The Rights Versus Treatment Debate

 

Just yesterday I coauthored a brief opinion piece on the issue of civil commitment and the issue of rights versus treatment (2). My co-author Mark L. Ruffalo had the great idea to initiate our commentary based on a letter from the late Darold A. Treffert, MD who was then the Superintendent of Winnebago State Hospital in Wisconsin. Dr. Treffert was also an expert on autism and savant syndrome.  I heard him speak on that topic about 15 years ago at the Door County Summer Institute.  His letter (2) was both a statement about the need for legal intervention and a call to action. In the final line, he attempted to solicit negative experiences from other physicians about a civil commitment process that erred on the side of rights rather than recognition of severe problems and treatment and the resulting problems.

Historically this letter came around the time that antipsychiatry forces were building and one of their main talking points was that there was no such thing as a mental illness.  People simply had “problems in living” and therefore no medical or legal intervention was necessary.  Certainly not a legal intervention that resulted in the deprivation of civil liberty.  The antipsychiatrists and liberty advocates failed to recognize the problem of severe mental illness and the associated lack of problem recognition and impaired decision making.  Those impairments greatly compromise any person’s ability to negotiate the world safely and take care of their self. The usual examples include suicidal or aggressive thoughts and behavior.  They can also extend to routine medical care and activities of daily living.  As an example – a person with severe mental illness may no longer see the need to take insulin for diabetes, or blood pressure medications, or anticonvulsants. That can precipitate a medical emergency in addition to any existing psychiatric emergency.

In Dr. Treffert’s letter, he mentions that the Wisconsin Supreme Court set a new commitment standard of “extreme likelihood that if the person is not confined he will do immediate harm to himself or others.”  Imminent likelihood became an impossible standard in many cases. Even if a patient had attempted suicide or assaulted someone, at any point during a one or two week court process – they could make the argument that the imminent danger had resolved – even if they were refusing treatment and continued to have severely impaired judgment. In that case what frequently happened was that courts experimented with rapid dismissals of commitment petitions – until there is a catastrophic outcome.  At that point they become as cautious as the physicians involved in assessing and treating the patient.

The dangerousness standard for commitment has additional unintended consequences. It functions as a de facto hospitalization standard. It is common that managed care companies deny payment for admissions or even continued stays in the hospital based on the imminent danger statute even in patients being treated on a voluntary basis. The applicable standard in this case should be an adequate treatment standard – also a quality standard.  It is highly likely that any patient admitted after a suicide attempt or episode of severe aggression will continue to have that problem if they are discharged without adequate treatment. Adequate psychiatric treatment generally takes much longer than typical 2-to-3-day crisis hospitalizations. As a de facto standard in the managed care era, it is also easy to discharge a patient who is uncooperative with care by documenting the resolution of the imminent crisis and discharging them rather than working on relationship building and a plan based on a therapeutic alliance. The adversarial legal standard becomes an adversarial medical process. 

Imminent danger standards also fail to recognize forensic populations, the subgroup of people with severe mental illness who have a pattern of violent crimes and have a chronic risk of violent and aggressive behavior. This group of patients often cannot be treated in the same setting as other patients with severe mental illness, and require treatment in forensic settings with adequate staffing and protections for both patients and staff. That segregation can also occur at the community hospital level, where just a few hospitals have psychiatric units and fewer have units that are designed to contain aggressive behavior. Aggression and violence in psychiatric settings is so stigmatized that its existence is commonly denied unless someone is trying to make a political argument that involves blaming societal violence on psychiatric patients.  Even then there are counterarguments that it does not exist. I have been advocating the position that violence and aggression secondary to mental illness are public health problems that should be addressed at that level for at least 20 years.  During that time, I have not seen a single public service announcement with that message.  Instead, the political and legal system continues to ignore that approach by flooding the country with firearms, closing many if not most community mental health centers, closing supported housing, and failing to provide affordable housing.

The response from journalists is not much better – ranging from overt misinformation about psychiatry and mental illness to the occasional human-interest story. The people who know the most about the problem – psychiatrists, social workers, and case managers are left out of the loop in favor of the most convenient critic. Journalists seem unaware of conflict of interest of many of their recruited experts and do not apply the same standard that they would for a psychiatrist.  Journalists and politicians also promote widespread cannabis use and in some cases legalization of many drugs that all pose serious health risks to psychiatric populations.  It is as if saying that out loud is bad for business and tax revenues.  

The humane aspects of involuntary treatment are often turned on their head in the rights versus treatment debate.  Is it more humane to keep persons with mental illness circulating between short term hospital with minimal to no treatment, jails, and homelessness because they do not recognize the problems they are having and fail to come up with solutions, or is it more humane to offer involuntary treatment?  Context is very important.  In my experience, during involuntary treatment – therapeutic alliances occur as it becomes evident that the treatment providers are helping the patient survive better. People with impaired insight and judgment require evidence that they are being helped and that is generally a turning point in the process. If a person is homeless, the evidence has to be provided right where they are – on the street.  That requires active outreach by treatment teams. Ideally that can happen before any crisis occurs that may lead to civil commitment and involuntary treatment. But even if the patient is committed active intervention to support them outside of institutional settings is possible.  This method of community psychiatry and community support has been around since it was invented by Len Stein, MD and Mary Ann Test, MSW in the 1970s. I was fortunate enough to have been supervised by Dr. Stein during residency and one of the key concepts was “the money has to follow the patient.”  In other words, the money used to finance extended state hospital stays had to be used to treat people in the community and provide them with their own housing.  This was a model to maintain people disabled by severe mental illnesses in their own housing.  The other elements included active outreach and 24/7 availability of staff to help them resolve any crises. That basic model has been around for 50 years and it is rarely implemented and only recently discussed in mainstream medical journals.

The primary reason we have a problem with both homelessness and untreated chronic mental illness in the United States is economic. The managed care model of health care administration showed how easy it was to deny and ration psychiatric care to make money.  That model was sold based on increased efficiency and cost containment – but at this point it is obvious that it does neither. It does reroute funds to pay for a massive increase in the number of administrators at both the private and public levels.  These administrators are largely focused on enforcing the rationing of care instead of providing quality care. In fact, the real onset of managed care heralded the total disappearance of quality metrics in medical care. Quality was no longer monitored by external agencies.  It was internalized in managed care organizations. The focus went from adequate treatment of a problem to how quickly a person could be discharged to maintain profitability under an unrealistic reimbursement system.  That approach is a disaster for acute care psychiatry, community psychiatry, and it makes involuntary treatment more likely from the resulting chronicity. It has also been a major frustration for outpatient psychiatrists trying to get hospital access for their patients in crisis. But the economics are generally swept under the rug or discussed at a superficial level by the critics.

