A Psychiatrist Reads the Washington Post

There are an endless number of ways that the appearance of conflict of interest can be spun to make any organization look bad.  The obvious question is why that always seems to occur with psychiatry?  The arguments all follow the general form that a financial benefit resulting from work related to the pharmaceutical industry disqualifies those experts from writing objective research about medication or rendering opinions about the treatment of psychiatric disorders in general. That is the theme of the latest article from The Washington Post entitled “Antidepressants treat grief? Psychiatry panelists with ties to drug industry say yes."  It is an old story with little variation and I add some commentary based on the organization of the article.

"In what some prominent critics have called a bonanza for drug companies, the American Psychiatric Association this month voted to drop the old wording against diagnosing depression in the bereaved, opening the way for more of them to be diagnosed with major depression and thus, treated with antidepressants.”

This statement assumes that this practice is not occurring right now. In fact, it is widely known that the diagnosis of depression is not rigorously made in primary care settings. It is highly likely right now that patients suffering from grief as well as psychological adaptations to acute stress are being treated with antidepressants. There is no reason to believe that the patients being treated in primary care resemble the patients with a diagnosis of major depression in clinical trials of antidepressants.

"The change in the handbook, which could have significant financial implications for the $10 billion  US antidepressant market, was developed in large part by people affiliated with the pharmaceutical industry, an examination of financial disclosures shows.”

The previous statement talks about a "bonanza for drug companies" and builds on this image in the second statement. It ignores the fact that most commonly prescribed antidepressants are currently generics and available for as little as four dollars per month. The only two major antidepressants at this time that are not generics are Cymbalta (duloxetine) and Vibryd (vilazodone).  Where does the "10 billion dollar" figure come from?  If you read the entire article on page 5, that figure was from IMS America a company that tracks total prescriptions from American retail pharmacies.  Anyone knowing the applications for antidepressants would know that they are prescribed for many conditions other than depression including headaches, hot flashes, and chronic pain. The total retail sales figure is unlikely to reflect either drug company profits or the amount of depression being treated.

A little arithmetic is always instructive. If we assume that a physician prescribes a generic antidepressant for a patient that costs four dollars per month that translates to a total cost of $48 per year. The $10 billion/year figure quoted here would represent 208 million prescriptions or 66% of the entire population of  the U.S. taking antidepressants 12 months out of the year.  Even if we take $2 billion out of the $10 billion figure for Cymbalta and Vibryd, that results in 53% of the population taking antidepressants 12 months out of the year. Those figures are 5-8 times higher than any actual estimation of antidepressant use.  The $10 billion dollar figure is certainly eye-opening but there is plenty of evidence that it is not remotely accurate and will not have the purported impact on the pharmaceutical industry.

"About 80% of the prescriptions for antidepressants are written by primary-care physicians and others, not psychiatrists, a fact that makes the APA handbook particularly important. Faced with a patient complaining of depression-like symptoms, a general practitioner may be likely to rely on the Association's handbook for advice.”

This statement reveals the authors lack of knowledge about the practice of medicine and about the DSM that he is criticizing. The DSM is strictly a diagnostic manual and it contains no treatment recommendations. Primary care physicians are not avid readers of the DSM and that has probably led to the practice of using a DSM-based checklist – the PHQ-9.  This practice has not been promoted by the APA or the pharmaceutical industry (although the PHQ-9 is copyrighted by Pfizer pharmaceuticals).  Using a checklist to make a rapid diagnoses (in minutes) and rapidly treat large numbers of patients is promoted by managed care organizations and HMOs. That is probably the single greatest factor contributing to antidepressant prescriptions but it is ignored by the author - probably because it challenges his contention that this is all driven by conflict of interest in psychiatry rather than the business world.  It is cheaper for HMOs to treat depression with medications rather than detailed psychiatric assessments and psychotherapy.

"The Association itself runs on a budget of about 50 million a year, and for years industry funding has been critical to its operations. Today, about 14% of the Association's budget comes from pharmaceutical companies, mainly in the form of advertising at annual meetings and publications."

The author does a good job of providing no context here. Is the APA any different from other medical specialty organizations? Does advertising create a conflict of interest? Is any other print media outlet held to that standard? There is information available in those areas.   An Institute of Medicine report focused on conflict of interest showed that the APA's revenue from the pharmaceutical industry was in the middle of the pack with regard to medical specialty societies. As an example, the year that report was done the APA reported that medical companies supplied 28% of their annual income.  The American Academy of Family Physicians reported that 42% of their annual income was from pharmaceutical companies (p 220).  That same report (Recommendation 6.1) noted that increasing work for the pharmaceutical industry correlated with a 7% reduction in real physician wages and recommended that there was nothing wrong with “consulting arrangements based on written contracts for expert services to be paid for at fair market value”.   Depending on the expert involved, restricting the amount to $10,000 per year could practically mean anywhere from 2 to 10 presentations per year or about 2 1/2 weeks of contract work. 

