia is quoted: "You really want us to go through these 2,700 pages? And do you really expect the court to do that? Or do you expect us to give this function to our law clerks?"  We have a check and balance system set up where the check and balance is as defective as the original process.

The overall process here illustrates why it was doomed from the start. The Affordable Care Act is a highly experimental piece of legislation at best. In order for it to function as advertised many unlikely events will need to occur. That would seem obvious to any intelligent person reading the bill but as we have determined there are no members of Congress and no justices in the Supreme Court that will actually do that.

George Dawson, MD, DFAPA

Wall Street Journal. "Complexity is Bad for Your Health" April 8, 2012.

Dawson G.  Medicare Drug Bill #1,  #2,  #3  Three real time posts on my observations on the Medicare Prescription Drug Bill in 2003.

Schleffer RM, Shortell SM, Wilensky GR.  Accountable Care Organizations and Antitrust: Restructuring the Health Care Market.  JAMA. 2012;307(14):1493-1494.

The Lancet has it about 40% right

The Critical Psychiatry blog listed a brief editorial in the Lancet commenting on the current state of affairs in psychiatry. The commentary describes psychiatry's current "identity crisis" as an international problem and cites recent comments by the American Psychiatric Association and the Royal College of Psychiatrists suggesting that psychiatry is not "scientific" enough, that it does not have a central role in medicine, that the image of psychiatry with other professionals is negative, and that the therapeutic interventions are weak. The conclusory statement is: “But more fundamental still, it is time for the specialty to stop devaluing itself because of its chequered history of mental asylums and pseudo-science, and to realign itself as a key biomedical specialty at the heart of mental health.”

The Lancet has it right in concluding that psychiatry has a long history of self-flagellation that continues right up until present times. The Lancet is also correct in concluding that the image of psychiatry is negative, and that was well-documented in the journal Psychiatric Treatment showing that press coverage for psychiatry is four times as negative as any other specialty. The remarks about the science of psychiatry, the lack of a central role in medicine, and weak therapeutic interventions miss the mark entirely. In fact, I think the only way an editor can lump all of those negatives together is the uncritical acceptance that all of the negatives about psychiatry must be true.

What the critics of psychiatry can never explain away is the fact that psychiatric treatment is effective. I have personally gone to work every day for over 20 years confident that I have been doing far more good than harm. When you are doing the same work for a span of decades rather than the time it takes someone to do a clinical trial and you are personally responsible to your patient and their family you need to realize that you are effective. If I did not think I was effective and doing a reasonable job for people I would have quit a long time ago.  I also work with hundreds of competent psychiatrists in my home state where being competent is the rule not the exception.

My personal sense of effectiveness is built on decades of watching people suffer. That happened before I was a psychiatrist. Many of those people were my own family members and neighbors with severe problems who did not have access to psychiatrists. They were treated by generalists and the treatment did not go well. In many cases it was worse than no treatment at all. When I was growing up, it was also a fairly common practice for counties to sequester people with mental illness at subpar facilities that were designed for containment.  In some cases that meant that people were placed in facilities that were also tuberculosis sanatoriums or “poor farms” for the indigent.  I think that many of us in the mental health field got into it to compensate for the deficiencies of the past.  Much of that “chequered” past has nothing to do with psychiatry at all.

Although the Lancet associates psychiatry with asylums it leaves out the fact that psychiatry invented the paradigm to care for people with severe mental illnesses in the community. That was the direct product of psychiatrists and their collaborators realizing that state-funded institutional care was completely inadequate. Psychiatry moved people out of asylums on a massive scale and helps them stay out.  At this time many of these programs have been in place for over 30 years.  These same programs are actively working on the health problems of the people that they serve.

The scientific basis of psychiatry has exploded in the past two decades.  The criticism of the “lack” of science in the field always astounds me.  The criticism often seems to flow from the lack of understanding of the process of science and how the scientific accomplishments within psychiatry are on par with other fields of science.  It also seems to ignore the fact that many prominent scientists like Kandel, Snyder and others are psychiatrists.