At the community level, rather than active outreach by trained mental health staff most communities end up using law enforcement or other first responders with minimal to no mental health training. In most communities they are the only staff available on a 24/7 basis and that is also a funding issue. There are situations where the police do need to be involved in a mental health crisis, but that is far less common than the need for mental health intervention.

What are the solutions? I have written about many on this blog over the years. At the top of my lost today is just moving past the rights versus treatment debate. It has been a stalemate for 50 years while the entire system of care has collapsed due to rationing. The rights have been adequately safeguarded for decades and arguments about abuses before that time are irrelevant. What do I mean about adequate safeguards? In the state where I worked, there was a prepetition screener, a prepetition screening team (to discuss the merits of commitment and whether the patient met statutory requirements), 2 court appointed examiners, a defense attorney, a country attorney, a probate court judge, and if necessary, a substance use assessor.  That is about 7-10 people independent of the treating staff and any one of who could disagree with the commitment process.  I am not aware of any legal process that provides more safeguards.

On the treatment side, there is a legal concept called least restrictive treatment. That simply means a treatment setting where the person is free to come and go as they please rather than being in a facility where they either can’t leave or have to ask for permission.  The goal of the Stein and Test model was to maintain people in their own apartment – the least restrictive of all. That is a goal that any functional system should aspire to.  When we hear about the homeless problem only a fraction of those folks have severe mental illnesses.  Another fraction has substance abuse problems. The obvious solution is a housing first option that may include social support or in the case of mental illness case management services with active community psychiatry outreach.  The first step is not transport to emergency departments and admission to psychiatric units.   

Another unmentioned dimension on the treatment side is well trained and motivated staff.  Police officers do not choose a career in law enforcement because they are interested in communicating with and treating people with severe mental illnesses. Mental health staff do.  Communication and relationship building goes a long way toward defusing a crisis and preventing involuntary treatment.

Addressing the dilapidated psychiatric infrastructure is the final step. The issue of psychiatric beds is a chronic problem with the ongoing political rhetoric that no more are needed compared with needs analyses based on bringing the length of stay (LOS) of psychiatric patients in the emergency department to the same LOS as medical and surgical patients. On that basis – there are very few places in the US with adequate psychiatric beds.

By far – the single most detrimental factor has been the managed care model of rationing in health care systems and by the states. Denying care will always be more cost effective than providing care.  It is also a good model for generating profits. Much of that early profit was made by shifting the cost of effective care for serious mental illnesses away from subscriber-based health care systems to state funded systems – at least until the states adopted the model for themselves. Any serious discussion of the rights versus treatment debate needs to start at that point. Involuntary treatment and civil commitment will never be a solution to the problem of homelessness or the revolving door of people with severe mental illnesses getting inadequate treatment.

I wish that I could end the year on a more positive note but things seem very grim out there. We are still in the midst of a pandemic that has showcased how susceptible the public is to misinformation and political manipulation.  I can't help thinking that this has been the state of affairs in psychiatry for the past 50 years and this post is some of that evidence.  I am hoping that we can see the rise of some leaders in psychiatry to counter these trends - just as we have seen experts in virology and engineering counter the coronavirus misinformation.  But it seems like it will take a lot more than that.

Here is hoping for a better year in 2023 and beyond!

 

George Dawson, MD, DFAPA

 

References:

1:  Ruffalo ML, Dawson G.  Still Dying With Their Rights On, 50 Years Later.  Psychology Today December 30, 2022 Link

2:  Treffert DA. "Dying with their rights on". Am J Psychiatry. 1973 Sep;130(9):1041. doi: 10.1176/ajp.130.9.1041. PMID: 4727765.

Photo Credit:

Eduardo Colon, MD with thanks.

Additional Posts Relevant To This Topic:

 1:  The Problem With Inpatient Units:  Link

 2:   Are There Any Good Jobs Left for Psychiatrists?  Link

 3:  The Bureaucratic Takeover of American Psychiatry: Link

 4:  There Is No Identity Crisis In Psychiatry  Link

 5:  Holding Tank or Psychiatric Unit?  Link

 6:  Medical Care of the Seriously Mentally Ill - The Way It Should Be Provided Link

 7:  Governments and Psychiatric Beds  Link

 8:  The New York Times Steers The Mental Health Conversation in the Wrong Direction  Link

 9:  Bedless Psychiatry and  Recipe for Remaining Bedless  Link

10:  The New York Times Article on Why Mental Health Can't Stop Mass Shooters  Link

11:  My Opinion on Community Mental Health from 1989  Link

12:  Minnesota's Abandonment of the Severely Mentally Ill - Nearly Complete  Link

13:  Treatment setting Mismatches - The Implications  Link

14:  Why There Are No Bipartisan Solutions to Exorbitant Health Care Costs in the USA  Link

15:  A Circular Ethical Argument About Psychiatric Services  Link

16:  The EMTALA Paradox  Link  June 11, 2017

17:  Managed for Mediocrity - Corporate Medicine in the 21st Century  Link

18:  Remission Before Discharge?  An Un-American Concept  Link

19:  Do Businessmen Dream of Medicine Without Doctors?  Link

20:  Americans Can't Do Basic Health Care Arithmetic  Link

21:  The Largest Psychiatric Hospitals in the USA Link

22:  Hospitalists...  Link

23:  A Better Analysis of the Psychiatrist "Shortage"  Link

24:  Just When You Thought American Healthcare Could Not Get Any Worse  Link

25:  Newsflash from the StarTribune - Psychiatric Patients Have Nowhere to Go  Link

26:  Medicine to Psychiatry to Parking Lot:  The Evolution of Detox Over the Past 30 years  Link

27:  Admission, Discharge, and Readmission Policies: No Better Example of Business Driven Pseudoscience  Link

28:  How To Ruin You Life Without Being Dangerous  Link

29:  How the Ruling Class Impacts Your Health Care and Why They Need to be Stopped  Link

30:  Trauma In Psychiatric Hospitalizations  Link

What drugs should psychiatrists prescribe?