“Other members of the committee have numerous ties to drug companies, too, and not simply conducting research, according to disclosures from last year. One was holding stock in Glaxo Smith Kline, one was a consultant to Servier and another consultant to Pfizer;  one had a grant from AstraZeneca and another a grant from Pfizer and AstraZeneca.”

This is a paragraph from a poorly written section illustrating ties between the 11 member Mood Disorders Work Group set up to draft the guidelines on major depression. There is some explanation of the selection criteria and conflict of interest criteria.  It discusses conflictof interest criteria that the APA designed and made explicit in response to this article.  It provides no context other than an off hand remark by the chairman that he probably regrets making. The article provides no reasonable context for expected reimbursement for experts as consultants to industries or the fact that this is a common practice in many academic departments on any major university campus. In some of those industries, the professional organizations actually make an effort to make sure that businesses are well represented in any process that involves making standards.

"The current handbook-the revised version will be published in the Spring-recommended against diagnosing major depression in the bereaved when the symptoms are milder and of less than two months duration. This is known as the "bereavement exclusion".  (If the signs of depression are severe-the patient has thoughts of suicide, for example-major depression is supposed to be diagnosed)….. The new handbook removes the bereavement exclusion."

There is really nothing new and nothing drastic as anticipated with removing the "bereavement exclusion". To provide a clear example I will quote a text copyrighted in 1982:

"There are many publications that deal with treating psychiatric patients who report recent and remote bereavement. It is possible to find a real or imagined loss in every patient's past. However, for the most part, because there is little evidence from reviewing normal bereavement that there is a strong correlation between bereavement and first entry into psychiatric care, those bereaved who are seen by psychiatrists should be treated for their primary symptoms. This is not to say that the death should not be discussed, but because these people represent a very small subset of all recently bereaved, they should be treated like other patients with similar symptoms but no precipitating cause. A physician seeing a recently bereaved with newly discovered hypertension might delay treatment one or two visits to confirm its continued existence, but treat it if it persists. So the psychiatrist should treat the patient with affective symptoms with somatic therapy but only if the symptoms are major and persist unduly. A careful history of past and present drug and alcohol intake is indicated. Then, the safest and most appropriate drugs to use are the antidepressants. Electroconvulsive therapy is indicated in the suicidal depressed." (Paykel p413-414).

Any psychiatrist worth his or her salt knows the difference between grief and depression and they should know the literature on treating grief, the natural history of grief, and the research on proven non-medical treatment of grief including Interpersonal Psychotherapy (IPT) and grief counseling. When you are seeing a psychiatrist, you are seeing an expert who should know the literature on grief, depression, and the differential diagnosis of depression.  Nothing in this article indicates that.  In fact, quotes are provided to suggest that the APA and psychiatry in general has an interest in redefining “the range of acceptable emotion” rather than using clinical research done by psychiatrists to limit suffering and prevent suicide.

I think the reality here indicates that there is no scandal.  The importance of the DSM-5, the appearance of conflict of interest, and the potential windfall for the pharmaceutical industry appear to be seriously overestimated.  Organized psychiatry is certainly not responsible for what happens  in primary care clinics under the direct guidance of business organizations.  There is a responsibility to establish professional standards for patients referred to psychiatrists for the assessment and treatment of complicated depressions that may occur during bereavement. The suggestion that medications may be useful in some of these situations and the importance of treating depression in bereavement has been around for at least 30 years.

George Dawson, MD, DFAPA

Peter Whoriskey.  Antidepressants to treat grief? Psychiatry panelists with ties to drug industry say yes. The Washington Post, December 26, 2012.

Clayton PJ. Bereavement in Handbook of Affective of Disorders.  Eugene S. Paykel (ed). The Guilford Press. New York. 1982  pages 413-414.

APA Reiterates Stringent Rules on Accepting Pharma Support.  Psychiatric News.  Monday December 31,2012.

Institute of Medicine (US) Committee on Conflict of Interest in Medical Research, Education, and Practice; Lo B, Field MJ, editors. Conflict of Interest in Medical Research, Education, and Practice. Washington (DC): National Academies Press (US); 2009. Available from: http://www.ncbi.nlm.nih.gov/books/NBK22942/  

 

Dr. Dawson's Neighborhood

 “Politicized science is an inevitable part of the human condition, but society must strive to control it. Although history shows that politicized science does much more damage in totalitarian societies than in democracies, even democracies are sometimes stampeded into doing very foolish and damaging things." – William Happer, Harmful Politicization of Science in Politicizing Science: The Alchemy of Policymaking

When I was a kid, I walked five blocks a day back and forth to primary school and kindergarten for the first seven years of my schooling. I got to know the people along that route very well. In those days in a small town people looked out for you when you were a kid. They offered you things to eat and you knew it was safe to eat.  You got to know their problems.  They told me about being gassed in World War I and never getting over it or drinking a pint of gin a day for thirty years and then stopping.  Some were engaged in behaviors that were difficult to explain such as laughing uncontrollably or making statements that seemed to be directed to you but that did not make any sense. Other people told me about their neighbors having alcoholism or having undergone shock treatments. There were adults with developmental disabilities. I visited several families with my parents and I can remember witnessing shocking behavior in those private residences - shocking for a kid but not so much for a psychiatrist.  Plenty of shocking events happened right at my own home.  That was my neighborhood as a kid and I lived there a long time.

