A Letter From The Surgeon General

Like most physicians in the United States, I got a letter from US Surgeon General Vivek H. Murthy, MD last week.  The focus of the letter was recruiting the assistance of physicians in solving what he describes as "an urgent health care crisis facing America: the opioid epidemic."  As an addiction psychiatrist about one out of every three new patients that I see is addicted to opioids.  I have been lecturing on this topic for 6 years now, so I have more than a passing interest in what the SG has to say.  I have to say that Dr. Murthy wrote an excellent letter.  I was particularly impressed with his second paragraph describing how the was a combination of good intentions to treat pain and aggressive marketing by pharmaceutical companies and the single most important sentence in the letter:

"Many of us were taught-incorrectly-that opioids are not addictive when prescribed for legitimate pain."

Since I was already out practicing for about a decade at the time, I was spared that initiative.  I never assumed that opioids were not addictive, only that some people were more predisposed to addiction than others and that some had such strong adverse effects that they were very unlikely to become addicted.  But in routine psychiatric practice, even before the epidemic it was common to see patients who demanded increasing amounts of addictive drugs or who were hospitalized for adverse effects.  I had treated numerous people who appeared to have dementia, but were longstanding users of opioids, benzodiazepines, and even older sedative hypnotics.

Dr. Murthy goes on to detail the costs in terms of 2 million people with prescription opioid disorder, increasing heroin use, and increasing numbers of cases of HIV and hepatitis C.  He acknowledges that treating pain with opioids and finding the correct balance between analgesia and addiction will not be easy.  He encourages physicians to take the pledge to turn the tide on the opioid epidemic at www.TurnTheTideRx.org and reading the enclosed pocket card to the CDC Opioid Prescribing Guideline.  He also encourages physicians to approach addiction as a chronic illness rather than a moral failing.  That will probably result in some blowback from the addiction is not a disease crowd.  I hope that it is clear from my previous postings that in popular surveys, most people consider addiction to be a disease.  At the scientific level, I think it makes the most sense.  A lot of the confusion in this area comes from a lack of appreciation about how substance use disorders are stratified.  Volkow came up with a good definition in a New England Journal of Medicine paper earlier this year (1) - separating substance use disorders in general from addiction and defining addiction as severe DSM-5 substance use disorders. (the DSM-5 refrains from using the term addiction).

The enclosed card entitled "Prescribing Opioids For Chronic Pain" touches on a few of the high points.  My section by section critique follows (the entire card is below in the supplementary section for review).  Section 1 focuses on pain ratings using the old 0  to 10 scale where 10 is the "worst pain you can imagine".  The unstated problem with that approach is that it is not quantitative and cannot be taken in isolation.  There are people for example where this rating is completely unreliable.  Section 2 is a consideration of non-opioid therapies.  It lists the usual medication prescribed for chronic pain.  The problem here is that acute pain is often an entry point for addiction.  There are many people getting opioids like oxycodone and hydrocodone for what used to be considered trivial injuries, like an uncomplicated ankle sprain.  The  other acute pain entry point for addiction is post operative pain.  There have been studies that show a significant number of patients are still taking opioids a year after their surgical procedure.  It is common for me to interview very young patients who were given opioids for trivial injuries or surgery who became addicted to these drugs.  Physicians need to be very clear on appropriate pain treatments and not offer choices.  For example,  I was told by a friend that he was in a situation where patients were offered acetaminophen, ibuprofen, oxycodone, or oxymorphone.  This is exactly the wrong way to approach the treatment of pain.  In a culture where many people consider themselves to be drug savvy - the overwhelming choice will always be the most euphoria producing opioid.

 Section 3 is a discussion of the treatment plan.  Treatment contracts can be useful here, because most patients need more than a discussion.  They need a document that they can refer to.  It also gives the physician clear anchor points that can be used when discussing a taper or need to discontinue the medication.  Section 4 involves the complicated assessment of harm and misuse.  For most physicians this means the capability to expand their diagnostic capacity from the primary condition and the associated pain disorder to being able to make the diagnosis of addiction.  In some cases there are clear markers (toxicology screens), but in many cases, the patient has developed an addiction as a direct result of the physician's prescription and the line between therapeutic use and addiction is less clear.

The card also provides clear examples of milligram morphine equivalents (MMEs).  This is a term used frequently in the research literature.  When comparing patients on different opioids it is useful to convert whatever opioid they are taking to MMEs.  Mortality and morbidity with opioid prescriptions are generally associated with daily doses greater than 90-100 MME range.  The card points out that this is about 90 mg of hydrocodone or 18 tablets of hydrocodone/acetaminophen 5/300 or 60 mg of oxycodone or 4 tablets of oxycodone sustained release 15 mg.  In patients with addictions it is common to see chronic use of 120-240 mg oxycodone per day.

The card provides advice on starting low and going slow with the dose escalation as well as a suggested taper of 10% per week.  It suggests limited supplies, much more limited for acute pain.  It cautions against prescribing opioids and benzodiazepines concurrently - a practice that remains all too common.  A sentence about how that happens might be useful.  Chronic pain is typically associated with anxiety, depression, and insomnia.  Patients typically are focused on symptomatic relief in all three areas.  That can result not only in benzodiazepine prescriptions but also the prescription of cross tolerant sleep medication like zolpidem or eszopiclone.  Another worse case scenario is the patient using extra opioids for treating these associated symptoms and that is very problematic.  Educating patients about all of these contingencies easily exceeds the time that most primary care physicians have to spend with people.  That may be another reason to have ample documentation available to assist physicians.  There also needs to be a complete discussion of side effects and adverse effects from opioids.

