The New York Times Editorial Board on Parity

The New York Times Editorial Board came out with a comment on mental health parity entitled Equal Coverage for the Mentally Ill.  Like most sources with no knowledge of how mental health treatment works in this country - their outlook was very rosy.  I am  sure that is what the authors of the original bill - the late Senator Paul Wellstone and Senator Pete Domenici were hoping for.  Let me tell you why that is not going to happen.  As I followed the link to who is actually on the Editorial Board it is probably significant that there is nobody with health care expertise.  Even if there was the national press has a naive approach to health care and seems to present a distinctly politicized and business friendly viewpoint.  I would generally characterize that as a view that is very short on quality and long on cost effectiveness rhetoric.  The press seems to uncritically accept that "high quality cost effective" health care is the goal of businesses and governments.  Nothing could be farther from the truth.

The actual Rule that was published yesterday is a 205 page document.  It is written in a style that defies comprehension by anyone who is not a Congressional insider or an attorney.  Despite being highly acclaimed by a number of organizations including the American Psychiatric Association (APA) there is a surprising lack of details in why this is some sort of advance.  I go into this with thirty years of experience battling managed care in its various forms and needless to say I am no friend to that approach.  I know that the real goal is for managed care companies to make money and they make money by denying care and providing low quality care.  I also know that governments at all levels are very friendly to the managed care cartel and have bought their theology.  Practically all health care legislation is managed care friendly and the PPACA (Obamacare) facilitates super managed care organizations called Accountable Care Organizations.  With that backdrop and realizing that like most other people, I lack the legal qualifications to read this document, here are a few of my impressions:

1.  Medical necessity - there are 44 references to medical necessity in the document.  There is some concern about transparency.  It is quite easy for a managed care company to tell a person or their physician, pharmacy, or hospital that they are not covering a service because it is not "medically necessary."  This generally means that the company can employ doctors who can arbitrarily deny services.  In Minnesota in the 1990s, several psychiatrists were concerned that these companies were discharging people from hospitals prematurely and they insisted on seeing the actual criteria for these decisions.  They were advised that they were "proprietary" and not available.  The new Rule seems to demand adequate disclosure of these criteria.  Even if it did, the disclosure of this information is irrelevant.  In fact, there are criteria in use right now that are essentially made up on financial information and they have nothing to do with psychiatric treatment.  Unless there is an actual appeal process to a neutral party who has the power to overturn these decisions, managed care companies will continue to do whatever they want.

2.  Utilization review - there is one reference to utilization review (UR), a managed care tactic that is basically designed to harass physicians into discharging patients from a hospital based on the financial demands of the managed care company.  An example would be serial calls to a physician treating a patient with suicidal ideation.  The attending physician who sees the patient every day is concerned that the patient has a significant suicide risk and wants to continue to treat them on an inpatient basis.  The reviewer who is an employee of the managed care company, is sitting in a room several states away, and has never seen the patient and has no professional responsibility to them decides the patient is not at high risk and that they should be discharged from the hospital.  This leads to a series of unproductive conversations and forces the physician working with the patient to call him every day to justify keeping the patient in the hospital.  In many ways dealing with this process is like dealing with a bill collector.  The only difference is that you are paying a penalty for doing  your work and being responsible to a patient.

The rule seems to suggest that the amount of UR done is not a problem as long as it is equally applied across both mental health and general medical surgical services.  There are major problems with that idea.  The first is a decade long initiative by the managed care industry to internalize utilization review by case managers.  They claim these case managers are part of some kind of imaginary patient care team.   In fact they are there applying business standards to force physicians to discharge patients.  The second problem is that UR is completely unnecessary.  Managed care companies have huge financial leverage.  They reimburse a set amount per admission/discharge diagnosis that is a discounted rate.  The only conceivable uses for UR today are to pressure inpatient physicians and to create an incentive through internal UR to increase profits by managing discounted rates.  That happens when a hospital receives a fixed payment for what is probably a 5 day hospitalization and they now have UR by case managers to get physicians to discharge these patients in 3 days instead of 5.  There is no major psychiatric condition requiring hospitalization that  responds to three days of treatment.

3.  Small employer exemption - the Mental Health Parity And Addiction Equity Act (MHPAEA) does not apply to small employers:

 "MHPAEA and the regulations under it do not apply to employers with 50 or fewer employees (although, separately, the EHB regulations adopt MHPAEA)."   