Over the next four decades, I have thought a lot about my old neighborhood from time to time. The most frequent thought I get is how common psychiatric disorders are and how they are easily recognized by most people in your neighborhood.  The second most frequent thought I get is how there was nearly a complete lack of professional help for people with those problems. There was an extremely high threshold for assistance and when that threshold was met people were often sent hundreds of miles away to institutions until they recovered or remained in those institutions on an indefinite basis.  Some of these institutions doubled as sanatoriums for the mentally ill and patients with tuberculosis.  My aunt was a nurse in one of those places and was assaulted.  I can remember thinking: “Why would somebody with TB attack her?”

My mother had severe bipolar disorder, and was treated for years with tricyclic antidepressants by her family physicians. She eventually was able to see a psychiatrist and got more appropriate mood stabilization, but only after decades of mood instability.  My father seemed very depressed and lethargic. He probably had obstructive sleep apnea, a condition that psychiatrists routinely screen for these days but back then it was unknown. I found him dead one morning when he was 42 years old.  Medical treatment in general was pretty bad in those days.  Treatment for mental illness and access to psychiatry was practically nonexistent.  

There was no DSM when I was walking back and forth from school.  And yet the people with mental illnesses who were impaired were obvious to most people. That consensus was necessary, because their neighbors knew that they had to be more patient and kind based on those problems.  They knew they had to keep children from teasing or ridiculing these folks and teach them how to treat the disabled.  Some of our neighbors who interacted with my mother were incredibly tolerant at all hours of the day or night.   I don't know where I would have ended up without that level of assistance and recognition that there was a huge problem.  I think that level of common sense prevails today and is the basis of studies that look at whether or not psychiatric disorders are considered to be "diseases" by most people.  Those survey studies generally show that most people view severe mental illnesses and addictions as diseases. The idea that there is no such thing as a psychiatric disorder, forms the basis of anti-psychiatry rhetoric, but it is not rooted in reality or common sense.  The average person on the street does not need a DSM to detect mental illness.

The reality of psychiatric disorders and their treatment is really the focus of this blog.  It is something I have been focused on since before I became a psychiatrist.  Psychiatry is the most politicized and maligned medical specialty. It is rarely covered in an objective manner by the media. It has been manipulated by businesses and the government for their mutual advantage. It is the only specialty where there are significant profits made from continuously criticizing every aspect of the discipline.  It has few rational and fewer effective advocates.     

I continue this blog with those thoughts and the memories of my old neighborhood in mind and wish any readers here a Happy New Year.

Psychiatric opinion on same-sex marriage is more acceptable than an opinion on violence and aggression

I was surprised to see an insert in my psychiatric newsletter this month describing the efforts of four major mental health professional associations in opposing an amendment to the state constitution that would exclude same-sex couples from legal marriage.  The Minnesota Psychiatric Society, the Minnesota Psychological Association, the Minnesota chapter of the National Association of Social Workers, and the Minnesota Association of Marriage and Family Therapists produced this document that in essence says that there are no research findings to suggest that children from same-sex parents differ from heterosexual parents in outcomes.  The newsletter editor's column explains that there is apparently no policy on the MPS taking a stance on political and societal issues.  She put that question out to the general membership.  MPS President Bill Clapp, M.D. stated the issue succinctly:

"The MPS Executive Committee was painfully aware that the development of a consensus statement regarding marriage amendment could not possibly represent the diverse opinions of all Minnesota psychiatrists.  On the other hand we felt a responsibility to act faithfully in representing our many patients who believed the marriage amendment violated their civil rights and was overtly discriminatory". 

I think there are a number of issues relevant to this opinion that are interesting to contemplate.  First and foremost is bias in the media.  Over 2 years ago the MPS partnered with two other mental health organizations The Barbara Schneider Foundation, and SAVE - Suicide Awareness Voices of Education in producing a statement on violence prevention.  That statement highlights the lack of mental health resources, lack of training in dealing with these incidents, and the lack of quality standards in assessing and treating patients having problems with violent and aggressive behavior.  That statement was rejected by the newspaper editor. The only reason given was a potential conflict of interest because we were advocating for research and that nonspecific advocacy was viewed as a problem.  In the two years since the statement was produced, it is clear that the issues we raised are as important as ever.  My first question is why that statement pertaining to issues that mental health clinicians and the organizations involved deal with on a day by day basis was not acceptable and a statement on a purely political issue was.