The card transitions into treating an opioid use disorder with medication-assisted treatment like methadone, buprenorphine, or naltrexone.  At this point, I think that the expertise of most primary care physicians has been exceeded and they are looking for referrals to treat the addiction.  I think that the context of care needs to change.  It is very difficult to be in a primary care setting focused on pain as the disorder one week and then transition to addiction care the next.  Most patients will be unable to make that transition in the same clinic.  The idea of offering naloxone for those with high overdose potential on the same card is also confusing.  I could see how it might result in patients being treated for pain and getting prescribed opioids also getting naloxone.  I think that naloxone is more appropriately used with a defined addiction and plan to address the addiction.  The best approach to prevent oversedation and cognitive side effects is close monitoring and gradual dose increases.

All things considered this was a good first effort by the Surgeon General.  I would like to see him become active in changing the cultural attitudes in the US about opioids.  There is a myth that opioids are the magic bullet for pain relief and that is not true especially for chronic pain where the effects are modest and not typically better than non-opioids.  There is a large segment of the American culture that also values getting high and opioids are always discussed from that perspective.  Americans hoard opioid medications and give them away and trade them with other people for various reasons.  When a medication becomes an urban legend like opioids have - it is like the old travelling medicine shows.  Opioids are good for whatever ails you and they make you feel good as a useful side effect.

Countering all of those cultural biases about opioids is a big job - but I am reminded of Surgeon General Koop and his approach to altering American biases about tobacco smoke.                   




George Dawson, MD, DFAPA


References:  

1: Volkow ND, Koob GF, McLellan AT. Neurobiologic Advances from the Brain Disease Model of Addiction. N Engl J Med. 2016 Jan 28;374(4):363-71. doi: 10.1056/NEJMra1511480. Review. PubMed PMID: 26816013. (full text).


Supplementary:

TurnTheTideRx Pocket Card as graphics below.  You can also download the actual card as a pdf at this link:

A Better Analysis Of The Psychiatrist "Shortage"

A paper in Health Affairs on the "psychiatrist shortage" has been getting a lot of press lately (1).  People are acting like the authors' conclusions are definitive rather than highly speculative, but that is a standard approach in the press.  In the article they use American Medical Association (AMA) Physician Masterfiles from 2003 and 2013 to calculate the number of psychiatrists per 100,000 population for those two dates.  They compare it to similar data for neurologists and family physicians.  Between 2003 and 2013 there was a -0.2% change for psychiatrists as opposed to a +35.7% change for neurologists, a 9.5% change for primary care physicians and a 14.2% change for all physicians in this time period.  They also calculated medians for all groups and coefficients to look at workforce distribution.  As expected psychiatrists and neurologists showed some skew of distribution compared with adult primary care physicians.  That could also be seen in the density of psychiatrists by region:  24.47 per 100,000 in New England to 13.33 per 100,000 in the Pacific area.  They show the geographic distributions by highlighting quartiles of distributions on a quartile map of the United States.  The regions highlighted are 300 - Hospital Referral Regions rather than states.

There appears to be a significant typographical error on page 1275: "Our finding that there was almost a 10 percent decline in the population adjusted mean number of psychiatrists per HHR supports the belief that the supply of psychiatrists likely limits patient access to their services".  They are referring to median numbers here and in their abstract where they use the correct term.  The actual number of psychiatrists in 2003 was 37,968 and in 2013 it was 37,889.  The real numbers just don't seem that dramatic.

In the context of these statistics the authors offer a very inconsistent analysis frequently equating the number of psychiatrists with access to services or imposing severe limitations on treatment as illustrated by their statement: "Since the current supply of psychiatrists is not meeting the needs of people with mental illnesses and is not keeping pace with population growth, policy makers and the medical community must consider ways to address the shortage and improve access to mental health care".  This conclusion is quite a stretch considering data that the authors include in the paper.  They use the figure of 9.6 million adults with severe mental illnesses and only 40% of those people receiving care.  That means if the 37,889 psychiatrists they counted had only 250 people with severe mental illness on their caseload - 100% of these patients would be treated.  I propose that psychiatrists only see patients with the severest forms of mental illness and in today's world 250 patients is a very modest caseload.  In the heyday of psychoanalysis, some analysts did not treat many more patients over the course of their career.   At the maximum this suggests a geographical mismatch between patients and psychiatrists rather than a global shortage of psychiatrists.  Is increasing the supply the best approach to this problem?

In another section of their paper the authors point out that psychiatrists account for only 5% of the mental health workforce; 95% being psychologists, social workers, therapists , and counselors.  They acknowledge that they have no equivalent statistics for those disciplines or nurse practitioners or physician assistants.  Many systems of care these days see a prescriber as a prescriber and selectively hire non-physician prescribers over psychiatrists.  Even without the data it would seem fairly obvious that there has been a proliferation of non physician prescribers over the past decade and no shortage of antipsychotic, antidepressant, stimulant, or benzodiazepine prescriptions.  How can there be a shortage of prescribers in a sea of overprescriptions?

The authors notion that "policy makers and the medical community" are going to provide the solution here is also incorrect on several grounds.  First and foremost - if there is a problem - these are the same people who got us here in the first place.  The authors themselves reference a Graduate Medical Education National Advisory Committee study from 30 years ago predicted the shortage.  Any Medline search looking at "psychiatrist shortage" will also yield papers on this topic dating back to 1979.  In that time frame there have been very modest attempts to expand the workforce in psychiatry.  I made that statement based on expansion of residency slots.  The reality is that there are many International Medical Graduates who are well qualified for residency positions and may have even completed equivalent certifications in their country of origin.  The authors also seem to miss the point that these same "policy makers" have initiated policies to expand non-physician prescribing that has led to decreased staffing by psychiatrists in many settings.  They make the typical mistake that policy makers can't have it both ways and they seem quite intent on reducing rather than expanding the psychiatric workforce.  In the argument the only function a declaration of a psychiatrist shortage limiting mental health treatment is to scapegoat psychiatrists for a problem that may be imaginary but at the minimum is out of their control.  The appeal to policymakers also ignores the fact that policy makers in the US, generally advance pro-business policies that place both physicians and their patients at a distinct disadvantage compared to the business.  I will address some of those points below.

