Antidepressants Are Not Miracle Drugs - They Are Also Not Tools Of The Devil

I decided to end the year on a less intense but serious note about antidepressants. I am currently working on some posts on biological psychiatry most notably on the hypothalamus. When you see that posted it will hopefully contain some licensed graphics, numerous worthwhile references, and it will be the first post on this blog where copy-paste function will be blocked.  I have seen the results of not blocking my blog content and many people pointed out that it is just copied to another site and not referenced.  In what had to be a worst case scenario, I was at a conference where an academic used my custom graphics in his PowerPoint presentation without referencing that they were from this blog.  Hopefully those days are over.

But in the meantime a few comments about the war on antidepressants which is really a war on psychiatry. There are numerous posts on this blog refuting some of the published material but I want to speak about what happens at the clinical level without all of the academic references and articles. I decided to post this because antidepressants have been heavily politicized over the years. The initial rhetoric was that psychiatrists were prescribing them because they were being corrupted by pharmaceutical companies. The next step was to suggest that antidepressants were highly toxic medications for one reason or another. When both those criticisms were obviously not valid, the next step was to suggest that antidepressants simply don’t work at all.  In social media this takes on a tone that discourages people from treatment.  Psychiatrists are shamed for prescribing these medications and patients are shamed for taking them. Why would a rational person take a medication that did not work?

There have been slight modifications along the way. A good example would be the “chemical imbalance” theory that has been heavily criticized and attributed to psychiatry despite the fact that no psychopharmacology books contain this reference and the discovery that the term is an advertising meme from the late 20^th century. Some of the critics like the “critical psychiatry” movement came out with an actual position paper that proposed medications basically work because of side effects rather than any primary therapeutic effect. That is an incredible position to maintain and that may be why nobody pays attention to it. The critics of antidepressants and psychiatry are very vocal and if they are not complaining about psychiatric expertise or medications they are complaining about criticism they might receive. But the overall tone of their arguments illustrates that they have nothing positive to offer.  Many of these critics have the luxury of not treating people with severe psychiatric disorders.  In some cases that extends to denying that these disorders exist.

One of the critics complained about being “gaslighted” for some of criticisms. This is more than a little ironic for several reasons.  The standard positions of most antipsychiatrists is the very definition of gaslighting.  That position is to basically create a hostile environment that denies the legitimacy of psychiatry and psychiatric practice and treatments.  I have received hundreds of posts to this blog that never see the light of day. Some say (in many posts) that I am a hack who should not be treating patients. They claim I am an agent of the pharmaceutical industry (search all of the databases and you will see that I have not accepted as much as a nickel). They tell me that my research is poor and I have very little understanding of the literature. Some have suggested that they would like to see me physically assaulted.  One of them went so far as to hide the fact that he was a writer for a major anti-psychiatry blog until the last possible moment. I think he was really expecting that I was going to publish his post and name so that everyone on that website could have a good laugh at my expense. These critics seem to have a very thin skin and can’t take the slightest criticism for what are typically outrageous positions. 

I could quote all the evidence to the contrary hundred times but it would not do any good.  The dynamic is very similar to other antiscience arguments, like the arguments against vaccines.  The average person with a realistic concern about antidepressants should just be aware of the process at this point. There are a group of people who are out to discredit psychiatric care and medications that psychiatrists use strictly based on political agenda that has nothing to do with whether or not medications or psychiatry works.  The lesson of politics is that "the narrative" becomes the truth - particularly if one side "wins." Demonizing a perceived opponent is a common political strategy that may be amplified by social media.  This process focused on demonizing psychiatrists and the medications they prescribe can be observed in social media on a daily basis. 

There’s no better evidence that psychiatry works than the fact that we all go to work and see hundreds of thousands of people every day. Those people come back to see us because they are satisfied both with the relationship they have, the advice they get, and the fact that their treatment is effective. That includes treatment with antidepressants.  People don't take time out of their day, endure the problem of finding a psychiatrist who can see them and hassles with their insurance company, and follow treatment recommendations if the treatment is not effective.  

As I noted in the title - antidepressants are certainly not miracle drugs. About one person out of seven or eight that I see cannot tolerate selective serotonin reuptake inhibitors (SSRIs). About one person out of 15 cannot tolerate any antidepressant from any class. That fact alone points out one of the limitations of antidepressants. Additional patients will get more isolated side effects that create physical effects or affect their lifestyle and they have to make tough decisions especially if the medication is effective. They have to decide whether they want to keep taking it or not. But the clinical truth that you don't hear among the critics is that the majority of people can take an antidepressant and not get any side effects.  I know this because, I ask that specific question to every person I see who is taking a medication - every time I see them.

A more challenging clinical situation occurs when a patient asks me to start an antidepressant that they are certain has worked for them in the past and now they develop a symptom that may be a side effect that they did not have in the past. We need to figure out what is happening and what the best plan will be. The more common scenario is the person for whom the antidepressant does not work completely and we need to figure out how to get rid of their depression or anxiety.