 

That was a question posed by a recent paper in Academic Psychiatry (1).  The focus was on psychopharmacology agents from the perspective of older agents like lithium, monoamine oxidase inhibitors (MAOIs), and tricyclic antidepressants (TCAs).  Every few years, the debate about these drugs is rekindled – almost like the stereotypical old man shouting: “Hey you kids – get off my lawn.”   Should psychiatrists know how to prescribe older agents – of course they should. First off, the age of the agent has nothing to do with efficacy. Lithium is the best example there and it continues to have the best efficacy for bipolar disorder relative to new agents.  TCAs and MAOIs have comparable efficacy to newer antidepressants like selective serotonin reuptake inhibitors (SSRIs) but given the span of clinical trials – a strict comparison is not possible. Some authors do make unequivocal statements about both TCAs and MAOIs having superior efficacy to SSRIs. But in my opinion meta-analyses does not eliminate the differences in clinical trials technology over the past 50 years.

The authors make some of these arguments and suggest a number of biases that may be operating against prescribing these medications. Some of those biases originate in risk perception. In general, newer medications do tend to be safer.  They are certainly not without risk.  Serotonin syndrome and neuroleptic malignant syndrome are the typical rare but high-risk complications of prescribing psychiatric medications but there are many more. The rational discussion of risk involves knowing the pharmacology, knowing any risk mitigation strategies, knowing to what extent your patient can co-manage that risk with you, and the explicit informed consent discussion outlining the risks.

In my experience about 15-20% of outpatients do not tolerate modern antidepressants well at all. I have always encouraged people in that situation to try something different. TCAs and MAOIs are certainly not devoid of side effects but it is possible to change to one of those medications and the patient notices immediately that the drug is well tolerated and eventually effective.  Clinical trial data will show that as a group SSRIs are safer and better tolerated than either TCAs or MAOIs but in the clinic we are treating individuals and not groups.  On an individual basis, people are selected based on whether they tolerate a class of medications or not and that does not mean that they will not tolerate all medications.  With lithium, MAOIs, and TCAs – the informed consent discussion needs to include the potential toxicities with reassurances that the goal is to avoid side effects and complications. 

That has been my approach to psychopharmacology for 35 years. It was easier for me to have this perspective because when I started out back in 1986, the only antidepressants available were TCAs and MAOIs. I also trained with two psychiatrists, James Jefferson and John Greist who wrote the Lithium Encyclopedia and ran the Lithium Information Center.  In the days prior to the internet, it was a repository of all known hard copy references to lithium in the medical literature. There were additional formative experiences, most notable 22 years on acute care units where you are the person responsible for the total medical and psychiatric care of the patient. It was common to see patients on multiple psychiatric and nonpsychiatric medications with varying levels of adherence and instability. In some cases, they were accompanied by several shopping bags of medications and it was impossible to determine what medication was being taken and what was not. In many cases the medical providers and the psychiatric providers had never communicated and there was redundancy and drug interactions. My job in that situation was to make the best estimate of what medications could be safely started and to follow the patient closely so that they could be adjusted. That requires a good knowledge of medications that are used to treat endocrine/metabolic conditions, infectious diseases, rheumatic disorders, gastrointestinal disorders, cardiac conditions, dermatology conditions, chronic pain and neurological conditions.

In other words, most medications that are commonly used. And why wouldn’t psychiatrists prescribe everything both inside and outside of the specialty?  I have been fortunate enough to work with many Internal Medicine specialists and subspecialists. I have witnessed what happens when they encounter a medication that they do not routinely prescribe. They ask the patient about why it was prescribed and their experience with it.  They read the package insert and decide whether to prescribe it or not.  The idea that each specialty has limited knowledge about prescribing medications outside of that specialty seems like an erroneous assumption to me.  It is even clearer now that we have nonphysician prescribers with less basic science and pharmacology knowledge and less supervised prescribing training not restricted to any set group of medications. Physicians have been trained in all classes of pharmacology and should have worked out a general approach on how to safely prescribe any medication encountered.  Physicians also need to know about the range of medications in the population they are working with.  Adapting to the medications utilized by different populations is all part of the practice of medicine.  Today and in the future it is conceivable that a typical psychiatrist may cycle through 4 or 5 different practice scenarios, each one requiring unique a unique knowledge of pharmacology.

That does not mean that I am going to start diagnosing and treating arrhythmias like a cardiologist.  But it does mean that if I get a patient admitted to my inpatient service who is taking an antiarrhythmic that I should be able to decide to continue or restart it, what monitoring needs to be done, whether an ECG needs to be ordered, whether to get a Cardiology consultation or contact the patient’s cardiologist (stat or electively), and whether any medication I want to start or change will affect either the antiarrhythmic or the patient’s underlying cardiac condition. The same process is true for every medication on their list.

The typical argument I encounter with that suggestion is: “Well most psychiatrists don’t practice in that kind of intense medical environment.”  My answer is – open your eyes. It is not enough to look at a typical list of medications in an electronic health record (EHR) and focus only on the ones that psychiatrists should prescribe.  It is not enough to assume that your patient’s list of medical problems is being adequately addressed.  Psychiatry from my perspective still means that the psychiatrist has some responsibility for the total medical care of the patient. In today’s fragmented medical care environment, the psychiatrist may be the only physician the patient is seeing. When asked who their doctor is – many people will name their psychiatrist.

That opinion is bound to make some psychiatrists nervous. They may have the thought; “How can I provide that level of care when I am being reimbursed less and have to spend most of my time doing clerical work for the EHR?” That is a fair question and one without an obvious answer. If administrators were really interested in quality care, they would give primary care physicians and psychiatrists enough time for that level of analysis. Psychiatrists need more time to establish and attend to their relationship with the patient.  But the medical stability of the patient and assuring that they are not experiencing adverse effects and that treatment is effective is an absolute priority. 