According to the Census that eliminates about 34 million people or about the same number of uninsured that the PPACA purports to cover for the first time.  It also defeats the concept of parity.  But it turns out there are a lot of exceptions.  So who knows the total number of people who will be not even be covered:

"MHPAEA requirements do not apply to:

• Non-Federal governmental plans that have 100 or fewer  employees;
• Small private employers who have 50 or fewer employees;
• Large group health plans that are exempt from MHPAEA based on their increased cost.  Large group health plan sponsors that make changes to comply with MHPAEA and incur an increased cost of at least two percent in the first year that MHPAEA applies to the plan (the first plan year beginning after October 3, 2009) or at least one percent in any subsequent plan year (generally, plan years beginning after October 3, 2010) may apply for an exemption from MHPAEA based on their increased cost. If such a cost is incurred, the plan is exempt from MHPAEA requirements for the plan year following the year the cost was incurred. Subsequently, the plan sponsors must notify the plan beneficiaries that MHPAEA does not apply to their coverage.  These exemptions last one year. After that, the plan is required to comply again; however, if the plan incurs an increased cost of at least one percent in that plan year, the plan could claim the exemption for the following plan year. The following set of FAQ’s provide additional information related to the application of MHPAEA. In particular, see Q. 11 for a discussion of the processes by which plans may claim a cost exemptionhttp://cms.gov/cciio/resources/factsheets/aca_implementation_faqs5.html); and
• Self-funded non-Federal governmental employers that opt-out of the requirements of MHPAEA.  Non-Federal governmental employers that provide self-funded group health plan coverage to their employees (coverage that is not provided through an insurer) may elect to exempt their plan (opt-out) from the requirements of MHPAEA by following the Procedures & Requirements for HIPAA Exemption Election posted on the Self-Funded Non-Federal Governmental Plans webpage (Seehttp://cms.gov/cciio/resources/files/hipaa_exemption_election_instructions_04072011.html), then issuing a notice of opt-out to enrollees at the time of enrollment and on an annual basis. Thereafter, the employer must also file the opt-out notification with CMS"

4.  This bill will have no impact on gun violence.  You can't assess and treat potentially violent and aggressive people in a rationed, low quality system of care that is run by case managers bent on getting people out of the hospital.  There are many better suggestions on this blog but they require a system of quality care and professionalism.

5.  The bill will not save any money.  It should be painfully apparent that delegating the management of health care in the United States to a profit motivated middleman is a recipe for health care inflation.  That point is routinely lost on politicians and journalists.  The other point that these folks never seem to get is that managed care companies have in many cases acquired the means of production that they had sought to control.  This creates an additional conflict of interest.  If you now own all of the MRI scanners, you have an interest in seeing them run 24/7 especially when they might be covering a significant part of your hospital costs.  That might explain what an MRI of the C-spine is $1,500 in the US and $150 in Japan.

6.  The rule is doomed if the Editorial Board is serious about it depending on enforcement by state insurance commissioners.  The members of the Board must not have ever filed a complaint with a state insurance commission.  In many states it is difficult to find the state agency responsible for taking complaints against managed care companies.  Unlike Medical Boards, insurance complaints are often a well kept secret.  There are often pro-insurance and pro-managed care statutes in state law and industry insiders on the commission.  In my experience, the only hope state residents have against the managed care industry is an activist Attorney General.  Activist AGs happen about once a decade.    

These are all huge deficiencies in a Rule that is supposed to assure parity between mental health and substance use disorders and general medical surgical treatment.  Combined with pressure for collaborative care in primary care clinics, it is very easy to imagine that this Rule will not make any difference at all.  That is my preliminary take on the Rule with my previously stated qualifiers.

I fully expect a business friendly government to continue to be an obstacle to the provision of quality mental health and addiction services largely due to the conflict of interest it creates when it uses private businesses to make money by denying care at several levels.  But the New York Times won't be telling you that.

George Dawson, MD, DFAPA

Final Rule on Mental Health Parity.  Federal Register.  November 13, 2013.

Abstract Art

When I was a kid in a small town we had the same art teacher for the first eight years.  There were five elementary schools and Mr. Cooper would travel to all five schools and try to teach us art.  I just recently learned that he also taught art in the same way in elementary schools in the surrounding small towns.  When I went to junior high school I was surprised to see him in the 7th and 8th grade teaching in an old art deco building on the high school campus (my high school was grades 7-12).