All the negative talk about antidepressants is designed to take psychiatrists out of the equation. Nobody talks about the psychiatrist who is in the room with the patient actively working on and solving all of these problems. The problems that need to be solved from a medical and psychiatric standpoint can often make up a long list. Pre-existing medical conditions, 5-10 medications that are being taken for those conditions, drug interactions with any pre-existing conditions or medications, medication side effects, unstable medications, ECG abnormalities, medical causes of the psychiatric symptoms, neurological problems, significant renal or hepatic disease, and alcohol and substance use problems are all in that room and all need to be acted on by the psychiatrist and the patient in the room.  If somebody suggests that psychiatrists are doing less than that - take a look at the way psychiatrists are actually trained.  The ask yourself why you are not getting the whole story.

And even before we get to that point, there has to be some clarification of a diagnosis indicating that medication might be useful. There has to be a diagnostic formulation looking at how that diagnosis fits into that person’s life and conscious state. The prescription of a medication can’t be a formula based on a checklist. There are many times when a prescription medication is not the right answer. Don’t expect to hear that level of discrimination from somebody who tells you that antidepressants or psychiatrists are either generally bad or all bad.  When you hear that opinion - drill down and figure out what their conflict of interest is.  

In my current capacity, a significant number of people I see have suicidal ideation and many have attempted suicide or are actively contemplating suicide. Some have survived highly lethal suicide attempts. Most of them have depression and substance use disorders. I have to figure out the most likely diagnosis out of about 40 possibilities. In proceeding with treatment, my job is to help the person get well, recover from depression, and recover from suicidal thinking. That is a complex process and it is not just a question of prescribing medication. What is said and done in that process is not the same for any two people. I have to make sure the person is getting well and making necessary changes along the way to recover. There are many people along that path to confirm that the treatment is proceeding in a positive direction. This process is one of many leading to the demand for psychiatrists across the country. Psychiatrists have the clinical expertise to solve these problems and we are often consulted at the last possible moment after all of the other attempts have failed. 

With any luck it will be a better year ahead. I don’t expect the anti-psychiatry gaslighters to go away. I do want to reassure people that psychiatrists are result oriented and we are trained to work intensely with people to help them get better. If you see suggestions contrary to that fact - consider the source. If you see someone suggesting that they are being “gaslighted” by psychiatrists remember what I said about the posts I get here on this blog. And remember, antidepressants are just like any other medication. They don't work for everybody, but most people who can tolerate them notice a difference.  For some people the difference is life changing and it allows them to function the way they used to function. Like practically all medications, the decision to take antidepressants is a highly individual one and a decision that is not made lightly.  Most people making that decision are not making it based on what is on social media.

As professionals we take a safe recovery from mental disorders and substance use problems very seriously. 

Happy New Year!

George Dawson, MD, DFAPA

Graphics Credit:

Color gradient during the sunset in Antarctica. Vernadsky Station. Antarctic Peninsula 2008.

By Maksym Deliyergiyev from Shutterstock per their standard user agreement.

Supplementary:

Academic gaslighting?  Of course, it exists.  I realize that it is a vague and non-specific term A few examples follow from this blog.  Unfortunately, journal editors either don’t seem to get it or they are too desperate for content to care.

The Identity Crisis Card: https://real-psychiatry.blogspot.com/2019/11/there-is-no-identity-crisis-in.html

The Diagnostic Heterogeneity Card: https://real-psychiatry.blogspot.com/2019/09/recent-opinion-about-diagnostic.html

The Epistemic Injustice Card: https://real-psychiatry.blogspot.com/2019/07/some-of-greatest-minds-in-psychiatry.html

The Chemical Imbalance Card: https://real-psychiatry.blogspot.com/2019/05/chemical-imbalance-as-advertising-meme.html

The Critical Psychiatry Card: https://real-psychiatry.blogspot.com/2019/05/chemical-imbalance-as-advertising-meme.html

The Antipsychiatry Card: https://real-psychiatry.blogspot.com/2018/08/why-antipsychiatrists-have-it-all-wrong.html

The Antidepressants Are Toxic Card: https://real-psychiatry.blogspot.com/2018/04/sensational-antidepressant-piece-from.html and this recent review.

The Physicians Are Corrupted by Big Pharma Card:  https://real-psychiatry.blogspot.com/2017/05/wait-minute-is-psychiatry-less-unhinged.html

The Too Much Neuroscience Card: https://real-psychiatry.blogspot.com/2016/10/the-balanced-rhetoric-against.html

The Psychiatrist Shortage Card: https://real-psychiatry.blogspot.com/2016/08/a-better-analysis-of-psychiatrist.html

The Reductionism Card: https://real-psychiatry.blogspot.com/2015/11/reductionism-is-not-dirty-word.html

The Monolithic Psychiatry Card: https://real-psychiatry.blogspot.com/2015/06/the-myth-of-monolithic-psychiatry.html

The Philosophy Card - written by an expert on Foucault: https://real-psychiatry.blogspot.com/2013/02/moralizing-about-psychiatry-and-limits.html

This Supplementary section was added on 1/2/2020 at 0200.  The body of the original post is unchanged.