Some additional points not considered by the authors:    

  1.  Inefficiencies in the psychiatric workforce are large - Those inefficiencies are two fold.  First, the practice of psychiatry is notoriously inefficient.  I have done comparisons with both ophthalmology and orthopedic surgery on this blog where comparatively fewer specialists cover an impressive array of serious illnesses.  They do this largely through a much better triage system focused triaging the most serious illnesses.  By comparison, the conditions treated by psychiatrists all receive rationed care and in some cases - the care is completely displaced to a non-medical facility.  In most others there is inadequate infrastructure to address the problem.  The facilities themselves are managed by non-medical administrators who in may cases have caused disruptions in care and severe quality problems.  Care is further fragmented by the fact that managed care companies and governments do not provide realistic reimbursement for the care delivered and incentivize hospitals to provide minimal care.

Second,  managed care and government bureaucrats in their infinite wisdom have made psychiatry even less efficient.  I interject the term "medication management" here as an example and will elaborate below.

2.  The prevailing model of care is antiquated and a throwback to the 1980s - The preferred business and government model of care is the so-called medication management visit also more pejoratively known as the med-check.  It is based on a thoroughly poorly thought out idea that people with severe mental illnesses can be treated with medications for the symptoms of those illnesses.  That model does not work at even the most basic idea that there are social etiologies of symptoms that need to be addressed by social and psychotherapeutic interventions.  There are no medications that treat unemployment, separation and divorce, or the sudden loss of a loved one and yet the entire billing and coding structure for psychiatric visits was based on this model.  Even worse - the productivity scale for employed psychiatrists is still based on this model with a rough correlation between how many people are seen in one day and compensation.

3.   Academic and intellectual approaches to psychiatry are at an all-time low -  An intellectual approach to the field is critical whether considering phenomenology, the conscious state of the individual or all of the medical factors associated with treating the psychiatric disorder.  The environment is also frequently neglected because it is managed by non psychiatrists - at least until there is an incident or violence, aggression, self-injury, or suicide that requires analysis.  The intellectual approach to the field requires study of both the individual and the environment that they are in.  An intellectual approach to psychiatry also requires centers of excellence where people with those problems can go to receive expert care.  Centers of excellence are much less common in psychiatry than other fields.  Over the past 20 years academics and educators in the field have been subjected to the same productivity demands as clinicians.  Academic work of all kinds is devalued in order to increase the number of  patients visits focused on medications.  All incentives in place from the policy makers point toward a continued non-intellectual approach to the field.

4.  Practically all employer based positions are burn-out jobs - Reasonable people will work them for a time and then quit and ask themselves how they got involved in that situation in the first place.  The authors seem to think that better compensation or collaborative care models would increase the participation of psychiatrists in these flawed systems of care where they are "supervised" by unqualified business people.  To me the best insurance against burnout and practicing a higher standard of care is to not accept any payment arrangement that involves your work or professionalism being compromised.

5.  Public health and infrastructure needs are always neglected when it comes to psychiatry and mental health -  The most pressing issue is the dismantling of hospital structures and hospitals with therapeutic environments.  We cannot expect this to be rebuilt with the current paradigm of containment and maximizing profit by discharging people without adequate treatment.  Another way to look at the situation is that we cannot expect intellectually stimulating, state-of-the-art treatment environments when the only admission criteria is business and government defined dangerousness.  We also need therapeutic environments for the psychiatrically disabled rather than psychiatric slums and homelessness.

 The public health measures do not stop there.  America's huge appetite for addictive drugs drives a lot of psychiatric morbidity.  This offers one of the best areas for reducing the incidence of psychiatric problems and the need to see a psychiatrist.  Nobody at the policy level seems to be very interested in this problem.  Perhaps it is a resignation to the political success of the cannabis movement and more recent ideas about psychedelics being therapeutic drugs.  Reducing drug addiction and exposure would not only reduce the incidence of accidental overdoses but it would also reduce the incidence and severity of psychiatric disorders by an additional 30%.  Addictive drugs is just one aspect of prevention that is ignored by policy makers.  I would list violence and homicide prevention as a close second.

I still operate from the basic assumption that physicians are bright, well intentioned people.  That means they operate best when they have a manageable schedule, are not overworked and sleep deprived, and are allowed time for intellectual pursuits in their field.  You don't go into medicine to put in 8 hours, punch a clock and go home.  Ideally there is intellectual stimulation at work every day.  The intellectual stimulation certainly needs to be there if the psychiatrist has any involvement in teaching psychiatric residents.  It can't be there if physicians are managed like production workers especially when the product they are producing is an inferior one.

And practically every psychiatrist knows that the business-managed work product that they produce is markedly inferior to what they were trained to do and what they are capable of.  That is what fuels the private practice movement - NOT financial remuneration.

How can anyone expect to recruit and retain psychiatrists when their practice environment is actively being destroyed?  Why would anyone be interested in the field?



George Dawson, MD, DFAPA



1: Bishop TF, Seirup JK, Pincus HA, Ross JS. Population Of US Practicing Psychiatrists Declined, 2003-13, Which May Help Explain Poor Access To Mental Health Care. Health Aff (Millwood). 2016 Jul 1;35(7):1271-7. doi: 10.1377/hlthaff.2015.1643. PubMed PMID: 27385244.