I personally voted against the constitutional amendment and think that any reasonable person would.  None of my criticisms of this initiative outweighs the value of getting the research literature out there for public consumption.  It may have been useful to provide a link to all of the available research in an easily accessed format like Medline.  

On the other hand after treating violent and aggressive people and people with severe mental illnesses and addictions for 23 years, it seems like using a professional organization to take a political position on same sex marriage is a stretch.  One could argue that anything that affects the nurture of individuals is relevant to psychiatry, but there are probably few psychiatric societies that take positions on those topics.  I do think this illustrates that the media is much more willing to accept psychiatric opinion on a purely social and political issue, rather than an issue that is immediately relevant to the practice of psychiatry.

I have two minor objections about this initiative. First, it is too easy. The majority of psychiatrists are Democrats and psychiatry is the only medical specialty where that is true. It is fairly predictable that the majority of psychiatrists would support this initiative.  It is good to know that the position is supported by scientific data but I don't think that fact or the fact that psychiatrists support a political measure would carry any weight with voters.  Given the negative press associated with psychiatry and the tendency of the press to to cast psychiatry in the worst possible light, there is also the question of possible backlash against any measure supported by organized psychiatry.  The negative press about the DSM5 and antidepressants are two good evidence based examples.

My second objection is that there are numerous problems that affect psychiatric practice on a day-to-day basis where there should be immediate and very aggressive political action. Some of these topics have been ignored for decades at both the state and national levels. If I had to come up with a top 10 list (no particular order) it might look something like this:

1.  The intrusion of managed care into the practice environment.

2. The intrusion of pharmacy benefit managers into the practice environment.

3. The intrusion of managed care practices into government-funded programs.

4. Mismanagement of public facilities.

5. Mismanagement of quality measures at the population level in the state of Minnesota.

6.  The lack of timely care of acute psychiatric problems (considerable overlap with number one above).

7. Poorly thought out guidelines for reimbursement of psychiatric care emphasizing low quality high volume medication focused practices as opposed to psychosocial treatments that are often as effective.

8. Lack of uniform application of civil commitment statutes on a county by county basis.

9. Lack of crisis intervention services in more than half of Minnesota counties.

10. Inadequate residential services for people with chronic mental illnesses, addictions, and children with psychiatric problems.

In terms of a guiding principle, a professional organization needs to advocate for what adversely impacts its members every day. When you have issues on the above list that are not only pressing but have been pressing for two decades the question becomes: "Why has nothing been done?"  It is much more uncomfortable to do something relevant to every practicing psychiatrist than something that most psychiatrists would have done anyway.

The other factor is that none of the issues on the list was ever voted on.  This is a key dimension in American politics.  Business lobbyists working behind the scenes at the state and federal levels generally get what they want flying under the radar.  They are there every day pushing a pro-business and in many cases pro-government agenda.  The last thing they want is any political reform that actually tips the balance in the direction of patients and physicians.

There were no referendums or amendments put up for a vote when the Minnesota statutes were rewritten to favor managed care companies.  That is where the heavy lifting is for professional groups in American politics and that is where MPS needs to be.

George Dawson, MD, DFAPA

Daniel Christensen, Kathleen Albrecht, Bruce Minor and Bill Clapp.  Children parented by same-sex couples do just fine.  StarTribune October 28, 2012

What is wrong with the APA's press release about the NRA statement?

The APA released a statement about the NRA's comments, probably Mr. LaPierre's statements on Meet the Press on Sunday and a separate NRA release. There are several problems with the APA statement:

1.   The American Psychiatric Association expressed disappointment today in the comments from Wayne LaPierre…

Why would the APA be "disappointed" in a predictable statement from a gun lobbyist?  I really found nothing surprising in Mr. LaPierre's presentation or the specific content. As I previously posted, the NRA predictably sees guns as the solution to gun violence.  The concept "more guns less crime" has been a driving force behind their nationwide campaign for concealed carry laws. The concealed weapons that are being carried are handguns and handguns are responsible for the largest percentage of gun homicides in the United States. It is probably a good idea to come up with a solution rather than reacting to a predictable statement.

2.  The person involved in the shooting is named…

Although it is controversial, there is some evidence that media coverage is one factor that can lead predispose individuals to copy a particular crime.  Although this press release is a minimal amount of information relative to other news coverage, it does represent an opportunity for modeling techniques for more appropriate media coverage and that might include anonymity of the perpetrator.  The NRA release makes the same mistake.

3.   In addition, he conflated mental illness with evil at several points in his talk and suggested that those who commit heinous gun crimes are “so possessed by voices and driven by demons that no sane person can ever possibly comprehend them,” a description that leads to the further stigmatization of people with mental illnesses.