The idea that psychiatrists are ineffective seems to flow from the same biases.  Details about the effectiveness of primary care physicians are usually left out of that argument.  It is well known that 30-50% of complaints presenting to general medical and specialty outpatient clinics have no medical explanation even after extensive investigation. Other studies have shown that primary care physicians deliver error free care in uncomplicated situations 73% of the time and in complex situations 9% of the time.  It is really not possible for psychiatry to be worse than that and yet there are no movements critical of other specialities and those are specialities that generally have far more toxic treatments.

So we are left with an abundance of critics. The critics all have various motivations but one thing is clear and that is at least part of their agenda is not to recognize the fact that psychiatrists are currently effective,  care about their patients, and that their clinical practice really is not removed from the rest of medicine.  In order to recruit more psychiatrists, the best thing to do is expose students to psychiatrists working with patients and to follow those patients while they recover. It might be useful to expose them to the biases against psychiatry and why a lot of the criticism does not match reality.  The fundamental work for many psychiatrists is to stop devaluing themselves, but it also requires recognition that much of that devaluation occurs due to the uncritical internalization of criticism that is far from the reality of clinical practice.

George Dawson, MD, DFAPA

Let's get rid of worthless documentation

I just became aware of this article by Lucy Hornstein, MD on modifying the current documentation process and found it to be quite exciting because I have had very similar thoughts for some time:

I may be a fellow dinosaur, but I could not agree more.  The vast majority of documentation especially in the EMR is worthless largely because of the proliferation of stereotypical documentation to fit business and government requirements.  The businesses wanted to slow us down at least until they figured out that they could literally reimburse us for whatever they wanted irrespective of the billing code or note.  The politicians want all the bullet points because of the erroneous notion that coders can actually read a note and objectively  decide on the correct code (they can't) and therefore they can fight fraud. 

In the meantime, vast areas of hard drive space are occupied with worthless data because of these notes and the trees die anyway because requesting the information results in an EMR driven telephone book sized tome  with very little information (if any) on each page.

The only thing worse is the EMR driven initiative to rapidly assemble a massive note from existing data using smart text and a few key strokes.  I was on a committee once where we reviewed 10-16 page daily progress notes compiled in various fonts.  The majority of each note was already listed in the record.

I can recall working on a very busy neurosurgical service where we saw 30 patients a day (6-10 in the NICU) and did all the documentation in 2 - 3 hours before going to the OR.  All of the progress notes for the entire hospitalization generally fit on one page.

I have been thinking about Dr. Hornstein's approach for some time and have come to the same conclusion.  The current notes and coding system is basically driven by paranoia and not patient care.  Any EMR system worth its salt should be able to display all of the daily relevant data and provide a check box so there is documentation that the attending reviewed it all and signed off instead of the physician doubling as scribe and displaying it all (after a flurry of mouse clicks) in a massive note.  The actual note needs to reflect the fact that an intelligent life form visited the patient and there is a thoughtful analysis and plan. 


That doesn't happen by filling up templates in an electronic medical record.

George Dawson, MD, DFAPA

Another Managed Care Approach Bites the Dust

Managed care companies have always been big on patient satisfaction.  There are a number of reasons for this the largest one being that they hope to replace medical approaches to healthcare with business approaches. That involves applying paradigms used in automobile manufacturing and customer service such as patient satisfaction surveys. It also involves applying business strategies to those surveys so that any particular business will look as good as possible when it is advertised. It is no accident for example that all the hospitals in your area are "five-star hospitals" or "highly rated" if the companies involved know how to game the system, the deck is stacked in favor of high patient satisfaction ratings. That can be done by combination of survey structure, survey timing, or scripting. During scripting the patient is exposed to a number of statements by a healthcare provider who has been trained in how to do this so that their statements closely match questions on the patient satisfaction survey. It is very difficult for a person to say they were never provided with information if they received carefully scripted information five minutes before they took the survey.