Just When You Thought American Healthcare Could Not Get Any Worse.....

I was on a vacation/family reunion last weekend about 150 miles north of the Twin Cities and 120 miles west of the only large northern metro area.  We were in the heart of lake country and about an hour from the closest emergency department (ED).  About 20 people of all ages there  for a few days to get reacquainted after a number of years, enjoy some good traditional foods, and outdoor activities.  Things were going very well until the last day.  Everyone was exiting the lake home to go to a local pizza establishment.  One of the family members missed the last step and fell hard to the pavement, knocking the lens out of his eyeglasses and sustaining a contusion/abrasion over the left supraorbital ridge.   No loss of consciousness.  He did sustain an abrasion on the left hand with some residual wrist pain.  He has some chronic medical problems but is not on anticoagulants.  Another family member is a nurse and applied an ice bag and cleaned a small laceration in the area of the abrasion.  It did not appear to need sutures and it was steri-stripped.

The only other bit of information that is necessary about the injured man is that he is 80 years old.  As a geriatric psychiatrist I ran down the usual considerations of the old approaching the old old - especially anatomic traction on bridging veins and subdurals from that injury.  I did not want to miss any needed brain imaging protocol based on these factors.  I decided to call the local hospital emergency department and run it by the triage nurse.  The call went like this (this is not a transcript).

Hospital:  "Can I help you?"
Me: "Yes - I am currently out at a lake cabin and a family member took a fall and struck his frontal area.  No loss of consciousnesses, headache, visual change, or neurological findings.  I would like to talk to your ED triage person to see whether imaging is indicated."
Hospital:  "Is he from Minnesota?"
Me:  "No he is not."
Hospital:  "We cannot allow you to talk with the ED if he is not from Minnesota.
Me:  "Are you sure about that?"
Hospital:  "Yes very sure."
Me:  "I am a physician - is there any way that I can talk directly physician-to-physician with an ED physician."
Hospital:  "No you can't.  You have to call the number on the back of the insurance card."

That was a precedent setting call for me.  I did not identify myself as a psychiatrist, but I have really never encountered this kind of administrative obstacle to medical care.  I viewed my question as an important one and one that an ED physician would probably know more about than me.  In that context there was something about an out of state resident not getting equal access to medical care.  I am sure it would be easier to get access in France or Germany than it was in Minnesota.  I collected the medical card and made a second call to the nurse triage line listed on the back of the call.  My experience with nurse triage lines is that they at least call the physicians on call and get some semblance of an answer to your question - even on the weekends.

Me:  Explaining the situation again in its entirety and giving all of the relevant insurance information both on and off the card.  The off card data included date of birth and three repeats of a call back number.  It was at that point the triage nurse said:
Triage RN:  "Well I am afraid I can't help you because you have to talk with a nurse who is licensed in the state where your relative resides.  But I will transfer you."
Me:  "OK"
Cricket sounds and bad muzak for about 5 minutes.
Triage RN (back on the line):  "The wait times are too long.  Let me just tell you that as long as he has no headaches, nausea, vomiting, visual changes or neurological symptoms - you can just watch him.  Bring him to the ED if any of those symptoms occur."
Me:  "OK - there is no imaging study given his age?"
Triage RN: "No".

As multiple posts on this blog can attest - I am openly critical of how business and government interests have rationed access to health care.  I had really never imagined obstacles to standard health care based on your state of residence.  I had never encountered a system that refused physician contact with another physician in their system.  I can see the gears turning on how to turn these calls into billable fees, even if it means a steep out-of-pocket payment by the patient.  But even in that case giving me the correct medical information is money in their pocket if it results in a CT scan.  Medical imaging generally covers about one-quarter of the operating budgets of hospitals these days.

For now it appears that after hours physician consultation may be rare and a sequence of calls based on legitimate concern needs to be answerable by a triage nurse's database or a visit to the emergency department.

And you better hope that you are in the right state.



George Dawson, MD, DFAPA




Supplementary (posted on August 23):

Getting back home and doing a little more research shows that both the Emergency Medicine (2) and Internal Medicine (1) literature say that age alone is an indication for a CT scan following a minor TBI.  UpToDate says that age 65 years of age or older is an indication.  The emergency medicine literature uses New Orleans Criteria suggesting an age of > 60 and the Canadian CT Rule suggesting an age of > 65 under CT if any criteria present.  According to these criteria - age alone is an indication for a CT scan.

1:  Randolf W. Evans.  Concussion and mild traumatic brain injury. In: UpToDate, Aminoff MJ, Moreira ME (Eds), UpToDate, Waltham, MA (Accessed on August 22, 2016). - see graphic 50743.

2:  Haydel M. Management of mild traumatic brain injury in the emergency department. Emerg Med Pract. 2012 Sep;14(9):1-24. Epub 2012 Jul 20. Review. PubMed PMID: 23101569. (full text online).


Attribution:

That's me walking on a dock in Lake Country.

Indexing Versus Diagnosis - A Non-trivial Difference?

There was an interesting article written by Kenneth S. Kendler, MD in this month's American Journal of Psychiatry.  It addresses a phrase that I have seen in typed evaluations that causes me to cringe: "The patient does/does not meet criteria for major depression."  I was asked why that phrase bothered me so much and I basically pointed out that I don't care whether a person "meets criteria" for a specific DSM criteria - the overall assessment was more important to me.  Kendler describes the difference in terms of phenomenology - are there other aspects of depression that merit further description than what is in the DSM?  That seems true to me as well as, the time domain of symptoms development and how some of the critical symptoms may have developed.  On a developmental basis - sleep, anxiety, and depression all may have different time frame and given the length of time that the DSM approach has been around - there has been very little discussion of some of the key convergences and divergences.  Is primary insomnia beginning in middle school associated with depression in the twenties - the same problem as no insomnia in childhood and depression in the twenties.