It is always difficult to tell how rhetorical a person is being when they use terms like "evil" and "demons". If they are considered to be descriptive terms for a supernatural force that suggests an etiology of mental illness that was popular in the Dark Ages.  Evil on the other hand does have a more generic definition of "morally wrong or bad;  immoral; wicked”.  In this case it is important to know if the speaker is referring to a definition that is based on evil as a supernatural force or a more common description. This is another educational point. People who experience voices and irrational thoughts involving homicide can be understood. Psychiatrists can understand them and can help them to come up with a plan to avoid acting on those thoughts and impulses and getting rid of them.  The NRA release is basically an indication of a high degree of naïveté in thinking about the unique conscious state of individuals.  The APA release should correct that.

4.  The APA notes that people with mental illnesses are rarely violent and that they are far more likely to be the victims of crimes than the perpetrators

The actual numbers here are irrelevant.  Psychiatric epidemiology cannot be casually understood and the media generally has the population whipped up about the notion of psychiatric overdiagnosis of everything anyway. The idea that some mentally ill persons are dangerous is common sense and forms the basis of civil commitment and emergency detention laws in every state of the union. Advocates need to step away from the notion that recognizing this fact is "stigmatizing". The APA needs to recognize that their members in acute care settings are dealing with this problem every day and need support. It is an undeniable fact that some persons with mental illness are dangerous and it is an undeniable fact that most of the dangerous people do not have mental illness. Trying to parse that sentence usually results in inertia that prevents any progress toward solutions.

The APA seems to have missed a golden opportunity to suggest a plan to address the current problem. The problem will not be addressed by responding to predictable NRA rhetoric.  There several other nonstarters in terms of a productive dialogue on this issue including - the specifics of the Second Amendment and specific gun control regulations. The moderator of Meet The Press made an excellent point in the interview on Sunday when he asked about closing the loophole that 40% of gun purchases occur at gun shows where there are no background checks. It was clear that the NRA was not interested in closing that loophole. The main problem is that the APA has no standing in that argument. Second nonstarter is the whole issue of predictability. Any news outlet can find a psychiatrist somewhere who will comment that psychiatrists cannot predict anything. That usually ends the story. If your cardiologist cannot predict when you will have a heart attack, why would anyone think that a psychiatrist could predict a rare event happening in a much more complicated organ? Psychiatrists need to be focused on public health interventions to reduce the incidence of violence and aggression in the general population and where it is associated with psychiatric disorders. 

What about Mr. LaPierre’s criticism of the mental health system?

“They didn't want mentally ill in institutions. So they put them all back on the streets. And then nobody thought what happens when you put all these mentally ill people back on the streets, and what happens when they start taking their medicine.  We have a completely cracked mentally ill system that's got these monsters walking the streets. And we've got to deal with the underlying causes and connections if we're ever going to get to the truth in this country and stop this…”

Is it an accurate global description of what has happened to the mental health system in this country? He certainly is not using the language of a mental health professional or a person with any sensitivity toward people with mental illness.  There are numerous pages on this blog documenting how the mental health system has been decimated over the past 25 years and some of the factors responsible for that. Just yesterday I was advised of a school social worker who not only was unable to get a child hospitalized but could not get them an outpatient appointment to see a psychiatrist. The government and the managed care industry have spent 25 years denying people access to mental health care and psychiatrists. They have also spent 25 years denying people access to quality mental health care that psychiatrists are trained to provide. We have minimal infrastructure to help people with the most severe forms of illness and many hospital inpatient units do discharge people to the street even though they are unchanged since they were admitted.   Any serious dialogue about the mental health aspects of aggression and violence needs to address that problem.

That is where the APA’s voice should be the loudest.

George Dawson, MD, DFAPA

Supplementary Material:  Quotes from and locations of transcripts – feel free to double check my work.

MTP transcript  12/23:  http://www.msnbc.msn.com/id/50283245/ns/meet_the_press-transcripts/t/december-wayne-lapierre-chuck-schumer-lindsey-graham-jason-chaffetz-harold-ford-jr-andrea-mitchell-chuck-todd/#.UNlaJ-RqYrV

"I'm telling you what I think will make people safe. And what every mom and dad will make them feel better when they drop their kid off at school in January, is if we have a police officer in that school, a good guy, that if some horrible monster tries to do something, they'll be there to protect them." (p2)

"Look at the facts at Columbine. They've changed every police procedure since Columbine. I mean I don't understand why you can't, just for a minute, imagine that when that horrible monster tried to shoot his way into Sandy Hook School, that if a good guy with a gun had been there, he might have been able to stop..."—(p3)

"There are so many different ways he could have done it. And there's an endless amount of ways a monster.."—(p6)

"I don't think it will. I keep saying it, and you just won't accept it. It's not going to work. It hasn't worked. Dianne Feinstein had her ban, and Columbine occurred. It's not going to work. I'll tell you what would work. We have a mental health system in this country that has completely and totally collapsed. We have no national database of these lunatics." (p6)

"23 states, my (UNINTEL) however long ago was Virginia Tech? 23 states are still putting only a small number of records into the system. And a lot of states are putting none. So, when they go through the national instant check system, and they go to try to screen out one of those lunatics, the (p6)