Another advantage of patient satisfaction surveys is that they can be used as leverage against physicians. Managed care companies are always on the lookout for new ways they can reduce reimbursement to physicians. They already have an incredible amount of leverage with the so-called RVU-based compensation system but apparently that is not enough.  In many cases a percentage of the physicians reimbursement is linked to patient satisfaction surveys. The more satisfaction, the greater the reimbursement. The irony is that in many cases, the money used for that incentive is a "hold back" or percentage of what the physician has actually earned. They will not get their full reimbursement unless they have adequate patient satisfaction ratings. The problem with that system should be obvious, but it was made even more obvious by a recent article in the Archives of Internal Medicine.

In that study, the authors looked at a large sample of 51,947 patients over a timeframe of seven years. They focused on how their satisfaction ratings correlated with outcome measures. They found that the patients in the high satisfaction group had a 8.1% greater healthcare expenditure, 9.1% greater medication expenditure, and a 26% greater mortality risk.  The most satisfied group was at less risk for an emergency department visit but had higher inpatient expenditures.  The authors point out that patient satisfaction ratings correlate most highly with whether or not the physician fulfills the expectations of the patient.  That could lead to a lower threshold for elective admissions to hospitals, more invasive testing, and less discriminatory prescribing practices.

Their overall conclusion is that we do not know enough about patient satisfaction ratings and the implications for quality care. They make an excellent point about the need for physicians to discuss problem areas with patients “including substance abuse, psychiatric comorbidity, nonadherence, and the risks of requested but discretionary tests or treatments.”  Those discussions may not be conducive to high patient satisfaction ratings.  They also point out that these discussions necessarily take time. As I have previously pointed out, the time for discussions and clinics has practically been rationed out of existence.

I thought that this was an excellent article overall that points out significant problems with business approaches to the practice of medicine. Rating a doctor like you would rate your car salesman creates a unique set of problems that businesses and the government have no interest in addressing.  Ratings within healthcare organizations linked to physician "incentives" may be no more reliable than doctor ratings on Internet sites.

George Dawson, MD

Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures,and mortality. Arch Intern Med. 2012 Mar 12;172(5):405-11.

Mad Men scene

The scene between characters Don Draper and Peggy Olson in AMC TVs award winning show Mad Men (as in Madison Avenue) has an excellent bit of advice that I have tried to impart at times.  In this scene, Peggy is in what appears to be a psychiatric hospital and she is bedridden. She has just gone through a major life crisis and tried to conceal her whereabouts from her boss Don Draper. Prior to this crisis she had impressed Draper to the point that he promoted her and he brings that up during this conversation.

Draper on the other hand, had a similar life crisis when he was in his early 20s that involved changing his identity to the identity of a soldier he was serving with during the Korean War. He has a significant amount of psychological trauma from his childhood. His advice in this scene captures the way he has dealt with his own problems but also captures a larger thread of developmental psychology and speaks to the fact that as we deal with more crises through our lives it affects us less and and we can recover from it more quickly. That basic concept of resilience is not talked about enough in assisting people with crises in their lives.

Psychiatrists work for patients - not for pharmaceutical companies

That should be obvious by anybody reading this post but it clearly is not. I have already established that there is a disproportionate amount of criticism of psychiatry in the popular media compared with any other medical specialty. The most common assumption of most of those critics is that psychiatrists are easily influenced by pharmaceutical companies or thought leaders who are working for pharmaceutical companies. There are many reasons why that assumption is incorrect but today I want to deal with a more implicit assumption that is that there is a drug that is indicated and effective for every medical condition.

In the field of psychiatry this marketing strategy for pharmaceuticals became prominent with the biological psychiatry movement in the 1980s. Biological psychiatrists studied neuropsychopharmacology and it followed that they wanted to apply their pharmaceuticals to treat human conditions. At the popular level initiatives like National Depression Screening Day were heavily underwritten by pharmaceutical companies and the implicit connection was that you could be screened and be treated with a medication that would take care of your depression.