A Positive Story for Christmas

I ran across the story posted by Minnesota Public Radio about a psychiatrist retiring in northern Minnesota. The past 30 years or so Dr. Hardwig was the only psychiatrist in International Falls Minnesota. For people not familiar with Minnesota geography I included a map of the state at the top of this post.  It is a town of about 6400 people right on the Canadian border.  It is ranked as the 133^rd largest city in Minnesota. The closest Metro area would be Duluth with a population of about 85,000 people.  International Falls is 163 miles from Duluth and 296 miles from Minneapolis.  As noted in the article, this is a tough place to practice psychiatry. There are few resources and no easily accessible psychiatric beds.

Dr.  Hardwig practiced exclusively in this environment until his recent retirement. In the article we learn that his schedule was always full. He was always willing to fit people into his schedule based on need. He provided a valuable service to this patient’s and primary care physicians in the area. He successfully developed a way to interact with his patients in the community and maintain clear boundaries. He treated the entire spectrum of psychiatric disorders out of necessity. There were no specialists for him to refer to at least in the practical sense. When you advise people that they have to travel 100 or 200 or 300 miles to see a specialist they are willing to do it once or twice but not for the rest of their life.

Full disclosure on my part, I know Dr. Hardwig professionally. He was one of my predecessors as president of the Minnesota Psychiatric Society.  That means over the three years of that professional cycle, he commuted to the Twin Cities and developed agendas, ran meetings, met with MPS members, and conducted all of the other duties of those offices. He was a thoughtful president with a unique perspective also conducted one of our more unique scientific meetings. He also belonged to a discussion group about medicine and psychiatry in that group he talked about his ideas for recruiting psychiatrists into rural areas. That idea was one of the main points of the MPR article.  The shortage of mental health professionals in general and psychiatrists in particular was emphasized. 

This shortage is nothing new. When I started out as a psychiatrist back in the late 1980s, I was assigned to a physician shortage area in northern Wisconsin. I was the only psychiatrist in a county of about 50,000 people for a period of three years. During that time I was the medical director of a community mental health center and for one year commuted to a town 65 miles away to keep their small inpatient psychiatric unit open. They had a deal with the federal government and would lose significant funding if that unit closed down.

One of the early lessons I learned was that I was no longer practicing medicine in a large multi-specialty clinic with unlimited resources.  It is quite a shock to go from an academic psychiatry department with about 60 full-time staff and 24 residents to be the only psychiatrist in town. Professional isolation has been the term used to characterize that situation and also explain why psychiatrists don’t want to wander too far from Metropolitan areas. The atmosphere has improved to some degree with the advent of a functional Internet. While I was in that position, they were trying to get me a telepsychiatry connection through a local hotel satellite television. In the end the cost was exorbitant at about $20K/year and we never tried it.  Today telepsychiatry is routine in the same area and has been used for a decade by the local VA clinic.

The workload was fairly intense at times because our clinic handled all of the crisis calls from the county and I was backup for any nurse, case manager, or psychologist who was doing crisis intervention in the community or in some cases the county jail. There was no cross coverage for vacations or professional conferences.  I was on call 24/7 wherever I was across the country.  On any given night I could find myself seeing somebody in jail, at home, in the small general medical and surgical hospital in town, or any of several nursing homes. But even more pressing was the fact that I was a lightning rod for those people with mental illness and a propensity for violence. All these factors led me to return to a large multi-specialty group at the end of my three-year tenure.

When it comes to figuring out what it takes to be the only psychiatrist in town, treat all possible problems, and do that for decades - I don’t have the answers.  Dr. Hardwig clearly does and by all accounts he did a great job. In my postings of the MPR article in various places around the Internet, I had another psychiatrist question my use of the word “great”. I don’t really see any other way to describe it. What else can you say about the psychiatrist or any physician who practices intensely with minimal support and resources and gets the job done?

There are all kinds of reasons why physicians are critical of one another. There is the competitiveness of youth and the need to secure a position. Most physicians notice that slips away by midcareer and a more important function is teaching and mentoring rather than competing against everyone in the field. Psychiatry is at a disadvantage relative to other medical specialties. The media spin on psychiatry is decidedly negative as I noted in several recent posts. I don’t know if that just gets uncritically accepted or internalized especially by psychiatrists who are criticizing the rest of us. Even though this MPR story was positive it mixed Dr. Hardwig’s career accomplishments with the specter of psychiatrist shortages in rural America. I understand their point, but in terms of motivation focusing on this accomplishment would have potentially done more to motivate people to practice in that environment.  The accomplishments of Dr. Hardwig are certainly inspirational.

I have nothing but the best wishes for Dr. Hardwig in his retirement. Even though there are tens of thousands of psychiatrists to go to work every day and get the job done, his job was probably more demanding with no cross coverage for call or vacations. They have been trying to recruit a replacement ever since he announced he was going to retire and have no success so far. 