Psychiatrists need to be trained to make these assessments and they need to be able to prescribe and modify a significant pharmacopeia extending well beyond what exists in a psychopharmacology text. That skill is predicated on the extensive content in basic science and clinical literature on pharmacology and also the process of learning about new drugs and how to safely prescribe them. That learning process is largely implicit and not discussed enough.  If it was, it could be applied to older medications as well.    

 

George Dawson, MD, DFAPA

 

Supplementary:

I need to add a comment to this post because a lot of practice settings are designed to support specific prescription practices.  For example, there are a lot of private practices that focus primarily on the treatment of anxiety and depression.  There is also the assumption that more complicated pharmacotherapy such as the prescription of lithium needs referral out to a psychopharmacologist. In other cases, clinics will specialize in prescribing that fits specific diagnoses rather than the universe of psychiatric disorders.  Those practices stand in contrast to patients who are unable to get adequate medical or psychiatric care and routinely have their prescriptions disrupted. 

When that does happen they can end up in between prescriptions, self rationing prescriptions, or just not taking any prescribed medication for a while. Depending on the underlying medications, that alone can precipitate a crisis that any psychiatrist or trainee should be able to recognize and address. 

The first place that kind of training occurs is during the admission and coverage of inpatient units. The first orientation to these units should be a discussion of the expectations for prescribing to inpatients in acute care settings. It is not a question of waiting for a physician to sort things out the next day or hoping that a medical consultant will see the patient and make the necessary changes.  Each physician and trainee in that setting needs to know how to make acute assessments, determine the need for medications, and either make those changes or figure out how to get help on an acute basis.  Recognizing the urgency of situations like prescribing insulin for diabetes mellitus is as important as knowing the pharmacology.  Nobody should leave trainees guessing on their first call night.

References:

1:  Balon R, Morreale MK, Aggarwal R, Coverdale J, Beresin EV, Louie AK, Guerrero APS, Brenner AM. Responding to the Shrinking Scope of Psychiatrists' Prescribing Practices. Acad Psychiatry. 2022 Dec;46(6):679-682. doi: 10.1007/s40596-022-01705-1. PMID: 36123516.

Photo Credit:

Eduardo Colon, MD. - many thanks.

 

 

Electrophysiology 2nd opinion – implications for medical and psychiatric practice

 

Pandemic related inaccessibility prevented me from getting timely Cardiology appointments this year.  As a result, I ended up with my scheduled consultation and a second opinion consultation spaced just two weeks apart.  I talked with a 2nd electrophysiologist today. He had records about me dating back to 2009. I had consulted with a cardiologist who was an exercise physiologist and another electrophysiologist at that clinic. After reviewing the recent history of paroxysmal atrial fibrillation again we had a very interesting conversation.

He reviewed the issues of rate versus rhythm control again. The priority is reducing stroke risk and that is done by anticoagulation. When it comes down to trying to maintain a normal sinus rhythm and all the measures that involves the decision is based on "How much does the arrhythmia bother you". He gave many examples that I was familiar with including the person who is not aware of being in atrial fibrillation until you tell them. I have made the diagnosis many times by taking vital signs on people and noticing their irregularly irregular pulse and pulse deficit. Most of the time they have no awareness of the arrhythmia. In some cases, they have been advised of the arrhythmia but decided not to do anything about it. I am in the category of people with what I like to call "cardiac awareness". I know immediately if I am in atrial fibrillation or even having palpitations. I check my own vital signs 3 times a day-in triplicate. We had a discussion of my neurotic tendencies and how much this rhythm problem bothers me – even if I am in atrial fibrillation only a few times a year for a brief period.

This point is also critical when it comes to treating psychiatric conditions. A misrepresentation of medical and psychiatric treatment is that physicians are drumming up business and manipulating populations into unnecessary care. Either that - or the care is just automatic and dependent on a diagnosis or blood test.   One of the favorite fabrications is that the DSM is designed expand treatment and line the pockets of both psychiatrists and pharmaceutical companies. In fact, I have not seen a patient in outpatient practice that was not there because they were distressed, bothered by their current symptoms, and unable to get help anywhere else. In my conversation today with the electrophysiologist we are contemplating a 3-hour procedure under general anesthesia with significant potential complications including bleeding, stroke, the need for pacemaker placement, and death - all based on my subjective assessment of how much this arrhythmia bothers me. Based on level of risk – there are no equivalent decisions in psychiatry.

To reinforce that point, he said that cardiologists have been trying to show that rhythm control is superior to rate control for about 40 years and the evidence was very thin and possible non-existent. Based on the discussion of stroke prevention, that assumes that anticoagulation reduces stroke risk on the atrial fibrillation group to the same level as the normal sinus rhythm or rhythm group. I would give the edge to the rhythm control group on that parameter.  In terms of lifestyle measures rhythm control would potentially eliminate other nuisance rhythms like bigeminy and trigeminy if the origin was in the pulmonary veins.  Additional mapping occurs during the procedure to see if there is another focus for these rhythms.  The atrial flutter would need to be eliminated in a procedure on the right side of the heart. A concern that we did not discuss is a sudden worsening of the atrial fibrillation or atrial flutter to the point that a different antiarrhythmic would need to be used.  I have seen amiodarone added at that point and there are many complications with that medication – including death from pulmonary complications.

We got into a discussion about phenotypes based on the recent New England Journal of Medicine review. The focal point was whether a paroxysmal atrial fibrillation pattern like mine was easier to covert by an ablation procedure and remain in a normal sinus rhythm and remain in that rhythm.  He was aware of the review, but thought that not enough is currently known about phenotypes.  That seem to be a problem with a lot or intermediate or endophenotypes that are used in psychiatry and other fields like asthma or multiple sclerosis.  On the surface there appear to be a lot of easily described apparent subgroups, but the natural history of those groups and the underlying pathophysiology is essentially unknown and considerable heterogeneity in severity, course, and outcomes remains.   

There was a brief discussion of the athlete’s heart.  He had no reason to doubt that the slightly enlarged left atrium and aortic root on my echocardiogram was due to decades of intense athletic activity and knew that was also one of many potential factors leading to atrial fibrillation.