From the perspective of a pharmaceutical company this is marketing genius. You are essentially packaging a disease cure in a pill and suggesting that anyone with a diagnosis who takes it will be cured. The other aspects of marketing genius include the idea that you can be "screened" or minimally assessed and take the cure. We now have the diagnosis, treatment, and cure neatly packaged in a patent protected pill that the patient must take.  The role of the physician is completely minimized because the pharmaceutical company is essentially saying we have all the expertise that you need. The physician's role is further compromised by the pharmaceutical benefit manager saying that they know more about which pill to prescribe for particular condition than the physician does. That is an incredible amount of leverage in the health care system and like most political dimensions in healthcare it is completely inaccurate.

The pharmaceutical company perspective is also entirely alien to the way that psychiatrists are trained about how to evaluate and treat depression.  Physicians in general are taught a lot about human interaction as early as the first year in medical school and that training intensifies during psychiatric residency. The competencies required to assess and treat depression are well described in the APA guidelines that are available online.  A review of the table of contents of this document illustrates the general competencies required to treat depression. Reading through the text of the psychopharmacology section is a good indication of the complexity of treating depression with medications especially attending to side effects and complications of treatment and decisions on when to start, stop, and modify treatment. Those sections also show that psychopharmacology is not the simple act that is portrayed in the media. It actually takes a lot of technical skill and experience.  There really is no simple screening procedure leading to a medication that is uniformly curative and safe for a specific person.

The marketing aspects of these medications often create the illusion that self-diagnosis or diagnosis by nonexperts is sufficient and possible. Some people end up going to the website of a pharmaceutical company and taking a very crude screening evaluation and concluding that they have bipolar disorder. In the past year, I was contacted by an employer who was concerned about the fact that her employee had seen a nonpsychiatrist and within 20 minutes was diagnosed with bipolar disorder and treated with a mood stabilizer, an antidepressant, and an antipsychotic medication. Her concern was that the employee in question could no longer function at work and there was no follow-up scheduled with the non-psychiatrist who had prescribed medication.  Managed care approaches screening patients in primary care settings increase the likelihood that these situations will occur.

The current anti-psychiatry industry prefers to have the public believe that psychiatrists and their professional organization are in active collusion with the pharmaceutical industry to prescribe the most expensive medications.  In the case of the approximately 30 antidepressants out there, most are generic and can be easily purchased out-of-pocket.  Only the myth that medications treat depression rather than psychiatrists keeps that line of rhetoric going.

George Dawson, MD

American Psychiatric Association.  Practice Guideline for the Treatment ofPatients With Major Depressive Disorder, Third Edition. 2010

Wartime atrocities

The recent mass murders in Afghanistan and the analysis of the events in the press highlight my contention from an earlier post that the press really does not do a good job in these situations. We can expect a continued exhaustive risk factor analysis and discussions by various pundits. The accused soldier clearly had a lot of exposure to combat stress, there is a history of traumatic brain injury, there is a possible history of substance abuse, and there are multiple psychosocial factors. So far we have seen the statements by people who knew him describing this event as completely unpredictable based on his past behavior. The debate will become more polarized as the lawyers get involved. The real truth of the matter is never stated.

What we know about these incidents is more accurately described by anthropologists than psychiatrists or psychologists. The best book written on this subject is Lawrence Keeley’s War Before Civilization.  In that book Dr. Keeley explores the contention that primitive peoples were inherently peaceful compared to modern man and a warfare that was waged was brief, fairly nonlethal, and stereotypic. In order to explore that theory, Dr. Keeley ends up writing a fairly definitive book on the anthropology of warfare. There are more lessons in that book about war and peace then you will ever hear on CNN or in the risk factor analysis that is produced in the popular media.