I hope they do succeed in finding a psychiatrist as unique as the one who just retired.

George Dawson, MD, DFAPA


References:

Alisa Roth. In International Falls, the last psychiatrist for 100 miles just retired. December 20, 2019. Link.


Graphics Credit:

User: Wikid77 (from National Atlas of the United States) [Public domain]: File URL: https://upload.wikimedia.org/wikipedia/commons/e/ed/Map_of_Minnesota_NA.jpg

Sleep and Addiction

One of the major problems that I treat in people with significant substance use disorders is insomnia of all types.  I see people who have had insomnia since childhood.  A significant number have had insomnia and nightmares since childhood.  In that case the insomnia often precedes the development of any associated psychiatric diagnoses – it is a primary problem. In many cases, it is one of the reasons that people develop a substance use problem.  Alcohol, sedative hypnotics (often benzodiazepine type drugs), opioids, and cannabis are commonly taken for sleep and typically lead to many secondary problems.  Alcohol for example, will often lead to faster sleep onset, but as tolerance develops, the person will start to make up at 2 or 3 in the morning.  With increasing tolerance, a decision about taking more drinks at that time or toughing it out until the morning will need to be made. Some people can get to the point that they ingest large enough quantities of alcohol that they sleep the entire night and wake up with elevated blood alcohol levels.  Some do not realize the problem until they are arrested driving into work the next morning for intoxicated driving.

The available medications for treating insomnia in patients with addiction are limited.  We can currently treat a significant number of patients with sleep problems but there are still many that have very difficult to treat insomnia.

Medication	Probable Sleep Mechanism of Action
Trazodone	H-1 antagonist, NE antagonist, 5-HT2 antagonist
Doxepin	H-1 antagonist, NE antagonist, Ach antagonist
Mirtazapine	H-1 antagonist, 5-HT2 antagonist
Hydroxyzine	H-1 inverse agonist, Ach antagonist
Quetiapine	H-1 antagonist, NE antagonist, Ach antagonist, 5-HT2 antagonist, DA antagonist
Ramelteon	MT-1/MT-2 agonist  MT-1> MT-2
Melatonin	MT-1/MT-2 agonist  MT-1>MT-2
Prazosin	α1- adrenergic antagonist
Gabapentin	inhibition of the alpha 2-delta subunit of voltage-gated calcium channels
Benzodiazepines (detox only)	GABAA receptor agonist
Opioids (detox, MAT)	MOR agonist

 

The general strategy of using these medications is apparent from the purported mechanisms. For example, brain histamine (H) and acetylcholine (Ach) are alerting and arousing neurotransmitter systems so that antagonists/inverse agonists would be expected to decrease arousal and facilitate sleep.  Noradrenergic (NE) systems are wake promoting so NE antagonists would be expected to decrease this function.  The compounds in the above table work the best in addictive states when a person is abstinent from intoxicants and chronic use of intoxicants and after they have been detoxed.  Benzodiazepines and opioids are in the table for that purpose.  Although I have seen detox protocols that include many of the medications listed in the table as needed for insomnia and anxiety it is unlikely that they will work until detoxification has occurred.  In many cases, the expected duration of detox is much longer than anticipated and sleep problems are a prominent reason.    

That brings me to the primary focus of this post and that is a recent paper entitled “Drugs, Sleep, and the Addicted brain.” I generally don’t get too excited about research papers these days, but after reading this brief paper by Valentino and Volkow – I was fairly excited.  In this paper the authors main goal is to demonstrate how the biological substrates that regulate sleep interact with the reward system and how they can be direct targets for substance use. 

The first system they look at is the locus ceruleus (LC)-norepinephrine (NE) system that is involved in arousal. LC-NE neurons do not fire during REM sleep.  Activation of the LC results in firing of noradrenergic neurons that activate the cortex. Corticotropin-releasing factor (CRF) leads to LC activation and heightened arousal.  Endogenous opioids lead to damped excitation and decreased arousal.  Tolerance to exogenous opioids would lead to an expected inability to dampen the LC-NE system and increased activation and arousal during opioid withdrawal.

The serotonin (5-HT) dorsal raphe nuclei (DRN) system is also a system implicated in both sleep and arousal.   5-HT neurons are active during waking and do not fire during REM sleep. 

Histaminergic (H) neurons in the tuberomammillary nucleus (TMN) have an arousal function on cortical neurons.  They are active in the awake state.

Midbrain dopaminergic neurons (DA) in the ventral tegmental are (VTA) specifically those projecting to the nucleus accumbens (NAc) increase wakefulness upon activation but activation of the other major set of DA neurons in the substantia nigra has no effect.  This is a critical circuit in substance use because this system determines the value function of stimuli in the environment including addictive compounds and affects arousal.