The question of early rather than late ablation was discussed and the idea that there is progressive remodeling in the heart due to atrial fibrillation even in the case of a few episodes per year. He thought that in general, ablation prior to persistent atrial fibrillation resulted in better outcomes and earlier ablation was better than late ablation.  He emphasized that these were across group comparisons and there was a heterogeneity factor at work.  All the ablation that he does is radiofrequency ablation and the result is anywhere from 75-90% effective depending on how well the pulmonary vein isolation goes.  That is balances against a 2-3% risk of adverse effects – largely in the form of bleeding and hematoma formation at the catheter sites.  Chest pain and migraine headaches are also common post procedure.  Very serious complications during the procedure including death and the need for pacemaker placement were at about 1%.  The only death he had seen during the procedure was unrelated to the ablation.

He had a different opinion about the dose of flecainide and moving on to other antiarrhythmics like sotalol.  He thought I could take twice as much flecainide as a standard trial dose 150 mg BID), but agreed that it might not make much difference in the low frequency of atrial fibrillation.  That is quite a difference in flecainide dosing compared to the other group of cardiologists that I consult with.

In terms of recovery time give my current workout schedule he thought it would take a month to get back up to speed.  At that point I could resume my usual activities. If I decided to do that soon it would mean putting speedskating on hold for another winter.

That is where I am at after the second opinion.  Assuming that my insurance is the same across facilities – I have two to choose from and two electrophysiologists willing to try the ablation. My choice is to weigh a moderately successful procedure against the low frequency but significant complications and make the decision. And I know at this point it is an elective procedure based on how disruptive this arrhythmia is to my life. It is possible that at some point due to worsening atrial fibrillation and/or flutter and associated worsening symptoms or cardiac function that it would be less elective.

In terms of comparison with psychiatric practice and the usual critiques – these are the same choices that people would have if they were seeing me in clinic with a few exceptions. I am not treating anyone with invasive procedures or general anesthesia.  The medications prescribed by psychiatrists are generally safer that antiarrhythmics. There is a long list of absurd complaints made by antipsychiatrists that could similarly be applied to this cardiology scenario. But most importantly – in either case the treatment decision by the patient is subjectively based on how much the symptom is bothering them. I do not know how to translate 4 hours of symptoms per year into what I have been told about daily anxiety and depression symptoms every week. Some of those symptoms are also cardiac in origin.  

But I think this highlights a completely neglected dimension of medical and psychiatric practice.  Treatment is based on more than a rational informed consent discussion and weighing the risks and benefits. It is based on more than a scientific diagnosis and confirmatory tests.

It is highly subjective and based on the personal experience of the patient that is rarely know to casual observers.

 

George Dawson, MD, DFAPA

 

 Supplementary:

I thought I would add some additional observations about my recent cardiology consults and how they compare with psychiatric practice. Putting these in the main body of the post would have increased the reading difficulty.

Categorial diagnosis versus something else:  It is fashionable these days to say that medically diagnosed syndromes are a thing of the past and we should be making dimensional diagnoses or systems diagnoses.  Of course, these have been tried in the past. Contrary to a standardized approach – the diagnostic and treatment approach is highly practice dependent as can be noted by comparing the recommendations of the last 2 posts.  In addition, there is a fine structure to categories that is so detailed that it cannot be listed as criteria. Diagnostic categories in medicine have been talked about as prototypes – but it is really an indexing system for each physician to catalogue everything they know about that disease especially in the populations they are treating.

There may be objections to this conceptualization of categorial diagnosis.  Shouldn’t all clinicians be making the same diagnosis based on some sort of standardization?  That is certainly the argument many people make – but it certainly is not realistic.  Experts have seen more cases, know more variations, and have seen more diagnostic errors in the conditions they are diagnosing and treating. They have studied those conditions more thoroughly than anyone else. To suggest that a non-expert can read criteria in a diagnostic manual or administer a checklist of symptoms from that manual and get the same results is a significant misunderstanding of the process.  

Any medical category can be parsed based on severity and using that metric will lead to different assessments and treatments within the same category That is as true for cardiac arrhythmias as well as categories of depression and psychosis. A related issue on the medical side is that all the associated symptoms that might be lumped into lifestyle effects or suggest a psychiatric disorder are basically ignored if they do not show up on a PHQ-3 that is given as part of a preregistration packet.

The good news here is that subjectivity is alive and well in medicine and psychiatry as it should be.  Our biology determines unique presentations of our illnesses as well as our reaction to them.  The physicians treating us have to understand that.

 

A Visit To The Electrophysiologist

I have been waiting for today’s appointment since January 19^th of this year. At that time I saw a cardiologist who recommended that I see an electrophysiologist for atrial fibrillation.  I have had paroxysmal atrial fibrillation - just a few episodes per year for 10 years.  It didn't start out that way.  I was having frequent episodes until the dose of the antiarrhythmic was adjusted.   It all began while I was speedskating one night and my heart rate monitor began chirping uncontrollably.  Since then I have been seen by 4 cardiologists and 4 electrophysiologists.  The first one suggested that I hold off on any ablation procedures until “the technology improves”.  I was back to seeing that doctor today.  The first time I saw him he impressed my with detailed drawings and notes about atrial fibrillation and the time he took to explain it all.  He wrote out all of the details of CHADS-VASc Score for atrial fibrillation stroke risk and tried to convince me to start anticoagulation.  I was not impressed with the addition of one point to the score just based on age so I deferred. I did start apixaban 3 months ago when I realized the systems of medical care was fragmented and if for some reason I did not come out of one of these episodes in a reasonable period of time I might run out of luck and end up with a stroke. This time the visit was a bit different – it went something like this (not a transcript):

EP:  “We have seen each other before – what brings you back?”

Me:  “A few things – the cardiologist I saw in January recommended it, I have some concerns about the Holter results, can I expect a better result from medication changes, and to get your opinion about ablation.”

EP: “How often do you have episodes?

Me:  “This year so far I have had three – one for 2 hours, and 2 for 1 hour each in February, July, and August.  Triggers may be anxiety and nightmares. Exercise is not a trigger acutely but I did have an episode the next day after I increased my pushups from 100/day to 150/day.

EP:  “That is actually pretty good considering you are 10 years out.  We generally see this as a progressive process….

Me:  “ I have been having 2-3 episodes per year for the past 10 years.”

EP:  “Even so there may be progression there.”

Me:  “What about the Holter result?  I noticed there was a brief episode of trigeminy. When this all started I had a much longer episode of bigeminy and was advised it was a benign rhythm.  Is there a ventricular component?  Does something need to be done about that?