"I talked to a police officer the other day. He said, "Wayne," he said, "let me tell you this. Every police officer walking the street knows s lunatic that's out there, some mentally disturbed person that ought to be in an institution, is out walking the street because they dealt with the institutional side. They didn't want mentally ill in institutions. So they put them all back on the streets. And then nobody thought what happens when you put all these mentally ill people back on the streets, and what happens when they start taking their medicine."We have a completely cracked mentally ill system that's got these monsters walking the streets. And we've got to deal with the underlying causes and connections if we're ever going to get to the truth in this country and stop this"—(p7)

NRA transcript 12/21: http://home.nra.org/pdf/Transcript_PDF.pdf

"The truth is that our society is populated by an unknown number of genuine monsters — people so deranged, so evil, so possessed by voices and driven by demons that no sane person can possibly ever

comprehend them." (p2)

"Yet when it comes to the most beloved, innocent and vulnerable members of the American family — our children — we as a society leave them utterly defenseless, and the monsters and predators of this world know it and exploit it. That must change now!" (p2)

"As parents, we do everything we can to keep our children safe. It is now time for us to assume responsibility for their safety at school.  The only way to stop a monster from killing our kids is to be personally involved and invested in a plan of absolute protection. The only thing that stops a bad guy with a gun is a good guy with a gun. Would you rather have your 911 call bring a good guy with a gun from a mile away ... or a minute away?" (p5)

"Now, I can imagine the shocking headlines you'll print tomorrow morning: "More guns," you'll claim, "are the NRA's answer to everything!" Your implication will be that guns are evil and have no  place in society, much less in our schools. But since when did the word "gun" automatically become a bad word?" (p5)

"Is the press and political class here in Washington so consumed by fear and hatred of the NRA and America’s gun owners that you're willing to accept a world where real resistance to evil monsters is a lone, unarmed school principal left to surrender her life to shield the children in her care?" (p6)

Additional Reference:

Copycat Phenomenon in medical literature (references 5, 13, 20, 26 are most relevant).

90862 Redux?

My original post on the problems with the 90862 CPT code has turned out to be one of the most popular posts on this blog.  I decided to revisit that post in the context of the impending code changes the first of the year.  The headline in this weeks Clinical Psychiatry News says it all: "New E&M Coding Set to Go Into Effect Jan. 1".  The article encourages psychiatrists to learn the new system in the hope that they will be able to get more fair reimbursement in the future.  The explicit downside is that more documentation will be required.  In my own practice more complex E&M codes can require anywhere from two to four times as much time and effort to document with additional time to managed the case apart from additional telephone calls, lab review, and consultation.  The implicit downside is that despite the promise of more reasonable reimbursement that will actually take political action as stated: "Values might rise in 2014, after the professional societies have a chance to survey psychiatrists on the new codes and the RUC (Relative Value Update Committee) looks at revaluing those codes..."

For anyone reading this who does not have a knowledge of this coding system this template from the American Academy of Family Practice provides a good summary.  To give a general idea of the subjectivity of this entire system, I have been documenting and billing 15 and 30 minute 90862s at my current employer for over two years.  Our coding expert told me that all of these notes would meet criteria for 99214.  Actual time with the patient is roughly 20-30 minutes with 10-20 minutes added onto that for associated tasks (lab ordering, call to other doctor, associated paperwork, etc).  I have been billing like this for most of my career, except in a previous specialty clinic where I used E & M codes.

The interesting aspect of this coding system that I always come back to (and can't emphasize enough) is the near total subjectivity of it.  I have described my 90862 procedure and that usually results in a note of about 300 to 500 words.  When I review the notes of other psychiatrists, I often see the note condensed to 4 brief sentences.  The entire note can be less than 75 words.  It is often difficult to tell if an actual conversation occurred between a doctor and a patient.  I describe this to point out the huge variation in the documentation of clinical practice and there is good reason for it.   Compulsive documentation takes an incredible amount of time.  It is usually not possible for me to complete the documentation that I think is necessary during the regular work day and I know I am not alone.  I have called primary care physicians at 7 or 8 PM to find many of them still there trying to catch up on all of the paperwork and documentation from that day.  That is a lot of time investment because of a vague guideline.

The most interesting aspect of coding is how it has been used to intimidate physicians by both the government and the insurance industry.  Apart from satisfying billing requirements most physicians engaged in compulsive documentation are doing it because of the threat of a coding audit.  In that situation the actual notes are reviewed and somebody makes a decision about whether the documentation meets certain coding requirements for a particular bill.  If the decision is no - the physician involved could face massive financial repercussions.  Some insurance companies will look at 10 notes and on that basis calculate a rate of overcoding and multiply that rate by the total patient they cover in that practice and demand repayment.   Although this physician has apparently not been told why the FBI decided to close down her practice, the tactics described on her blog are the similar to those described in cases of alleged billing "fraud".  Keep in mind the only scientific study of this process showed that professional coders could agree that a document reflected a particular billing code at a rate no greater than chance.