The format in his classes was generally the same.  He would spend the first 10-15 minutes talking about art - usually a specific artist or groups of artists, or a technique.  A couple of times a year he would bring in a large orthographic projector that would allow him to project pictures from art books onto a movie screen.   He would typically turn us loose for the last 45 minutes using a specific technique.  During that time he would walk around and make comments on what we were doing and make suggestions on how to improve our art.  Mr. Cooper was very serious and talked with us in a serious manner even though we were kids.  He was serious about art.

The most memorable sessions for me involved finger painting.  That day we would all get a blank piece of white paper.  Mr. Cooper would walk around and place a dollop of thinned wheat paste onto the paper and tell us to spread it around.  He would them come around and place red, blue, green, and yellow powdered paint on the corners of the paper - several tablespoons of each.  For a class of 20-30 kids it takes a while to set all of that up.  Before he could get back up in front of the class, 90% of the kids were already smearing the paint around and 98% of them had smeared it all together.  The standard mix resulted in a lavender clay colored product.  When that happens you are limited to geometry - whatever lines or shapes you could put into the surface.  The few people who keep their colors separate - had many options based on the primary color options and combinations of those colors.  I have never thought about it before but this is a science intersection of sorts - more degrees of freedom or combinations from the basic step of not mixing all of your paint together.

I was one of the people who never mixed the colors together.  I liked the boundaries between bright colors and the areas of pure bright colors.  I liked the non geometric shapes stretched across the paper through numerous color zones.  There was something very satisfying about creating a painting from this simple technique.  At the same time, we were presented with art work by the masters.  We saw plenty of meticulous realistic art from the masters of several eras.  Even then it seemed like many had an abstract quality.  I can remember liking Edward Hopper's work at first sight.  This Andrew Wyeth image had the same effect.  Over the past 40 years, I have studied art where I could find it but I always gravitate to the abstract.  If I have a choice it is typically color field artists like Hans Hoffman, but any abstract artist will do.  I used to tell myself that I would start painting again in my spare time, but practicing medicine these days is not conducive to spare time or doing anything creative during it.  My wife and I do have time to appreciate local abstract artists and purchase some of our favorite pieces like the work of Steve Capiz below (click to enlarge):

    
The artist in this case has been painting abstracts for 50 years and he is still going strong.  He is currently painting very large canvasses on the order of 6-10 feet high and wide.  The last time I was in his gallery there were probably 40 - 50 paintings on sale and I honed in on exactly two of them including the one above.  If you walk into my house you will find the above 36" x 36" painting to the right of the entrance and as you look across the room to the left there is a 48" x 48" abstract above a fireplace in your line of sight.  If you look down the stairwell there is a large print - Morris Louis #2703.  There are four other paintings by Steve Capiz throughout the house.

The reaction to abstract art is always interesting.  When I post some of the art on my Facebook page, friends often comment on what the painting looks like.  It seems like a projective test.  My wife takes the interior design approach.  The colors of the painting need to "pull together" the colors in the room.  Our painter wears a T-shirt that says: "Don't buy art to match the furniture."  He encourages my wife to listen to me when it comes to abstract art.  But I am really not aware of why I love abstract art and why I can discriminate enough to select 2/50 paintings from my favorite artist.  Did it have something to do with my fingerpainting experience?  Or is my brain set up to fingerpaint in a certain way and be attracted to abstract art?  My life experience has certainly been broadened by art.  I have no idea how it has affected my thinking.  Some of those details are known for musical performance.  Learning to play the cello and clarinet has probably led to some enduring changes in my brain plasticity.

Experiments aside - I am glad I met Mr. Cooper when I was a kid.  It has been my experience that you never know enough at the time to optimize your experience with good teachers.  That is as true for art as it was for neuroanatomy.

George Dawson, MD, DFAPA

Accountability - The Last Refuge of a Scoundrel

On April 7, 1775, Samuel Johnson said:  "Patriotism is the last refuge of a scoundrel."  His biographer had to clarify that Dr. Johnson was not talking about love of country but "pretend patriotism which so many have made a cloak for self interest".  We see the rhetorical application in American elections where politicians spend more time on discussions of their military records rather than issues relevant to any kind of plan that they have for the nation or solving any real problems.  Nunberg makes the observation that that the term can also mean an irrational bias favoring one's country and that Americans have applied the term indiscriminately at times. He also points out that it can be a word designed to put people on the defensive.  