Cannabinoids promote sleep, sleep onset, slow wave sleep, and sleep duration.  They decrease REM sleep.  CB1 agonists and antagonists respond in the expected manner.  The effects of CB1 agonism may be mediated by adenosine which increases in response to the stimulation of this pathway.  Caffeine is an adenosine antagonist and that may be the reason is promotes wakefulness.  Endocannabinoids also inhibit orexin neurons (arousal promoting) in the lateral hypothalamus and increase the activity of melanin neurons.  These combined effects of cannabinoids on the endogenous cannabinoid system explain the expected insomnia when these compounds are stopped for any reason.

The orexin system in the lateral hypothalamus and dorsal medical hypothalamus/perifornical area is activated during wakening and silent during sleep.  It is the system that is disrupted in narcolepsy.  It is also the system that coordinates the activity of the other arousal centers in the brain including the TMN-HA, LC-NE, DRN-5-HT, VTA-DA, and cholinergic neurons in the Nucleus Basalis of Meynert (NBM-Ach).  This relationship is depicted in the following graphic from the paper and detailed in reference 3.

Orexin A and Orexin B are wake  promoting neuropeptides the general structure of which is given below.  These peptides bind to Ox1R and Ox2R G-protein coupled receptors.  Orexin A has equal binding affinity to both receptor but Orexin B preferentially binds to the Ox2R receptor.  Detailed information is available from PubChem.

Human Orexin A

The orexin system may be critical not just in arousal but also in reward.  Patients with narcolepsy have orexin deficiency and generally do not overuse opioids and are less likely to overuse stimulants even though many have been prescribed very high doses.  Opioid users have increased orexin neurons in the lateral hypothalamus.  This increase in orexin signaling may lead to profound insomnia and the associated arousal state after prolonged exposure to opioids and makes this insomnia very difficult to treat.  Orexin can directly potentiate reward in some models.  Orexin is implicated in states where a high level of motivation to acquire the target substance is required or where there are external stimuli like stress, and specific cues for drug use that lead to increased motivational states.  The authors in reference 2 refer to orexin's ability to affect the approach toward a reinforcing stimulus or active withdrawal from an aversive stimulus as motivational activation.

Suvorexant is an interesting compound in that it antagonizes Orexin A and Orexin B wake-promoting neuropeptides and prevents them from binding to Ox1R and OXxR receptors decreasing wakefulness.  It is currently FDA approved as a treatment for insomnia, but the authors propose that it is a compound of interest in that it can potentially counter the arousal and reward potentiation associated with drug seeking states.  If that is the case it could be a useful treatment for both insomnia and the primary addictive disorders.

When I look at possible treatments for insomnia in addiction, a central question is whether or not they will potentially worsen the addictive state.  That is why there are no specific benzodiazepine related sleep compounds in the table at the top of this post.  The benzodiazepines listed there are all basically used on a short term basis for detox and then tapered and discontinued.  In the case of mu-opioid receptors (MOR), medication assisted treatment with both buprenorphine and methadone are possible on an ongoing basis. The package insert for suvorexant suggests possible problems in that subjects with recreational polydrug use rated their "liking" of the drug as being similar to zolpidem 15 and 30 mg doses.  Zolpidem is a standard sedative hypnotic that can be used to treat insomnia.  It definitely has abuse potential and in some cases patients can end up taking very high doses per day until they can be detoxified.  That is not reassuring in terms of safety for persons with substance use problems but I would not take it as proof that it cannot be safely used.  According to the DEA, suvorexant is currently a Schedule IV drug or low potential for abuse or dependence. Some articles on insomnia suggest that despite what appears to be a comprehensive mechanism, the short term efficacy of suvorexant is no greater than zolpidem but at a much greater cost.

I am currently looking at the medicinal chemistry and clinical trials literature to assist me decision making on orexin receptor antagonists and just how much of withdrawal related insomnia is due to orexins. The other important question is whether it will also decrease drug seeking states and withdrawal avoidance.   

George Dawson, MD, DFAPA

References:

All full text and all excellent

1: Valentino RJ, Volkow ND. Drugs, sleep, and the addicted brain. Neuropsychopharmacology. 2020;45(1):3–5. doi:10.1038/s41386-019-0465-x

2: James MH, Mahler SV, Moorman DE, Aston-Jones G. A Decade of Orexin/Hypocretin and Addiction: Where Are We Now?. Curr Top Behav Neurosci. 2017;33:247–281. doi:10.1007/7854_2016_57

3: Peyron C, Tighe DK, van den Pol AN, et al. Neurons containing hypocretin (orexin) project to multiple neuronal systems. J Neurosci. 1998;18(23):9996–10015. doi:10.1523/JNEUROSCI.18-23-09996.1998

Graphics Credit:

The brain graphic is from reference 1 and is used here without modification per the Creative Commons Attribution 4.0 License.

Disclaimer:

This post may change significantly over the next two weeks.  I had to put it up to see what it looks like and plan to elaborate the behavioral pharmacology of orexin and the pharmacology of suvorexant.