To study the issue Kendler looks at 19 textbooks and 18 symptoms domains described in each of those textbooks.  He has specific criteria for textbook selection that resulted in 19 texts from 5 countries published between 1899 to 1956.  He included full criteria published by Wendell Muncie in 1939 and Aubrey Lewis in 1934 as being particularly instructive.  He looks at the number of authors describing a particular symptoms and additional descriptors of the symptoms they found in depressive states.  Just looking at neurovegetative states, the results are interesting.  The atypical depressive symptoms of hypersomnia and increased appetite and weight gain were essentially absent. Fourteen authors described sleep problems as initial insomnia or non restorative sleep.  Three authors described early morning awakening.  Poor appetite was listed by 10 authors and weight loss by 9 authors.  Anhedonia was listed by seven authors.  Kendler provides a detailed analysis of the remaining symptoms and how many of the authors consider these symptoms to be representative of depression.

One of the most instructive aspects of the paper was a direct comparison with DSM5 criteria across 18 symptoms, whether they are covered in the DSM and to what extent.  The symptoms not covered included volition/motivation, speech, other physical symptoms, anxiety, and depersonalization/derealization.  Experienced clinicians commonly encounter depressed people with all of these symptoms in everyday practice.  As an example, some of the most severely depressed people that I have treated were somatically focused to one degree or another on a continuum to the point of somatic delusions.  Adhering to DSM5 criteria would leave out the most important feature of their illness.  A more complete description of these symptoms allows for a better demarcation of the line between depression and psychotic depression - a critical line for developing a treatment plan.  Another critical aspect is the relationship between anxiety and depression.  The DSM tends to sacrifice a broader phenomenological approach for narrow, easily determined diagnostic markers.  Instead of describing the anxiety associated with depression, depressed patients often end up with additional diagnoses of anxiety disorders and in the DSM field trials it appears that anxiety and depression morph into on another and the criteria appear to have low diagnostic reliability in that context.

The broader concept from Kendler's philosophical perspective is whether meeting criteria is that same thing as having the disorder.  From a phenomenological perspective it is certainly possible to produce detailed analysis of patients that do not resemble one another in many regards.  Considering the fact that depression is always mapped onto unique conscious states that should not be too surprising.  Kendler's idea is that the DSM5 criteria do a "reasonable but incomplete job of assessing the prominent symptoms and signs of depression in the western post Kraepelinian tradition  ".  The idea of indexing cases of depression from what is not depression is relevant here.  I think that he should have been a little more specific in his criticism.  I don't think they do a reasonable job when they are not part of a psychiatric assessment by a psychiatrist who has enough time to do a good job.  Taking the DSM5 criteria and converting them into a checklist and applying that to the masses comes to mind.  This is probably the most absurd conclusion to the indexing concept, surpassed only by telling those who are screened that "you meet criteria for depression and that meets our health plan criteria to start citalopram".

 Kendler points out the consequences of reifying diagnostic criteria to the point that they become distinct disorders in the absence of any quantitative markers.  Andreassen made similar arguments about DSM technology and the death of an interest in psychopathology in a previous paper (2).  Both authors seem to miss the mark in terms of what is really missed here.  The diagnostic nosology has shifted from a relative simple mind based paradigm to one that purports to pick up extreme conditions at the fringe of human behavior.  The accuracy of those diagnoses is less as the described disorders get more common.  Human consciousness appears to be the critical variable here and there remain very few commentators on this issue.  Psychiatric disorders become very complex once the psychiatrist goes far beyond symptom lists and even personality disorders and what is commonly considered personality traits to recognizing that the person in front of you is a truly unique conscious state associated with a unique neurobiological state.

              

George Dawson, MD DFAPA



References:

1: Kendler KS. The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria. Am J Psychiatry. 2016 Aug 1;173(8):771-80. doi: 10.1176/appi.ajp.2016.15121509. Epub 2016 May 3. PubMed PMID: 27138588.

2: Andreasen NC. DSM and the death of phenomenology in America: an example of unintended consequences. Schizophr Bull. 2007 Jan;33(1):108-12. Epub 2006 Dec 7. PubMed PMID: 17158191; PubMed Central PMCID: PMC2632284. (full text)


Attribution:

Quote at top is from reference 1 by Dr. Kendler.

Open Psychiatric Units Mean Fewer Suicides and Elopements ?!!

There is a headline making the rounds in the media about whether or not locked psychiatric units are useful in preventing suicides and "absconding" behavior in inpatient psychiatric units.  Absconding is running away before the formal discharge and in the US it is referred to as elopement.  The media handling of this article is a bit less scholarly than you might expect from the average psychiatrist reading this article.  Even media circulating to psychiatrists sends out the headlines from a news service:  "Locked psychiatric wards may mean more suicide or escape attempts." Since I have spent the majority of my career on locked psychiatric units and consider myself an expert in this area - reading the article and looking at its deficiencies comes naturally to me.

The article looks at a coalition of 22 German psychiatric hospitals and their affiliated psychiatric services.  Sixteen of the hospitals had at least one locked psychiatric unit over the course of the study.  Four hospitals had no locked wards over the course of the study.  One of the hospitals started out with no locked wards but "had to introduce locked wards for legal reasons" in November 2000. organized under a central agency that looks at quality assurance and quality management.  Twenty one of the hospitals participated in data analysis by a central quality assurance/management agency the Dokumentationsverbund Psychiatrie (DVP).  The study period ran from January 1, 1998 to December 31, 2012.  This was  an entirely retrospective analysis based on anonymized data.  During the study period there were 271,128 admissions to locked wards and 78,446 admissions to open wards.