If I had to pick a word in the medical field that has similar uses - it would be "accountability".  There has probably been no single word more responsible for facilitating managed care and recent government intrusions into the practice of medicine.  If you think about the premise of physicians being "accountable" to politicians and businesses - it is absurd on the face of it.  Taking a professional who has been trained to be accountable to an individual patient and who operates in a professional environment that specifies behavior toward that person and telling them that they are now going to be monitored by businesses with a goal of maximizing profits or politicians with numerous conflicts of interest and a clear interest in getting re-elected - is an ongoing disaster.  So  how has it happened?  I would suggest that most of it has to do with rhetoric.

Before I point out the medical applications of the accountability rhetoric let me say that I don't consider this to be specifically applied to medicine.  Accountability rhetoric is broadly applied by any person or group seeking some kind of political advantage.  An obvious example is education and teaching.  Politicians everywhere get a lot of mileage out of the idea that they are going to hold teachers accountable usually through standardized test scores.  It has become a pat answer to taxpayers concerns about the money being spent on education and low graduation rates.  In some states, the test scores are marched out every year and used to rank schools and teachers.  Never mind the fact that the school system that produces the top international performance scores does not work that way.  In Finland, a professional teaching culture is by far and away the most significant factor in their academic excellence.  In the book written about this the teachers say they would not tolerate the kinds of intrusions that are common in the United States.  These intrusions are all based on accountability rhetoric.  

In preparing for this post, I searched my e-mails from the past three years and found 1800 e-mails containing the word accountability.  Most of those hits were due to the Health Insurance Portability and Accountability Act (HIPAA).  If you read the long title of this act it was clearly doomed out of the box.  The major impetus for the PPACA (Obamacare) was health insurance portability suggesting that HIPPA was already a failure.  That did not deter legislators from including a Privacy Rule under HIPAA to supposedly crack down on privacy violations.  My read of the bill is that is actually broadens the use of anyone's medical information among all "covered entities" affiliated with your health plan.  In the meantime,  the Privacy Rule was so threatening that it almost immediately made it more difficult for the doctors doing the work to get access to data.  Was it necessary for physicians?  Absolutely not - physicians are trained in medical privacy and all broad breaches of medical privacy have been due to either hacking or business people losing computers with significant amounts of data.  Make no mistake about it - politicians will be there to make the most accountable people accountable and greatly decrease their efficiency.   A great example of the title of this post.

I have recently posted a number of examples of accountability rhetoric being used for political leverage against physicians.   It can be used by medical boards, advocacy organizations, state agencies, federal agencies, and specialty boards in addition to politicians.  I am going to focus on a single example and that is Medicare.  All of the information that follows is public and can be accessed through the Medicare link on the American Psychiatric Association's web site.  I picked it up on my Facebook feed but it disappeared and I had to call APA staff to figure out where it went.  I am very familiar with the history of Medicare quality initiatives because I was one of their quality reviewers for inpatient hospitalizations in Minnesota and Wisconsin in the late 1980s and 1990s.  If you look for inpatient psychiatry measures you will find that many of them (polypharmacy, multiple drugs from the same class, discharge planning) are unchanged from that era, despite the fact that the review organization was disbanded because it did not find enough quality or utilization problems to justify its ongoing existence.

The APA points out that Medicare now has a fee scale that takes into account "quality of care measures instead of just paying a standard fee for every procedure (CPT) code".  They have a Physician Quality Reporting System (PQRS) that requires psychiatrists to report on one measure in order to avoid a 1.5% penalty.  For 2013 that report has to be made on one Medicare patient.  This is described as an "incentive" to report on quality performance measures and of course a "penalty" for those who fail to report.   A managed care company would call it a "holdback" in that it is technically work that has been done, but the no cost way to turn it into an "incentive" is just to take it from the people doing the work and make it seem like they are rewarded with it later.