MPS Meeting on Emergency Department Congestion

From the Flyer for this Meeting - Not an indication that MPS has anything to do with the opinions that follow. 

I attended the Minnesota Psychiatric Society 2019 Fall Program last weekend. The theme was addressing Minnesota’s Mental Health Access Traffic Jam: Coming Together to Build a Better Roadmap. That traffic jam has been there for the duration of my career in Minnesota and that is approaching 30 years. 

When I looked at the agenda and the speakers my first association was “stakeholders”. That jargon has found its way into the administration of medical and psychiatric systems over the past 20 years. It is basically a codeword to suggest that administrators, politicians, and everybody in between somehow has a “stake” in medical care and the relationship of physician has with the patient and their family is peripheral to all of these outsiders.  Nothing could be farther from reality – but that is the attitude we have to deal with from politicians and administrators.

The keynote speaker was the director of Psychiatric Emergency Services at the Denver Health Medical Center – Scott Simpson, MD. He was not able to make and his presentation was given by a colleague - Kristie M Ladegard, MD. Denver Health is a 525 bed Level I Trauma center. Psychiatric Emergency Services has a 17-bed psychiatric unit and a 60-bed detox unit.  The Emergency department also has mobile crisis services and consultation services.  For the last data they had in 2013 a little over half of their emergency visits were for “depression, anxiety, or stress reactions”. About 40% were for substance use disorders. An additional 20% were for psychosis or bipolar disorder. As expected, suicidal ideation led to a more complicated disposition plan. The incidence of delirium in elderly patients remaining in the emergency department and the high mortality rate of missed delirium was discussed. Factors leading to boarding in the emergency department were discussed. An interesting approach to substance use treatment was the “No Wrong Door” approach. Using approach intake for substance use treatment occurred right in the emergency department or at other points of contact within the medical system.  Medication Assisted Treatment for opioid use disorder was also started in the ED, with buprenorphine inductions. That resulted in a greater number of inductions and greater percentage of people retained in treatment.

Emergency services lecture also talked about four goals of implementation including access, quality, cost, and provider resiliency. The most interesting method discussed knew the end of the lecture was Dr. Simpson’s paper on single session crisis intervention therapy (1). The specific techniques are given in the open access paper in reference number one, and they should be familiar to people who are involved in crisis intervention especially with people who are suicidal in those situations. It was part of the overall message that I don’t think is emphasized enough. That message is-interventions need to be incorporated into the clinical assessment and not compartmentalized into the few minutes at the end. Experienced clinicians should be able to forgo entire sections of a standard template if an intervention is necessary and they can use the time to provide it.

There was a complementary panel in the afternoon that consisted of two psychiatrists and two emergency medicine physicians in a dialogue about what each discipline wanted to tell the other. Early in my career it was often a source of conflict. There always questions about “inappropriate admissions” psychiatry. Those questions faded away without any psychiatric presence in the emergency department. People were admitted to my service irrespective of their associated medical complexity. It was often my job to determine whether or not they needed to be transferred to a medical or surgical service. With this panel there was not a lot of controversy. Much of the concern had to do with nursing home and group home patients being sent to the ED with no hope that they could be placed anywhere quickly. The ED physicians had a very valid argument that it is no environment for boarding people until placements are available. The spaces are confining and there is very little to do. Communication about these patients and what the outpatient staff’s expectations are is critical. One of the psychiatric panelists pointed out during the session that all of the presentations indicated that additional beds within the system were necessary - but the state and managed care representatives were denying that basic fact.  This was later denied by a state representative who tried to say that there are a lot more beds that are not being counted but the basic fact is that just in terms of state hospital beds Minnesota ranks 49/50 states.

There was a Forensic Assertive Community Treatment (FACT) team representative there as well. There are currently 56 ACT teams in 43 counties in the state of Minnesota. There are approximately 90 patients per team. The FACT team specializes in seeing patients with severe mental illness who also have probation officers. The leader that team talk briefly about forensic cognitive behavioral therapy (CBT). Therapy focuses on a number of maladaptive cognitions that typically promote repetitive criminal behavior. One example was the error of “super optimism” or “negative consequences of this behavior do not apply to me”. Since the therapy for repetitive criminal behavior is generally considered futile to try to locate literature on this type of therapy but was not successful. The psychiatrist who headed the FACT team also talked about the importance of “felony-friendly housing” and “felony-friendly supportive services”. Both of the social features are critical for stabilizing people in the community but these resources are rare.