Primary outcome variable was completed suicide and secondary outcome variables were suicide attempts during treatment, elopement without return, and elopement with return.  Some of the characteristics of the populations were described and they appear to have diagnoses similar to what might be found on inpatient units in the US with major difference - some of the primary diagnoses listed would likely not be admitted - like somatoform disorder or personality disorder as a primary diagnosis, but the study says very little about admission criteria.  On American inpatients psychiatric units pure substance use disorders are actively discriminated against, by insurers and government agencies that govern hospitalizations and in the German sample. they constitute 18-25% of the primary diagnoses.  The authors do a statistical comparison between the locked ward and open ward groups across the outcome variables.               

There are two logical flaws with the study and the researchers comment on one.

The first is generalizability of the data.  The authors seem to recognize this in their use of OECD data and the rates of psychiatric bed utilization in Germany (2.8 per 1,000 population) versus the UK (0.5 per 1,000) and the US (0.3 per 1,000)  suggesting that there is greater acuity in the populations with fewer beds and that there is a greater proportion of acutely ill patients.  The other parameter that is critical in American inpatient psychiatry is the number of aggressive and homicidal patients.  At large metropolitan hospitals units comprised almost entirely of highly aggressive patients are not unusual.  Other patients are generally considered too vulnerable to be admitted to these units.

Aggressive behavior can create near riot conditions on units like this and an unlocked door would create numerous situations leading to violent confrontations with staff.  The striking part about this comparison to the German system was that this paper left out all mention of aggression, violence and homicide suggesting that these patients were not being admitted to these hospitals.  The only line containing these words in the entire paper was in one of the references.  That makes this study impossible to compare with any set of metropolitan psychiatric units in the US.  There is the associated question of what the Germans do with their aggressive patients?  Are they sent to forensic hospitals or specialized units?  It would be very unlikely to not encounter thousands of highly aggressive patients in any American sample this large even at a time when the largest psychiatric hospitals in the country are county jails.

The second is that the implicit notion about a randomized controlled trial.  For the reason I previously mentioned it is not likely to be ethical, amenable to human subjects approval or therefore doable.  The authors suggest that being under a mandate to treat all patients in a certain geographic area reduces selection bias.  That is difficult to accept if potential for aggression and overt aggressive behavior is not an admission criteria and if it not compared between the locked and unlocked units.      

That said, what can American psychiatric units learn from the German experience?  The first and most important is that unlocked units are possible.  I worked at a facility that typically had 4 psychiatric units and when we started one unit was open.  It was a transitional unit where people were sent after their acute disorder, agitation, aggressive behavior. and suicide risk was treated but they were not quite ready for discharge.  The management of psychiatric units by business managers eventually dictated that these partially stabilized people should just be discharged - frequently when there had been an almost imperceptible improvement.  This was all based on the fallacious "dangerousness" argument by managed care companies.  They decided about 20-25 years ago that the only reason anyone should be hospitalized on an inpatient psychiatric unit was if they were dangerous to themselves or others.  That also led to locked hospital wards, if not by implication by explicit managed care feedback as in: "If the patient does not need to be on a locked unit - they don't need to be in the hospital and therefore we are denying payment for this admission."  Have these managed care tactics dumbed down inpatient treatment and adversely affected the atmosphere of these units?  Of course it has.  It has created a palpable corrections-like atmosphere in many units.  The only reason people are there is to figure a way to get out.  This reinforces the thought that the people there really don't have any problems in the first place they are just being discriminated against.  So the first lesson from Germany is to restore the running of hospitals to psychiatrists and not business managers.

The second issue is infrastructure and length of stay (LOS).  Most EU countries have significantly more psychiatric beds available to their populations.  The most likely reason is that they are not rationed (nearly out of existence) by managed care companies or the government like they have been in the US.   Lengths of stay are also significantly greater.  The interesting dimensions for comparison would be the functional status of patient at discharge as well as the therapeutic milieu in comparing German to American units.  That would require a more sophisticated research approach but it might bring some science to inpatient psychiatric care.  It would also be interesting to know if the German hospitals have state of the art specialized programs for specific conditions and whether their environment is designed to emphasize the therapeutic rather than containment aspects.

There is also the opportunity to look at the administrative aspects of these units more specifically the impact of a business management approach to a more clinical or at least less of a short term profit approach.

We have all witnessed what healthcare businesses can do to inpatient care in the US - and it is never good. 

George Dawson, MD, DFAPA

References:

1: Huber CG, Schneeberger AR, Kowalinski E, Fröhlich D, von Felten S, Walter M, Zinkler M, Beine K, Heinz A, Borgwardt S, Lang UE. Suicide risk and absconding in psychiatric hospitals with and without open door policies: a 15 year, observational study. Lancet Psychiatry. 2016 Jul 28. pii: S2215-0366(16)30168-7. doi: 10.1016/S2215-0366(16)30168-7. [Epub ahead of print] PubMed PMID: 27477886.

News Flash From the StarTribune - Psychiatric Patients Have "Nowhere To Go"

Not to be outdone by the local television stations, the Minneapolis StarTribune came out with their own stunning analysis of the problems with psychiatric care in the state.  At least the opening line was stunning:

"Hundreds of Minnesotans with mental health problems are languishing in hospital psychiatric units for weeks, even months, because they have nowhere to go for less intensive care, according to a comprehensive study to be released this week. " 

Notice the expertise in this sentence - we now have a comprehensive study.  We have a comprehensive study of what every inpatient psychiatrist in the state of Minnesota has known for the past 30 years!  There is a lot behind this headline that is not included in the story.  For example, they left out the part that inpatient psychiatrists and social workers are routinely scapegoated by administrators and government officials for the problem.  The system is not blamed for patients staying in the hospital too long - the doctors are.  I had the opportunity to work with outstanding social workers when I was in this setting and at some point they have to quit.  One of my social work colleagues spent all day, calling over 30 facilities to try to get the patient discharged and she failed.  She failed for two reasons.  First, the infrastructure for accepting patients with chronic psychiatric disabilities has been rationed out of existence by state and county officials.  Second, the existing facilities do not want to accept people with psychiatric problems especially if they have had a history of aggression or suicidal behavior.  The next sentence makes even less sense:

"As a result, private hospitals are absorbing millions of dollars in unreimbursed costs, while patients who are well enough to be released are being deprived more appropriate care at a fraction of the cost."