The document goes on to document "measures identified as pertinent to psychiatrists (along with their designated codes)".  If you are a psychiatrist read through these reporting measures and marvel at the morass of initial codes that I am sure are going to grow as this administrative nightmare continues.  The further problem is that Medicare/CMS clearly has the goal of comparing physicians and holding them accountable based on the fantasy that these measures actually mean something in clinical practice or even the world.  And if this list of measures is not enough, there are also 50+ page guidelines online like: "The American Medical Association-convened Physician Consortium for Performance Improvement - Adult Major Depressive Disorder Performance Measurement Set" that describes an additional set of performance measures.  The AMA is involved and if you click the link 2013 PQRS Quality Measures you can search on Major Depressive Disorder and find the following links.  You can download the 50+ page document from the top link.

Most people realize that physicians currently have some of the highest burnout rates of any group of professionals.  Those burnout rates are directly related to micromanagement even before we get to the level I just described in the above paragraphs.  The paradox that every physician is aware of is that these reportable measures are not valid objective markers and they are being promoted by bureaucrats who not only have no accountability but in the case of the mental health system of care are some of the same people who destroyed it in the first place.  Don't forget that Congress skewed insurance coverage of mental illness and addictions so badly that Senators Wellstone and Domenici had to write legislation in an attempt to correct that.  At this time the final form of their legislation is still pending.

So accountability has become the last refuge of scoundrels.  Be very skeptical of any politician or bureaucrat waving that flag.  It has little to do with reality and more to do with promoting their own self interests while creating a tremendous and unnecessary burden for the doctors they regulate.

George Dawson, MD, DFAPA

Nunberg G.  Going Nucular: language, politics, and culture in confrontational times.  Cambridge: MA Perseus Books Group, 2004.

For a complete analysis of political doublespeak as applied to medicine see:

Robert W. Geist:  Hot Air Index: Political/Commercial Double-speak Lexicon for Medicine

Sleeping Cleans Your Brain

Why we need sleep and what happens during that process is an area of great interest for both the basic and clinical neurosciences. I recall listening to a lecture by Giulio Tononi at the 75th Anniversary of the University of Wisconsin's Department of Psychiatry on a theory of how synapses were processed during sleep in order to renew the brain's learning capacity for the next day.

I encountered a fascinating paper in this week's Science magazine on a possible sleep function that I have never seen described before - flushing toxins out of the brain.  The lead author hails from the Division of Glial Disease and Therapeutics, Center for Translational Neuromedicine, Department of Neurosurgery, University of Rochester Medical School.  That probably says a lot about the focus of the paper and that is the movement of interstitial fluid (ISF) as it circulates through the interstitial spaces around neurons and removes toxic waste products including β-amyloid (Aβ)  Since the brain lacks a lymphatic system convective exchange between CSF and ISF controls this turnover.  One author named the system the glymphatic system since the system is dependent on astrocytic aquaporin-4 (APQ-4) channels for establishing the  convective movement of ISF and this is homologous to peripheral lymphatic movement and removal of toxic byproducts from peripheral tissue by the lymphatic system.  The authors also note that the observation that (Aβ)  protein has been observed to be at a higher concentration in the daytime as opposed to during sleep.  To explain this one hypothesis was that production was greater in the daytime.  They tested the alternate hypothesis that glymphatic clearance is greater at night.

The basic experiment for the paper involved teaching mice to sleep on a two-photon microscope.  That allows imaging of dye moving through living tissue.  The researcher would inject mice with  green dye at sleep onset and red dye upon awakening.  They could determine that during sleep a much higher volume or CSF flowed through the brain.  They also injected labelled (Aβ)  protein and showed that the brain of a sleeping mouse cleared these proteins twice as fast.  The art below shows the experiment and the 60% increase in channels carrying CSF during sleep.  I would encourage anyone interested to read the original in color as Science has outstanding graphics.  To download my original PowerPoint slide use this link.

The authors went on to demonstrate that the increase in interstitial space was a sleep related phenomenon because it could be induced by natural sleep and anesthesia but not circadian rhythm.  In looking for a mechanism they postulated that adrenergic mechanisms associated with arousal like locus ceruleus derived noradrenergic signaling was involved.  They demonstrated that adrenergic antagonists could induce the expected increase in tracer influx and interstitial volume so that it was similar to what was seen in the sleep state. 