EP:  “No this is atrial bigeminy/trigeminy and you are right it is a benign rhythm.  Your Holter shows less than 1% isolated PACs and VPCs so there is nothing to be concerned about there and I don’t think changing any medication would be useful.”

Me:  “My primary care doc called one of your colleagues about increasing the flecainide to 200 mg/day and he said the arrhythmia risk increased at the higher dose.” 

EP:  “I just don’t think it will do much in terms of eliminating 3 episodes per year.  Are you using CPAP?”

Me:  “I don’t sleep without it – my AHI is typically less than 1.  I also my check BP twice a day in triplicate and the systolic is typically in the 100-110 range.  It always seems elevated when I come here.”

EP:  “Everybody’s BP is higher here. Do you drink alcohol?”

Me:  “No.  I had a question about NSAIDS.  I have gout but have not had an attack in a long time. I know what the package insert says about NSAIDs and apixaban – can I safely use them for a few days?”

EP:  “Well I can’t tell you it is OK to use them because it is listed as a contraindication – but you would probably be OK for a couple of days.” 

Me:  “What about an ablation?  The last time you and I talked you advised me to hold off because the technology was improving at the time. Has it improved to the point it is safer?”

EP:  “It improves every year.”  [ draws a diagram of rate versus rhythm control and on the rhythm control arm antiarrhythmics versus ablation].  About 70% of people respond to ablation but in 33% of those patients it requires multiple procedures.  There is a 5% complication rate across all procedures and that includes damage to the esophagus or phrenic nerve but we monitor to prevent that. [Another diagram to show proximity of esophagus and phrenic nerve to the structures to be ablated].   There is also a risk of stroke but you are anticoagulated during the procedure to prevent this.  It is done under general anesthesia. It takes about 3 hours.  At the end of that time, you spend 2 hours in recovery to monitor the catheter sites and if you are OK – you can go home.”

Me:  “I have also had two episodes where the afib converted to atrial flutter at a rate of 130 – I understand that takes a right sided procedure in addition to the pulmonary vein isolation on the left?”

EP:  “They can both be done at the same time [demonstrates lesion and current pathway on his drawing].”

Me:  “I have seen photographs of the radiofrequency ablations and they appear to be full thickness burns….”

EP:  “We use a cryo procedure for the pulmonary vein isolation.  Any other questions?”

Me:  “On the Eliquis – my initial concern with it was ’nuisance bleeding’ described in the package insert but I noticed that I am bleeding a lot less than with aspirin.  Is that common.”

EP: “Yes.”

Me:  “Well at this point – I guess it’s up to me to decide on the ablation.  Let me think about it and get back to you.”

EP:  “OK here is my direct number.  Either way let’s get back together in about 6 months.”

That was the approximate content of the encounter. I am used to memorizing these details and summarizing them from long and detailed discussion in a psychiatric context.  I also compared the process with the first time I met this physician.  We were both wearing masks and this was significant and of course he worked through the entire pandemic and I bailed out after the first 18 months.  Both of those factors seemed significant.  The first time I saw him I was probably wearing my white hospital coat because I worked in the same hospital and would never take time off for an appointment in the building.  This time, he either forgot I was a physician or possibly had the view that psychiatrists don’t know much about medicine. At any rate the interview seemed pressured and he was running 30 minutes late.  I had advised his nurse that I thought I had dysgeusia (altered taste) from the apixaban.  That was not passed on and I forgot to ask about it again. I also wanted to ask about exercise and resuming speedskating now that I am retired but I also forgot to ask that question. But every cardiologist I have asked that question to in the past 16 years says the same thing: “Exercise as much and ask vigorously as you want to.”  I have come to realize that is not necessarily the best advice.

The overriding goals never seem to make it into medical appointments.  There always seem to be the assumption that you address a medical problem separate from your overall life.  For example, my goal is to live as long as possible and be as active as possible.  Never touched on.  With any cardiology problem there is also the issue of cardiac neurosis – will I at some point consider myself disabled from cardiac symptoms when I am not? Is it possible to do something that will make my symptoms worse? It helps to have a clear answer to that problem.  The closest I ever get is the exercise advice (that I question) – although today it seems that the episode frequency is minor and stable and the Holter results are nothing to be concerned about.

There was potentially some controversy in the appointment that I could have brought up.  The progression of atrial fibrillation irrespective of frequency seemed new and may not have been consistent with a recent New England Journal of Medicine review.  In that review it seemed like paroxysmal atrial fibrillation was a stable phenotype compared with persistent atrial fibrillation.  On the other hand remodeling at the molecular level potentially occurs every time there is an episode and for that reason my goal is to do everything possible to minimize them.

Was there another reason to post this?  There are a couple of reasons that I use my own medical experiences for didactic purposes.  The first is to illustrate the uncertainty in all medical diagnosis and treatment. Psychiatry is constantly (and erroneously) criticized for not having a discoverable lesion or testable abnormality as a cause of most non-medical psychiatric disorders. In this case, I am talking about two conditions (atrial fibrillation and atrial flutter) that seem to have a clear medical cause or do they? There are several pathways (genetics, heart disease, excessive exercise) leading to atrial fibrillation.  What is the true etiology in my case? The excessive exercise is largely based on preclinical studies in animals and observing a higher incidence of atrial fibrillation in endurance athletes. If I opt for an ablation – the first part of that will be an electrophysiology study to detect the conduction problems to be ablated. It is not a specific treatment for a lesion – it isolates the lesion or interrupts the circuit pathway.  The medication is similarly non-specific.  As the electrophysiologist said today: “Of course the medication will not cure anything. I can’t say whether the ablation will work. We can’t be certain of anything.”  Just a few weeks ago I saw a debate saying the psychiatric medications don’t “cure” anything. Cardiology and the rest of medicine seems to be in the same boat.

The other reason to use my own data is that I don't have to worry about consent and I don't have to disguise anything - although I have deidentified the ECG with respect to the physician and hospital. 