The author here clearly does not know how state and county officials think.  There is an assumption that they want cost effective and appropriate care.  In my 23 years on an inpatient unit - there is no evidence that those motivations exist.   To any career long student of the system, it should be abundantly clear that all of these administrators and bureaucrats want free care.   Only the Orwellian rhetoric of managed care could spin free care into appropriate care.  I will elaborate on free care instead - how does that happen?  It basically happens in four ways:

1.  The patient is admitted to a psychiatric unit and is too disabled to be discharged to either the street, an apartment, or their original living situation .  The hospital needs to get the patient out in 6 days or less in order to make a profit on the limited payment they get for admissions or discharges (a DRG payment).  The patient is stranded for much longer.  The patient's care is essentially free at that point.  Not only that but if the county rations placement options - they don't spend any money on placements.

2.  The patient is admitted and ends up on a probate court hold or a civil commitment.  In this case they can be stranded for months waiting to get to a state hospital.  Insurance companies and the state do not pay for people in this situation.  The care again is for free.  

3.  Homeless psychiatric patients circulate in an out of the emergency department.  They come in because they are in distress.  They know that they need to verbalize serious problems in order to get admitted.  If not they are discharged back to the street only to appear in the emergency department at a later date.  There is a large circulating population of these patients who may get briefly admitted but never get stabilized.  Apart from the nominal emergency department fee - their care is free.  But of course they are really getting no care.  

4.  Up to 2/3 of people with substance use problems have psychiatric disorders.  Many of them will show up in the emergency department with various levels of symptomatology.  If they are intoxicated they will be sent to county detox facilities - where once again the care is free but it is not psychiatric care.  

These are well hidden secrets of modern psychiatric care.  First, psychiatrists have nothing to do with how the system is managed.  Second, the myth that care is expensive.  People would always ask me if they were being charged a mythical "$1,000/day" fee to be on a mental health unit.  I can assure anyone that when all of the discounts and free care is rolled into the meager reimbursement from insurance companies, the actual reimbursement is more like hotel rates without the hotel accommodations.

The article also discusses the differences between general medical surgical care and psychiatric care. The question is asked if cancer patients were stranded and could not get to tertiary cancer care - would it be as acceptable as the case for psychiatric care?  That question minimizes the scope of the problem.  The problem with the "bottlenecks" described in the article is that they are all a result of rationing of psychiatric services.  There is nobody rationing cardiology or oncology services.  Any middle aged person who goes into an emergency department with chest pain will get state of the art care for chest pain and have all of the necessary testing.  There are no similar services available for psychiatric illnesses.  As soon as a person is admitted the current goal is to get them stabilized and discharged as soon as possible.  The resources are so meager that people frequently do not get the care that they need, because it is rationed.   The article also points out that inpatient treatment at some level is little more than containment.  With administrators rather than clinical psychiatrists running the system, there is no longer an emphasis on a therapeutic environment.  In many cases the experience is sitting around in a facility with little to do, waiting to talk with a doctor about getting released.

So - don't believe what you read in the papers.  Nothing in this article is news.  The system of psychiatric care in the state of Minnesota is dysfunctional by design.  It has been designed by managers at all levels who routinely ignore what psychiatrists have to say and who don't want to spent an additional penny on psychiatric care.

That produces deficiencies at both ends of the spectrum - the people who need to be admitted for psychiatric care as well as the people who need to be discharged.  People with mental disorders should get the same level of care as people with medical and surgical disorders.  That will never happen as long as rationing psychiatric care is justified as being "cost effective".

George Dawson, MD, DFAPA 

References:

Chris Serres.   Nowhere to go, psychiatric patients languish in Minnesota hospitals.  StarTribune August 10, 2016.

George Dawson.  News Flash From Channel 5:  "There is a shortage of psychiatrists."  Link

Supplementary 1:

Every now and then the news media comes up with a shocking story about the rationing of psychiatric services at least they are hyping it that way.   One of my favorites is on Greyhound Therapy and yes this also happens in Minnesota and probably every other state in the USA.  When it comes to rationing and denying care - nothing beats the cost of a bus ticket.

Supplementary 2:

For a look at how modern medical managers and bureaucrats running managed care organizations view psychiatric services - read this post on the Dog Quadrant.

Supplementary 3:

I posted two brief sentences and a link to this post on the page with this story on the StarTribune website.  It was deleted.  If you are reading this please direct anyone interested to this post of what is really happening with mental health and psychiatric care in the state of Minnesota and everywhere.

Hutterite Dust versus Amish Dust

From previous posts, I consider asthma to be a good comparison illness with mental illnesses for a number of reasons.  The diagnosis is frequently unclear.  There are no specific diagnostic tests for asthma.  Attending even a state of the art clinic for asthma usually consists at some point of filling out a subjective checklist of symptoms and disability - including the frequency that a rescue inhaler is used.  The majority of asthmatics are symptomatic with wheezing.  The symptomatic state is often considered a sign of compliance with treatment measures, but the reality is that asthma is difficult to treat and there is a strong environmental component to treating it.  Depending on the physician, environmental engineering like air filters, dust removal, and avoidance of certain allergens is typically discussed but less often than in the past.  The mainstay of treatment is corticosteroid inhalers with long acting beta agonists where the corticosteroid inhaler alone is not enough.  Some authors have defined endophenotypes that may represent different disease mechanisms.  The overall prevalence of asthma has increased significantly suggesting an environmental component.