Implications for psychiatry?  To some extent, those of us interested in neuroscience and not forgetting what we learned in PChem will always be interested in article at the interface between the biochemical and the biophysical.  Despite having this elegant system coupled with our arousal state and metabolic state none of this information was around during the recent Decade of the Brain.  The authors discuss the sensitivity of neurons to various toxic products and proteins and the implications for neurodegenerative diseases.  I can start with insomnia and build from there.  People with addictions can have sustained insomnia and associated impairment in cognition the next day.  Delirium also affects the sleep-wake cycle and some experts have suggested that two different types of delirium can be distinguished based on EEG spectra.  The obvious questions are is the insomnia associated with these states literally toxic to the patient by restricting ISF clearance?    Another key correlate mentioned by the authors is the decrease in ISF with age.  Does that account for the predisposition to delirium and protracted delirium as people age?  And finally what about the toxicity of medication?  We are used to receptor based explanations of why certain medications have sustained or unexpected toxicity.  How much of that is due to a collapsed ISF and restricted clearance to the CSF?

Brain energetics is also an interesting question specifically the AQP-4 channels.  Most psychiatrists are familiar with the renal aquaporin channels when considering renal water metabolism.  The fact that you have these channels on astrocytes and that removing them reduces (Aβ)  clearance by 65% is fascinating and seems like another potential intervention point for brain disease.  What needs to happen to keep these AQP-4 channels healthy and what happens when they are not? 

There are many more questions that come to mind based on the mechanism these authors have elucidated.  I hope that papers like these are translated into both clinical research and our thinking about newer and more innovative ways to think about whole brain function and think about all of the mechanisms instead of just the usual receptors.

George Dawson, MD, DFAPA

Xie L, Kang H, Xu Q, Chen MJ, Liao Y, Thiyagarajan M, O'Donnell J, Christensen DJ, Nicholson C, Iliff JJ, Takano T, Deane R, Nedergaard M. Sleep drives metabolite clearance from the adult brain. Science. 2013 Oct 18;342(6156):373-7. doi: 10.1126/science.1241224. PubMed PMID: 24136970

Footnote:  I decided to update (12/13/2013) this post by adding this interesting piece of news.  According to Altmetric, this paper received the 4th highest rating of online interest in scientific papers.  For the Top 100 papers click on the link.

Stigltiz Commentary and The Implications for the Politics of Psychiatry

Nobel prize winning economist Joseph Stiglitz came out with a recent commentary of the economic recovery and why things are not a rosy as they seem.  He points out that many of the structural problems with the economy including predatory lending and credit, abuses by the credit card industry and abuses by the credit reporting industry are still in place.  In addition there are inadequate capital reserves and no real limits on the kind of low risk speculation by certain parts of the financial services industry - the basic problem that started everything 5 years ago.  I have been posting in political forums for the past 15 years that the American economy at times seems to be based on a fantasy rather than the way a real economy should work.

We have taken an alleged retirement system (401K, 403B) and turned it into a windfall for the financial services industry.  Instead of an actual retirement system, we find that the average American is not able to put away nearly enough to retire and in the process ends up paying significant fees to financial services companies.  In return for these fees they receive the standard boilerplate about no guarantee against losses and frequently have very poor investment choices since they are determined by their employer.  At the same time, low risk retirement vehicles like money market funds are paying negligible amount of interest.  Rather than being a reliable retirement system this is essentially another tax on the American people to fund the financial services industry.  Retirees are left with the option of accumulating cash only or putting their retirement funds at significant risk all of the time in order to accumulate enough capital to retire.

We are in the process of starting a huge health care mandate know as the PPACA or more popularly as Obamacare.  It will create a large influx of capital into the healthcare system based on coverage mandates.  The American health care system is currently the most expensive system of health care in the world.  The standard model used by the federal and state government has been to use managed care companies as intermediaries to contain costs.  There should be no doubt that model is a near total failure.  Recent data for example suggest that a couple nearing retirement should have an additional quarter of a million dollars saved for health care expenses during retirement beyond the cost of Medicare.  The health care system in this country can be viewed as a second tax on the American people.

How do Americans end up with two additional taxes being levied on them in addition to the usual income, Medicare, Social Security, sales, and property taxes?  How does it happen when we have a supposed radical element of one of the major parties working on fiscal responsibility?  I think it comes down to one American institution and that is the US Senate.  The Senate is full of aging, wealthy politicians who have worked for years to develop a power base in Washington and keep it.  They are completely out of touch with what the American people need and pass laws that will largely benefit the businesses that they are heavily lobbied by.  In some cases, they wrote the laws to invent the industry.  The disconnect of this group from the public was evident during the recent stand off to shut down the government and nearly default on our creditors.  In other words they risked the world economy to make a point instead of fairly representing what the average American wanted at that time.