Death was not discussed as a possible outcome and I know that it happens.  Within the past few years there was a case posted in the NEJM that showed airlock in the ventricles based on and injured esophagus and air entering the heart from that pathway. There was also a celebrity who died following an ablation for atrial fibrillation.  Like most procedures, people who do them a lot are probably more successful, but there are never any guarantees.  Henry Marsh the British neurosurgeon has written about his complications and states that even in procedures where everything seems to go right there can be a bad outcome. Over the course of my lifetime I have experienced good and problematic surgical outcomes. It is a far cry from a coin toss - but they happen.

The phenomenology of the episodes was basically irrelevant today. I have them correlated with nightmares, anxiety, and other stimuli leading to increased adrenergic input.  None of the seemed relevant.  There was no discussion of sleep or how to get rid of the nightmares. Most people may have the expectation that cardiologists don’t cover this area.  Psychiatrists do and that’s why I am trying to figure that part out myself. On the other hand – I spend a lot of time talking with people about their cardiac symptoms and often tell them to call their physician immediately at the end of my session.

The nurse who got me into the room was very pleasant and professional. She went out of her way to make me feel comfortable. Her efforts were appreciated.  She was also charged with getting an ECG done before I saw the electrophysiologist.  She did this expertly and then offered me a copy of the ECG.  The electrophysiologist gave me an additional copy!  I posted a copy here (it is unremarkable) but I will add that if this had happened in a primary care clinic within the same healthcare organization – it would have elicited eye rolls, the statement: “Let me ask my supervisor if I can do that.”, followed by a rejection of that request. Again this is all the same healthcare organization presumably schooling each clinic differently in the nuances of HIPAA.  There should be no reason why you can’t walk out of the clinic with test results and I appreciate the efforts of the Cardiology Clinic.

That is where things stand today. I am playing it by ear and tracking my blood pressure, heart rate and rhythm, sleep apnea, nightmares, anxiety level, neurosis, headaches, and long COVID symptoms. I have decisions to make and will probably get a second opinion on the ablation issue as well as where to have it done.  Should it be at my local health care organization or at a larger referral center where they do a lot more of them?

But that is another story….

 

George Dawson, MD, DFAPA

References:

1:  Michaud GF, Stevenson WG. Atrial Fibrillation. N Engl J Med. 2021 Jan 28;384(4):353-361. doi: 10.1056/NEJMcp2023658. PMID: 33503344.

2:  Thomson M, El Sakr F. Gas in the Left Atrium and Ventricle. N Engl J Med. 2017 Feb 16;376(7):683. doi: 10.1056/NEJMicm1604787. PMID: 28199804.

   

A DSM for Psychiatrists?

 

 

No matter what version - the DSM is clearly a flash point for criticism by psychiatrists and non-psychiatrists alike. There are too many diagnoses.  People don’t like certain diagnoses or complain when some categories are eliminated. There are endless debates about diagnostic criteria, reliability, and validity. Categories are a wrong approach and we need dimensions. Philosophers have a field day imagining what the DSM is and making suggestions.  In an early post on this blog, I responded to the philosophical suggestion that the DSM was supposed to be a blueprint for living. Antipsychiatrists have no problem rejecting the entire volume of course because they are stuck in the 1970s with Szasz and maintain that there are no mental illnesses. The more flexible antipsychiatrists reframe this into everyday problems in living another decades old formulation that did not stand the test of time. Others suggest that the DSM exists to make diagnoses that lead to pharmaceutical treatment and make profits for drug companies.  The more legitimate criticism from psychiatrists is focused on the criteria and whether any diagnostic categories exist. Some of that criticism comes full circle back to why a classification system was needed in the first place. Clinical psychiatrists tend to use a fraction of the available diagnoses and in most practices can recall the diagnostic codes without looking them up. In fact, most psychiatrists use the DSM as a reference, pulling it off the shelf for rarely encountered diagnoses and then typically to look up a diagnostic code for coding and billing purposes. 

The title Diagnostic and Statistical Manual – is the first clue about the original intent of the manual and it antedates the psychiatric profession and the APA in the United States by several decades. The abbreviated history is available on the APA web site and several other Internet sites.  Initially it was to determine numbers of people by diagnosis both in the varied mental illness facilities across the country and later in military service. This function was described as administrative but there was also a consensus building aspect in the early 20^th century as diagnoses shifted from a unitary psychosis model to more nuanced.  The advent of the DSM-III was a turning point because it provided atheoretical definitions of disorders that were subsequently adopted by the ICD-9. Subsequent revisions in the DSM-IV and DSM 5 included revisions based on professionals and professional organizations, assigned work groups and their research, and eventually the general public. The original goal of classification and statistics has remained but it is used for various reasons by non-psychiatrists.

There are many examples of non-psychiatric use.  In the legal and political sphere, most states have rationed services for people with severe mental illnesses who are at high risk for hospitalization and other morbidities. Qualifying for those benefits depends on a  DSM diagnosis.  The same is true for state sponsored services for autism and developmental disabilities. In forensic settings experts are called upon to give diagnoses in an adversarial setting.  Disability, veteran’s benefits, and worker’s compensation are all linked to diagnoses.  All medical billing to insurance companies and government payers depend on DSM equivalent diagnostic codes in the ICD-11. Managed care companies ration care based on many of these codes by refusing to cover them. None of these functions were designed as an original intent for the diagnostic manual.

Heterogeneity – either explicit or implicit is another frequent criticism of the manual. Human biology and the biology of diseases and disorders teaches us that the etiopathogenesis of illnesses is diverse. There are many possible underlying biological and nonbiological causes.  Many genes and lesions can often lead to the same apparent presentation or phenotype.  That lead to the idea of intermediate phenotypes or endophenotypes to get a more consistent population to study but that has only been partially successful. The DSM was never designed to biologically classify mental illnesses, but DSM diagnoses are used for studies of biology and pharmacology. Other systems have been suggested for that purpose – most notably the RDoC system, but so far it has not exhibited any widespread success.  There is no reason to think that a verbally based system will accurately describe biologically based illness whether those descriptions are in the DSM or RDoC.