Additional epidemiology has shown that exposure to high microbial environments such as livestock exposure on traditional farms confers some protection in terms of the development of asthma.  The Amish are noted to have a decreased rate of asthma and allergic sensitization than non-farmers.  These factors led to a very interesting study in this week's New England Journal of Medicine.  In this study the authors elected to compare schoolchildren from both Amish and Hutterite families on a number of genetic and immunologic markers.  Sixty children were studied from both communities.  They were sex and age matched to within one year.  Half of the children were from an Amish community and half from a Hutterite community.  Both groups are from a similar European geography and on an SNP analysis of genetic association were strikingly similar in terms of comparison groups.  The main environmental variable was that the Amish farms were single family dairy farms and the Hutterite farms were communal mechanized farms.   Previous reports had determined that the Hutterite children had a higher prevalence of asthma (21.3% versus 5.2%) and allergic sensitization (33.3% versus 7.2%) than the Amish children.

Blood tests were done on the children to determine immune markers.  The Hutterite group had higher levels of IgE to common antigens.  The Hutterite children also had increased eosinophils, decreased neutrophils and about the same number of monocytes as the Amish children.  Blood samples were screened for 26 cytokines and 23 were found.  Median cytokine levels of each were higher in the Hutterite group even when the known asthmatics were excluded (there were no asthmatics in the Amish group).  Gene expression profiles were also generated for all of the subjects and pathway analysis was done with a standard informatics based approach.  From these analytics the authors concluded that the most significant module in both the Hutterite and Amish children contained 43 genes.  Eighteen of the genes resulting in overexpression of tumor necrosis factor (TNF) and and interferon regulatory factor 7 (IRF7) were present in the Amish children.  Both of these proteins are important in the innate response to microbial stimuli.  

The house dust experiment was conducted in a mouse model of asthma.  Dust extracts were administered intranasally over 4-5 weeks.  Hutterite dust produced airway hyperresponsiveness and eosinophilia in bronchoalveolar lavage specimens from the mice but the Amish dust did not.  Mice deficient in MyD88 and Trif - proteins required for innate immunity signaling (5a) did not respond to the inhibitory effects of Amish dust extract on airway hyperresponsiveness or eosinophilia as further evidence that innate immunity is involved.                          

The authors and the accompanying editorial by Chatila (2) emphasize the importance of this study.  Amish dust is able to activate innate immunity by very specific mechanisms that led to its protective effects against allergic sensitization and allergic asthma. The authors cite the main deficiencies of the study as not looking at children younger than 6, limited dust sampling, and a sampling strategy of asthmatics that resulted in a higher numbers of Hutterite children with asthma.  The editorial suggests that the dose of dust to prevent or possible moderate asthma is not really determined.

This was a very elegant study that has the potential to create novel therapies for an illness that is currently not very well treated.  It highlights that fact that polygenic illnesses, especially those representing complex systems and complex interacting systems are difficult to characterize but with modern methods of analysis we are getting closer.  It was not too long ago that many of the molecules listed in the diagrams at the top of this page were not known to exist.  The best example I can think of is the leukotrienes that were collectively known as Slow Reacting Substance of Anaphylaxis or SRS-A. (4).  Cytokines were also unknown.  The fact that all asthmatics are not alike and that some authors believe that clear endophenotypes exist suggests that in the genes and proteins mentioned in this article significant variation should be expected.  If these findings are accurate, it also points out the importance of slight differences in the environment in the development of asthma.          


George Dawson, MD, DFAPA


References:


1: Michelle M. Stein, B.S., Cara L. Hrusch, Ph.D., Justyna Gozdz, B.A., Catherine Igartua, B.S., Vadim Pivniouk, Ph.D., Sean E. Murray, B.S., Julie G. Ledford, Ph.D., Mauricius Marques dos Santos, B.S., Rebecca L. Anderson, M.S., Nervana Metwali, Ph.D., Julia W. Neilson, Ph.D., Raina M. Maier, Ph.D., Jack A. Gilbert, Ph.D., Mark Holbreich, M.D., Peter S. Thorne, Ph.D., Fernando D. Martinez, M.D., Erika von Mutius, M.D., Donata Vercelli, M.D., Carole Ober, Ph.D., and Anne I. Sperling, Ph.D. Innate Immunity and Asthma Risk in Amish and Hutterite Farm Children N Engl J Med 2016; 375:411-421; August 4, 2016; DOI: 10.1056/NEJMoa1508749

2:   Talal A. Chatila, M.D., M.Sc. Innate Immunity in Asthma. N Engl J Med 2016; 375:477-479; August 4, 2016;  DOI: 10.1056/NEJMe1607438.

3:  Chapter 2:  Innate Immunity in Peter Parham.  The Immune System, Third Edition.  Garland Science, Taylor and Francis Group, LLC.  New York.  2009.  pp 31-70.

4:  Roitt I.  Essential Immunology, Third Edition.  Blackwell Scientific Publications, Oxford. 1977, p 157.

5:  Links to Kyoto Encyclopedia of Genes and Genomes (KEGG):

a) KEGG (MyD88-3 and trif):  Link

                

b) Toll like receptor signaling:  Link

                

c) NF- Kappa B signaling:  Link

                

d) Innate immunity:  Link

                

e) Adaptive immunity:  Link

Attribution:

Both graphics at the top of this page are from VisiScience.com and posted per their user agreement.