Anyone who has read along to this point have probably picked up on the fact that I am not very hopeful that this is a major reform in psychiatric reimbursement.  This whole system was invented to control physician reimbursement and not improve it.  It is a system that looks like it may have some objectivity on the surface but beyond the surface it is pure politics.  The best example I can think of is that any insurance company can decide to reimburse physicians at any rate they want.  They may decide for example that "Dr. Dawson has been billing 90862s for decades, why would we want to suddenly reimburse him for 99214s?  We will just pay him the same regardless of what his coding expert or billing document says."  Just another inefficiency that physicians need to tolerate that detracts from the provision of medical care.

George Dawson, MD, DFAPA  

King MS, Lipsky MS, Sharp L. Expert agreement in Current Procedural Terminology evaluation and management coding. Arch Intern Med. 2002 Feb 11;162(3):316-20.

"The only thing that stops a bad guy with a gun is a good guy with a gun"

That is a direct quote from the NRA's chief lobbyist Wayne Lapierre.  In the same NYTimes piece he goes on to say that declaring our schools gun free zones serves only: "“tell every insane killer in America that schools are the safest place to effect maximum mayhem with minimum risk.”  There has been some mild outrage in response to this comments but I don't know what people would expect from the NRA.  They see guns as a solution to everything.  They literally believe that with guns there is less crime despite the hard data that points to the fact that the USA has the highest (by far) homicide rate by firearms, the highest rate of gun ownership, and the highest rate of assault deaths of any of the top 30 countries of the Organization for Economic Cooperation and Development.  In fact, this NY Times graphic of the data shows that over half of the homicide rate is firearm related.  The total homicides in the US at 9,960 is nearly seven times greater than the total of all the other countries on the list.  The total number of suicides by firearms greatly exceeds this number (18,735 in 2009).  It seems to me that the gun data suggests that we currently have maximum mayhem with maximum risk.

Getting back to the proposed NRA solution.  Let's look at the arithmetic first.  Just considering the number of public schools in the US, current data from the National Center for Education Statistics puts that number at 98,817.  Assuming a cost of one armed guard per school with vacation coverage and benefits I would conservatively estimate a cost of about $100,000 per year or a total of about $9.8 billion dollars per year.  That is a substantial outlay of capital for what is an unproven strategy.  According to the Wikipedia list there have been 40 school shootings since 1989.  Using a a mean number of schools during the period (or about 91,638) would mean that the odds of one of these armed guards encountering a shooter would be about 2/91,638 on an annual basis.  The Transportation Security Administration responsible for airport security has a total budget of  $7.7 billion and they cover 450 airports but confiscate 1,300 firearms and 125,000 prohibited items per year.  $929 million of the TSA budget is for the Federal Air Marshal Service that assigns agents to commercial flights.  To put an armed guard in the schools would roughly cost what it costs to secure air travel in the US.  The main difference would be that school guards might have a much lower level of vigilance than air travel security and they would need to be very vigilant to head off a sudden and potentially very lethal attack.

Arithmetic aside, there is also the question of associated costs.  In medicine we are familiar with the screening arguments for breast and prostate cancer.  There is always a false positive and false negative cost.  With false positive PSAs and mammograms there is the ordeal of unnecessary biopsies and exposure to other unnecessary tests.  There is no way to estimate the impact of armed guards at schools.  Currently there are about 500,000 violent crime and over a million thefts committed against teachers in America's middle and high schools.  In a previous Institute of Medicine report,  the authors found that a  "substantial number of boys" carry firearms in schools.  That same study reported:

"Despite all this effort to keep guns from children  the committee was somewhat astounded at the ease with which the young people in these cases acquired the weapons they used.  Only in the Jonesboro case were the powerful weapons in the home of one of the too well secured for them to access.  But it was easy to defeat the security measures of another relative and get hold of a powerful semiautomatic rifle with a scope.  In general, it is easy for young teens to circumvent both the law and informal controls designed to deny them weapons they use in their crimes." (ref 1)

There is also the risk of unintentional discharge of weapons.  The New York City Police Department keeps a public record of all weapons discharges from its 33,497 police officers.  According to this report there have been 15-27 "unintentional discharges" per year over the past ten years.  With a school workforce nearly three times as large and possibly less vigilant than an NYPD officer that is potentially a lot of accidental discharges.   How many are acceptable in and around our schools?  The false negative/false positive cost of putting  armed guards into schools based on these factors is really unknown.  

Considering this problem has also led me to think about some epidemiological concepts that we were all taught in medical school.  Primary prevention measures are designed to reduce the incidence of new cases of disease.  Secondary prevention is focused more on people who are identified as being at risk but who are unaware of the fact that they may have the problem.  Tertiary prevention occurs after the problem is declared.  In the case of suicidal or homicidal behavior that means after the critical incident occurs.  This paper looks at these concepts in the case of suicidal behavior.  As far as I can tell there has been no exhaustive look at a timeline of all of the preventive factors that occur prior to mass shooting events or school violence events.  The usual method of analysis is looking at cases for a common profile and as the IOM report showed - there was none.