So what do we know about the mass murder of civilians during warfare? The first thing we know is that it is commonplace. It happens in every war and no military force despite their level of training is immune to it.  In prehistoric times, the most frequent scenario was a surprise attack on a village with the goal of killing as many inhabitants as possible. In Keeley's review, that number was generally around 10% of the population and that could have devastating consequences for a particular tribe including the complete dissolution.

Keeley also makes the point that: “Only the "rules of war," cultural expectations, and tribal or national loyalties make it possible to distinguish between legitimate warfare and atrocities.”  He gives the examples of Wounded Knee and My Lai as well as larger scale bombings of Hiroshima and Dresden.  My Lai was a highly publicized incident from my youth. It occurred during the Vietnam War when the US Army massacred hundreds of Vietnamese noncombatants – largely women, children, and old men.  In that situation, 26 soldiers were charged and only one was convicted. The convicted soldier served 3 1/2 years under house arrest.

In addition to outright killing, mutilations of bodies and the taking of body parts as trophies continue to occur in modern civilized warfare in much the same way that these practices occurred in primitive warfare.  Haley reported on a series of Vietnam veterans seen in psychotherapy and the special problems that exist in patients who have been exposed to or participated in wartime atrocities. Based on the literature at the time she suggested that the war in Vietnam resulted in a disproportionate number of atrocities.

My current final analysis of the situation is that there are important social and cultural determinants of war and the inevitable wartime atrocities. Risk factor analysis and analysis of individual biology is very unlikely to provide an explanation for what occurred. The moral, legal, and political environment has changed since Vietnam and that is obviously not a deterrent. A comparison of the final legal charges and penalties in this case with what happened in Vietnam will be instructive in terms of just how far those changes come. If there is a conviction, there will be a lot of pressure to portray the convicted soldier as very atypical and probably as a person who underwent a significant transformation of his conscious state.  There will be many theories. The idea that this transformation predictably occurs during warfare will not be discussed. I have already heard some experts talking about the thousands of soldiers who go though similar situations and seem to do just fine.

The best approach to these events is a preventive one that includes minimizing the exposure to war instead of being involved in the longest war in American history.  I don't expect that much will be said about that either.

George Dawson, MD

Lawrence H. Keeley. War Before Civilization. Oxford University Press, 1997.

Haley SA. When the patient reports atrocities. Specific treatment considerations of the Vietnam veteran. Arch Gen Psychiatry. 1974 Feb;30(2):191-6.

No Time to Heal

I sent an e-mail to one of my colleagues last night about a bill introduced in the state of Minnesota that would potentially allow managed care companies to replace inpatient psychiatrists with nonphysicians. She thought that was consistent with the managed-care model of high volume and low quality inpatient treatment. She also reminded me of the concept that inpatient units used to be a place where people came to heal. Over the years that I worked in inpatient settings it is apparent that severe psychiatric disorders take their toll and it takes a lot to recover.  Many people are admitted with acute hypertension, dehydration, malnutrition and weight loss, tachycardia, acute blood loss, and any number of stressful physical conditions in addition to their primary psychiatric diagnosis. At least half of the patients admitted to the acute psychiatric inpatient units have been using alcohol, cocaine, or other intoxicants that worsen their physiological state. In some cases such as catatonia, the psychiatric illness alone is life-threatening.  Before there were effective treatments some forms of catatonia had an 85% mortality rate.

Not too long ago when we had more functional inpatient treatment people had time to recover. It was not uncommon to see patients with bipolar disorder take at least 2 to 4 weeks to recover from an acute episode. Inpatient psychiatrists and nursing staffs were experts in supportive care and patience invariably left the hospital in much better condition than they came in.  That is no longer the case. Today the artificial pressure to make money restricts inpatient care to a number of days rather than weeks. That is well below the time frame that it takes for any of the known psychiatric medications to actually work. In the case of the patient with mental illness and substance abuse disorder, they may have only completed detoxification stage by the day of discharge. They leave the hospital in only slightly better shape than they came in.  In many cases, their families were trying to assist them prior to admission and they discovered they could not help.