Apart from classification for statistical, administrative, and planning purposes what good is the DSM to psychiatrists? I recently saw it criticized for not including enough psychopathology. The criticism was bitter and partisan but apart from some very basic definitions the DSM is not a course in psychopathology.  All psychiatric residents need to be taught psychopathology to the point that they are experts in it. That will never happen from reading the DSM. It also doesn’t happen from reading a psychopathology text or taking a college course in psychopathology.  It happens from seminars, reading, and clinical experience – discussing psychopathology with colleagues, supervisors, and instructors.  It happens from learning in treatment relationships with people who have psychopathology not just a list or criteria but experiencing firsthand the interpersonal aspects. The DSM explicitly states that it is for use by trained professionals and that it can be used to facilitate communication between trained professionals.  

The DSM is clearly not a treatment manual of any kind. That is why I have always found the charge that it is a source of prescriptions for the pharmaceutical industry ludicrous.  There are roughly six times as many prescribers of psychiatric drugs as there are psychiatrists and the only medication in that category that is more likely to be prescribed by psychiatrists is lithium. It is easy to speculate that the prescribing patterns of that larger group are not contingent about what is in the DSM.

What about the diagnostic side and what psychiatrists need? Although there was some criticism that the neo-Krapelinians have had too much influence on the manual it is time to acknowledge that verbal descriptions have come to their logical limits. It is also time to acknowledge that psychiatrists need to know a lot more about medical diagnoses in general in order to function in a medical environment. If medical conditions are in the differential diagnosis – how many medical conditions do psychiatrists need to know about and diagnose?  Every psychiatrist I know has stories about medical conditions that were referred to them as a psychiatric disorder where they made the correct medical diagnosis. They are typically conditions from neurology, endocrinology, and infectious disease but also general medical conditions like diabetes mellitus, hypertension, and atrial fibrillation. Approaches I have seen in other specialties include lists of conditions that the trainee or practitioner needs to know about.  That is a useful approach but lists like that in a DSM are likely to raise objections about medicolegal risk and that a larger recipe book is being made for what it takes to be a psychiatrist. There are also many psychiatrists in settings where medical assessments are impossible, where they are referred out, or where the practitioner may feel inadequately trained. I see all of those reasons as being an opportunity to advance the quality of psychiatric treatment.   

A related issue is the diagnostic process in psychiatry as opposed to the rest of medicine.   Nassir Ghaemi, MD had a recent commentary about this on his blog suggesting that the DSM approach prioritizes comorbidities rather than differential diagnosis like the rest of medicine.  He describes the typical pattern matching that occurs early in the process and suggests that the differential diagnosis point, the DSM encourages listing all of the comorbidities rather than going through a differential diagnosis process.  In other words there is a lack of a hierarchical process. 

That has not been my experience. Granted – I may be a more medically oriented psychiatrist than most (but then again had 20 colleagues doing the same work) – but when I see a patient the universe of diagnoses are all possible both in and outside the DSM. The number one priority was making sure that a life threatening medical condition was not misdiagnosed as a psychiatric disorder.  Every physician can recall being taught about differential diagnosis and having to write an exhaustive list for the first few Internal Medicine inpatients. That process illustrated that a lot of the “rule outs” occurred as a mental exercise and really did not need to be written down. By the end of that rotation the differential diagnosis list collapse from the low double digits to the low single digits. There was also a triage element based on the more pressing problem or diagnosis.   A DSM for psychiatrists could make this process explicit, discuss the cognitive aspects of pattern matching and completion necessary for generating hypotheses in the differential diagnosis, the differences between differential diagnosis and comorbidity, and probabilistic considerations in selecting the preferred diagnosis. It would potentially have training implications because in order to optimize the pattern matching required - adequate training experiences need to be supplied to develop those skills. 

A DSM for psychiatrists needs to be much more information intensive in terms of research on validators, psychiatric genetics, multiomics, endophenotyping, drug mechanisms of action, and biological markers for each category.  A typical response to that suggestion is "Well there are no biological markers, labs tests, etc."  I don't find that to be a compelling argument when I think about what is currently being ignored.  We are on the cusp where more of that information is becoming relevant and we are past the point where much relevant information can just be dismissed. Any concern about cost of a more extensive manual can be dealt with by placing it online for subscribers. This may seem like a significant task given the accumulating information, but it is time the APA and research leaders in psychiatry to realize that the task has changed.  Psychiatrists are different from other physicians and other mental health professionals.  Psychiatrists need the technical information to provide quality care and compete against other systems that claim to know more about psychiatry and medicine than they do. Time to adjust to that reality and have the necessary internal debates first.

That concludes my suggestion for a DSM for psychiatrists, but I am open to more suggestions.  And for the record I am suggesting two different publications instead of a general manual full of qualifiers about expertise.  We need a manual for experts and another one like the current version - for everybody else.

 

George Dawson, MD, DFAPA

References:

1:  Horwitz, A.V. (2014). DSM - I and DSM - II . In The Encyclopedia of Clinical Psychology (eds R.L. Cautin and S.O. Lilienfeld). https://doi.org/10.1002/9781118625392.wbecp012

2:  Kim YK, Park SC. Classification of Psychiatric Disorders. Adv Exp Med Biol. 2019;1192:17-25. doi: 10.1007/978-981-32-9721-0_2. PMID: 31705488.

3:  Cooper R, Blashfield RK. Re-evaluating DSM-I. Psychol Med. 2016 Feb;46(3):449-56. doi: 10.1017/S0033291715002093. Epub 2015 Oct 16. PMID: 26470724.

4:  Shorter E. The history of nosology and the rise of the Diagnostic and Statistical Manual of Mental Disorders. Dialogues Clin Neurosci. 2015 Mar;17(1):59-67. doi: 10.31887/DCNS.2015.17.1/eshorter. PMID: 25987864; PMCID: PMC4421901.

5:  Blashfield RK, Keeley JW, Flanagan EH, Miles SR. The cycle of classification: DSM-I through DSM-5. Annu Rev Clin Psychol. 2014;10:25-51. doi: 10.1146/annurev-clinpsy-032813-153639. PMID: 24679178.

6:  Grob GN. Origins of DSM-I: a study in appearance and reality. Am J Psychiatry. 1991 Apr;148(4):421-31. doi: 10.1176/ajp.148.4.421. PMID: 2006685.

Supplementary:

It has been suggested that a hierarchical approach informs the usual differential diagnosis exercise but it may be the application of the parsimony principle. To me there is an open question about how well parsimony works for complex biological systems.

Photo Credit:  Eduardo Colon, MD