This analysis cannot predict whether the NRA stand on guns in schools will be protective or not.  It is much more complex than a statement that guns are a solution to gun crimes.  Based on what we know about these situations a key strategy is preventing the shooter from picking up the weapon in the first place.

George Dawson, MD, DFAPA

1.  National Research Council and Institute of Medicine. (2003) Deadly Lessons - Understanding Lethal School Violence.  Case Studies of School Violence Committee.  Mark H. Moore, Carol V. Petrie, Anthony A. Braga, and Brenda L. McLaughlin, Editors.  Division of Behavioral and Social Sciences and Education.  Washington, DC: The National Academies Press.

2.  Ganz D, Braquehais MD, Sher L (2010) Secondary Prevention of Suicide. PLoS Med 7(6): e1000271. doi:10.1371/journal.pmed.1000271

3.  New York City Police Department.  Annual Firearms Discharge Report 2011.

4.  Meet  the Press Transcript. Sunday December 23, 2013.  Wayne LaPierre discusses current NRA positions on school safety and gun control.

Homicide Debate Goes Further Off the Rails

Apparently broadcast news is about as reliable as the Internet these days.  I was watching an "expert" on the weekend discuss the connection between homicide and antidepressant medications.  He apparently believed that there was one.  I understand that Sanjay Gupta made a similar comment today on CNN.  The misinformation is flying out there.  There are several political interests that would like that statement to be true and they appear to be out in full force. What is the short answer to the association between antidepressants and homicide?  Who can you believe?

Well there is always the scientific approach and a review of the medical literature.  Admittedly the literature is a lot drier and less entertaining than Dr. Gupta.

There is also simple arithmetic   The American media like to give the impression that violent crime and homicide are at epidemic levels.  It is always a shock when people discover that in fact we are at a 30 year low:

The homicide rate has actually declined from 10.2 per 100,000 in 1980 to 5.0 per 100,000 in 2009.  What are the odds of that happening if a major new cause of homicide is being added at the same time (namely antidepressants).  How does that compare with antidepressant use?  A recent study estimated that from 1996 to 2005, the number of Americans older than 6 years of age in surveyed households who received at least one antidepressant in the year studies increased from 5.84% in 1996 to 10.12% in 2005.  From the table there was a 24% reduction in the homicide rate during a time that antidepressant use nearly doubled.  One in ten Americans received an antidepressant prescription   The authors of this study noted this trend was broad based and correlated with a lower percentage of people receiving psychotherapy.

But what does that tell us about the observation that antidepressants cause homicide?  Technically there is no current way to demonstrate causality from a negative correlation between homicide rates and the rate of people taking antidepressants.  A large scale significant negative correlation between antidepressant use and lethal violence over a 15 year period has already been reported in the Netherlands.

What about the commentator suggesting that the toxicology of homicide perpetrators shows that they can have psychiatric drugs present that explain their homicidal behavior.  In fact, a study looking at that issue showed that 2.4% of 127 murder-suicide perpetrators had toxicology that was positive for antidepressants.  That is a lower than expected rate of antidepressant use than in the general population.   In a study of elderly spousal homicide-suicide perpetrators, depression was seen as an antecedent to this act but none of the perpetrators tested positive for antidepressants.

Given these observations any claim that antidepressant or any psychiatric drug causes homicidal behavior needs to be backed up with some hard data.  I don't mean a series of cases reported by somebody to make a point and I don't mean a legal decision where lawyers and judges can pretend that scientific data do not exist and make a decision about what they hear in a court room.  I also do not mean listening to somebody claim that we will never know the real relationship until we conduct "prospective double blind placebo controlled studies" of homicidality as a medication side effect.  If it isn't obvious, that study would by definition be unethical and would not pass the scrutiny of any human subjects committee.

Anyone with potential homicidal thinking needs close supervision and treatment.  They may need inpatient treatment in a unit that specialized in treating homicidal thinking and behavior.  Any clinician working in these settings will tell you that the people being treated generally come in with aggressive and violent thoughts and behavior before they take any medication.  If they have positive toxicology associated with homicidal thinking it is generally alcohol or an illicit drug like cocaine or methamphetamine.  Anyone with this problem also needs close monitoring and management of medication side effects.  Antidepressants can cause agitation and restlessness.  There are some people who do not benefit from antidepressants.  In the case of persons with the potential for aggression and suicide the medication response may need to be determined in a controlled environment before they can be safely treated.  Like all medications antidepressants are not perfect medications and they need to be administered by an expert who can provide effective treatment while managing and eliminating any potential drug side effects.

George Dawson, MD, DFAPA