On the darker side there were presentations from both the MN Department of Human Services and managed care representatives.  Not a great deal of detail was provided by DHS.  They briefly described improvement in the physical environment of their forensic units.  They gave the current bed capacity of Anoka Metro Regional Treatment Center (AMRTC) – the largest non-forensic state hospital.  They described the number of facilities for the treatment of psychiatric and substance use disorders as including AMRTC, 6 much smaller Community Behavioral Health Hospitals (CBHHs), 5 Community Addiction Recovery Enterprise (CARE) programs, and 4 Minnesota Specialty Health System (MSHS) Programs.  AMRTC has a 96-bed capacity and has been under significant stress since a Priority Admission Statute allowed county sheriffs to send patients who were incarcerated but mentally ill as direct admissions. That results in longer lengths of stay for committed patients in community hospitals.  Compared with previous statistics provided by Kylee Ann Stevens, MD - Chief Medical Officer, Minnesota Department of Human Services, the bed capacity at AMRTC has decreased from 110 to 96 beds.  A newer Child and Adolescent Behavioral Unit is being built but there is no net increase in bed capacity.  There was no comparable data to the January 2018 post beyond that.

The DHS presentation emphasized the 40% of the patients at AMRTC Did Not Meet Criteria (DNMC) to be there. As a Medicare PRO reviewer for Minnesota and Wisconsin one of my jobs was to review patient stays in their hospitals and determine if they were actively being treated or it was more of a rehabilitative stay. The point at which clear progress was not occurring was an endpoint beyond which hospital care was no longer covered. The problem is that this is an almost totally subjective determination in patients with chronic mental illnesses.  If for example a person is highly aggressive and no medical treatments have worked – is that an acceptable end point to say they should no longer be hospitalized. I don’t think that it is. I have concerns about the robustness of the 40% figure for DNMC.  They presented some graphs of a Continuous Improvement Project that increased patient flow and decreased the DNMC to 19%.  Some external validation that large community acute care hospitals like Regions and Hennepin County medical Center were noticing the effect of this project would have been useful.

DHS also presented a few slides about “innovation” within the system.  They discussed Lean Six Sigma training as adding value in that it provides business skills to clinicians and leads to innovation. I remember they told me the same thing when we got that training in the managed care company where I worked. The problem is that managed care companies don’t really want to hear any ideas from physicians at least none that are not reflected back from management.   There were three bullet points on Michael’s Game, Ligature Mitigation, and Harnessing the Power of the EHR.  They suggested the Michael’s Game was useful to treat delusions for the purpose of competency restoration.  The only available literature I could find suggests it is useful to try cognitive behavioral therapy (CBT) in people with psychosis, especially if there is little familiarity with the technique. Ligature Mitigation is basically a Centers for Medicare & Medicaid Services (CMS) mandate to ensure the safety of the inpatient environment by policies and environmental inspection.  It seems more like a requirement than innovation.  In terms of the power of the electronic health record – I think there is finally a consensus that it is more of a burden than anything else. If there is some power there within the state hospital system – please demonstrate that.

There were a number of other speakers from the managed care industry and affiliated organizations.  There were diagrams about patient flow in the ED and what service availability can do to reduce ED congestion.  There were no inpatient psychiatrists there. The people with the most insight into the problem were absent.  After being an inpatient psychiatrist myself for 22 years I thought about why that might be.  Inpatient docs after all are subjected to all of the unrealistic expectations of everyone else.  Toward the end of my inpatient career I was being sent patients with severe medical problems and either no psychiatric disorders or stable psychiatric disorders.  I was getting these folks because everybody knew that they would get the care they needed – and the case managers who were ordering hospitalists to discharge people would be out of the loop. Inpatient psychiatry became a place where in addition to acute care psychiatry – everybody’s problems could be worked out there. And I had the added advantage of a case manager sitting in my team meeting reporting back to administrators on whether I got people out in 4 or 5 days.  The discharge process was intolerable because there were no discharge resources.  The availability of state hospital beds and group home beds were all shut down by many of the agencies represented in the room. Managed care was responsible for the intolerable work environment and a policy of discharging people before they were stable in order to optimize billing.  Basically, many of the people in the room who created the problem were now saying they could solve it. And I have heard these refrains for the past 20 years.

In a form of ultimate irony, there was a rumor at the meeting that one of the Twin Cities metro hospitals was going to be shut down by the managed care company that owned it taking another 105 psychiatric and substance use beds off line.  Since this question entered the Q & A session it seemed more than a rumor.  There was no comment from the managed care people.  

Besides the ACT psychiatrists there was another bright spot.  Dave Hutchinson, the Hennepin County Sheriff described the progress he was making at the policing level. Deputies were getting crisis intervention training (CIT). He made the point that I think a many don’t consider – crisis calls about obvious psychiatric problems that are being observed by the public go to the police twenty-four hours a day. He described the toll on the police including the statistic that 80% of officers who are involved in the use of deadly force – never return to work.  The jail in Hennepin County – like everywhere is inhabited by a large number of people with mental illness. Sheriff Hutchinson was very clear about the fact that this is a suboptimal situation and he would prefer that these people are in settings where they can get adequate care.

At the end of the session, I met briefly with one of my former residents.  She was a panelist for the meeting. She asked me what she was missing: “It seems that all indications point to needing more beds.”  I reassured her that she didn’t miss a thing.  It was the elephant in the room.  I have seen two decades of smoke and mirrors about why more beds aren’t necessary. It doesn’t seem that the state of Minnesota is any closer to recognizing that this is a real problem. It doesn’t seem that professional psychiatric organizations are any closer to confronting managed care or opaque state bureaucracies about how they are at the minimum unhelpful to people with serious mental illnesses and at the maximum harmful.