I don't think that there should be any mistake that the current system is driven strictly by cash flow and the cash flow to psychiatry has always been limited. The business of managed care companies is not to give patients with severe psychiatric disorders the time they need to heal. The business of managed care companies is to make money and use any rationalization along the way to do that. Those currently include the idea that you should only be on an inpatient unit if you are acutely suicidal or aggressive.  The other consideration is that the inpatient atmosphere should not be designed with patient comfort in mind, because we all know that if is too comfortable - somebody might want to stay longer than the system wants them to.

George Dawson, MD

The Day the Quality Died

I don't know when it happened exactly but if I had to guess it was somewhere in the mid-1990's.  That was the time when quality changed from a medically driven dimension to a business and public relations venture. The prototypical example was this depression guideline promulgated by AHCPR or the  Agency for Health Care Policy and Research.  The guideline was written by experts in the field and there was consensus that it was a high quality approach to treating depression in primary care settings. One of my colleagues used this guideline in its original form to teach family practice residents for years about how to treat depression in their outpatient clinics. The actual treatment algorithm is listed below:

Managed care companies had a different idea about treating depression not only in primary care settings but also in psychiatric clinics. In less than a decade the standard of care had devolved to the point where antidepressants were started on the initial visit and the standard outpatient follow-up was at one month. In addition, even though cognitive behavioral therapy was proven to be effective for the treatment of depression the standard course recommended in those research studies was never used. It was common then and even more common now for depressed patients to see a therapist and be told that they seem to be doing well after two or three sessions and there is probably no need for further psychotherapy. They typically did not receive the research proven approach.

The latest innovation is to assess and treat depression in outpatient clinics on the basis of a PHQ-9 score, and have psychiatrists follow those scores and additional information from a case manager in recommending alterations in therapy for patients with depression.  Although it was never designed to be a diagnostic or outcome measure the PHQ-9 is used for both.

The current model of maximizing medical treatment of depression in managed care clinics is an interesting counterpoint to psychiatrists bearing the brunt of criticism for over treating depression with ineffective antidepressants. The recent FDA warning about prolonged QTc syndrome from citalopram is another variable that suggests there are potential problems in maximizing antidepressant exposure across a primary care population where the number of people responding to psychotherapy alone is not known but probably significant.

There is another aspect of treating depression in primary care clinics that illustrates what happens when you think you are treating a population of people with depression. The new emphasis by politicians and managed care companies is screening for early identification of problems. The political spin on that is early intervention will reduce problem severity and of course save money.  Various strategies have been proposed for screening primary care populations for depression. It reminds me of the initiative to ask everyone about whether or not they have pain when their chief complaint has nothing to do with pain.

In the Canadian Medical Journal earlier this year, Thombs, et al, concluded that the evidence screening is beneficial and the benefit outweighs the potential harm is currently lacking and that study should be done before depression screening in primary care clinics is recommended. A recent op-ed by H. Gilbert Welch, M.D. in the New York Times is more accessible in the discussion of the risks of screening.

The irony of these approaches to depression in primary care clinics can only be ignored if the constant drumbeat of managed care companies about how they are going to save money and improve the quality of care is ignored. Despite the frequently used buzzword of "evidence-based medicine" this has nothing to do with evidence at all. It is all smoke, mirrors and public relations.  It makes it seem like managed care companies can keep you healthy when in fact they have all they can do to treat the sick and make a profit.

That is the true end result when medical quality dies and politicians and public relations takes over.

George Dawson, MD, DFAPA

Thombs BD, Coyne JC, Cuijpers P, de Jonge P, Gilbody S, Ioannidis JP, Johnson BT, Patten SB, Turner EH, Ziegelstein RC. Rethinking recommendations for screening for depression in primary care. CMAJ. 2012 Mar 6;184(4):413-8.

H. Gilbert Welch.  If You Feel O.K., Maybe You Are O.K.  NY Times February 27,2012.