    

George Dawson, MD,

References:

1:  Simpson SA. A Single-session Crisis Intervention Therapy Model for Emergency Psychiatry. Clin Pract Cases Emerg Med. 2019;3(1):27–32. Published 2019 Jan 10. doi:10.5811/cpcem.2018.10.40443D

2: Khazaal Y, Favrod J, Libbrecht J, et al. A card game for the treatment of delusional ideas: a naturalistic pilot trial. BMC Psychiatry. 2006;6:48. Published 2006 Oct 30. doi:10.1186/1471-244X-6-48.   

3: Melnick ER, Dyrbye LN, Sinsky CA, et al. The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among US Physicians [published online ahead of print, 2019 Nov 12]. Mayo Clin Proc. 2019;S0025-6196(19)30836-5. doi:10.1016/j.mayocp.2019.09.024



Supplementary:

There are many estimate of optimal bed numbers and Minnesota does not come close on a number of them.  The Treatment Advocacy Center has a number of documents on their site that list Minnesota as 40/50 in 24 hr hospital inpatient and rseidential treatment setting beds, 41/50 in inpatient beds, and estimates that the state needs to add 1,165 beds to the system to establish an adequate base rate of available beds.

This document from the Pew Charitable Trust looks only at state hospital beds and shows Minnesota at 3.5 beds per 100,000 population with a ranking of 49/50 states.  

At least two panels of experts have concluded that 50-60 publicly funded beds per 100,000 is necessary to provide the same level of medical services and wait times for psychiatric patients in emergency departments as medical/surgical patients. 

Identity Chart for Psychiatrists

Adapted from drawing of Dr. M.A. Farmer (see Supplement 2)

My theme lately has been about how other people tend to characterize the identity of psychiatrists. The argument is that psychiatrists have some kind of "identity crisis".  This argument is invariably advanced by antipsychiatrists who distort psychiatric training and attitudes.  There are other interests who also want to distort the core identity of psychiatrists.   Health bureaucrats both in the government and in managed care systems would like to say that our role is to ration and undertreat people consistent with their goals of corporate profits or diverting tax revenues to their favorite cause.  They use the euphemism "managing resources" when psychiatrists frequently start out in these organizations with no resources.  The legal profession including legislators has forced a law enforcement role on us in the form of duty to warn - even though this is clearly a job for trained law enforcement officers. The most depressing identity arguments are made by people who should know better like the recent NEJM editorial.  This editorial used an argument by a journalist author who was clearly not familiar with how psychiatrists are trained or their skill set..  These numerous intrusions on the psychiatrist identity are presented as though they have something to do with the profession and they do not.

To make this diagram I read through the first two documents on the reference list below.  In order to make the diagram, only the broad intent of the detailed training criteria are included.  I could use a much smaller font and more detail, but the concept of a quick read of the basic elements would be lost.

The diagram could be much more complex since every psychiatrist (like everyone else) has a unique conscious state.  In the case of a psychiatrist, there is an interaction between professional identity and general identity and personality.

I am posting this for the purpose of educating nonpsychiatrists and for further collaboration with psychiatrists. Please feel free to send me training requirements for psychiatrists that are unique to your institution or country and I will include them here.  From my read of the top two references, there appears to be broad agreement at least across the Atlantic.  Also feel free to refer to this page when people inside or outside of the field mischaracterize what psychiatrists do or suggest that we are having an identity crisis.

I have been in the field over 35 years and my professional identity was firmly established in medical school and residency.  I have made the same intergenerational observations about my colleagues who range in ages from 30 to 85.


George Dawson, MD, DFAPA

 Professional Identity of Psychiatrist - the detailed references:

ACGME – the current real training and skillset https://www.acgme.org/Portals/0/PDFs/Milestones/PsychiatryMilestones.pdf?ver=2015-11-06-120520-753

RCP - A Competency Based Curriculum for Specialist Core Training in Psychiatry   https://www.rcpsych.ac.uk/docs/default-source/training/curricula-and-guidance/core_psychiatry_curriculum_may_2019.pdf?sfvrsn=f8594b3e_2

Royal College of Physicians and Surgeons of Canada Specialty Training Requirements in Psychiatry

http://www.royalcollege.ca/rcsite/documents/ibd/psychiatry_str_e

http://www.royalcollege.ca/rcsite/ibd-search-e?N=10000033+10000034+4294967084


Supplementary 1:

This is the original Visio drawing that I made based on the references.

Supplementary 2:

I was surprised and very pleased to receive a photo of a graphic that will replace mine.  It was done by Dr. Melissa A. Farmer and I think it is better than my original because it was designed to show the relationship among the variables.  A higher resolution graphic will be posted at some point and my thanks to Dr. Farmer!