How does all of this apply to the politics of psychiatry?  I can illustrate by looking at a few seminal events that apply to all front line psychiatrists and how their professional organization - the American Psychiatric Association (APA) responded:

1.  Managed care and the disproportionate rationing of psychiatric services:  Apart from Harold Eist, MD and a recent lawsuit against a managed care company there has generally been silence on this issue.  Some literature was generated regarding how to work with meager rationed resources but nothing about how to fight back as managed care became a government institution.  The APA's support of collaborative care means we have come full circle and the APA is explicitly backing a managed care model that involves treating patients without actually seeing them.

2.  The response to accusations of conflicts of interest related to the pharmaceutical industry:  There was a well known initiative against some prominent psychiatrists, the motivations for that initiative are still unknown.  It is well known that many academics in many university departments have contracting arrangements with industries in order to supplement their salaries.  It is well know that some professions charged with determining industry standards insist on industry representation in meetings where those standards are written.  It is known that many professional organizations got more support from the pharmaceutical industry than the APA.  The response to the attack from a Senator was to basically acknowledge that his attack was accurate and proceed with an appeasement approach that allowed critics of psychiatry to use this as additional rhetoric against the profession and any psychiatrist with a contracting arrangement.

3.  The Maintenance of Certification (MOC) issue:  This issue was forced by the American Board of Medical Specialties (ABMS) based on limited research.  The APA immediately aligned themselves with the ABMS despite considerable complaints and a petition by the membership.

The three examples given about are some of the main political issues for psychiatry, particularly the average working psychiatrist and the APA.  To say that the interests of most psychiatrists are not represented by the APA is a massive understatement.   Like the U.S. Senate, the APA seems almost totally disconnected from the people it is there to represent.  I have heard many reasons over the years about how the actual structure of the APA is the problem.  But nobody seems to want to remedy that problem.  I attended a seminar at one point where an APA official explained the MOC issue and how it would actually create a financial burden for the American Board of Psychiatry and Neurology (ABNP), despite the obvious fee generation to take a commercially monitored and administered test.  If it really is that burdensome -  why do it in the first place?  The initial rationale was that the public demanded it.  It seems that there is now solicitation for public support.  Who would not support an initiative to improve the competency of doctors - even if there is absolutely no evidence that a multiple choice exam with a high pass rate does that?

I think it is highly likely that the political structure of the APA is very similar to the political structure of the Senate.  While there is no lobbying there are ideas and affiliations based on those ideas.  Any political structure that is so far removed from what its constituents want it driven by cluelessness, conflicts of interest, or a divine mandate.  It is only logical to conclude that like the Senate, the issue is conflicts of interest.  In the 21st century, patriotism is no longer the last refuge of a scoundrel - accountability is.  The APA would do well not to follow the Senate on that course.

George Dawson, MD, DFAPA

Joseph Stiglitz.  5 Years In Limbo.  Project Syndicate, October 27, 2013.

Cravings

"Unlike most of our crowd, I did not get over my craving for liquor much during the first two and one-half years of abstinence.  It was almost always with me......"  Doctor Bob's Nightmare.  Alcoholics Anonymous, Fourth Edition, New York City, 2001, p 181.

Craving to use drugs and alcohol is a common problem.  As Doctor Bob points out in the above quote, craving is rare for alcoholics beyond the acute detoxification phase, but protracted for many other drugs depending on the class of addictive compound and the pharmacological properties of the specific drug.   Apart from the biological determined heterogeneity of response to addictive compounds there are also the subjective aspects.  In order strive for more objectivity, modern psychiatry has established diagnostic criteria for disorders of interest.  These disorders are grouped in categories to seem uniform.  Depending on the criteria of interest there is a broad range of subjective experience and description when describing common problem like anxiety and depression.  Some people don't know the difference between them.  Others have a mixture of both.  Some people are anxious all of the time independent of their surroundings.  Others get depressed or panic only in certain situations.  The interpretation of what a person considers to be a craving is as diverse.

Craving for an addictive drug or alcohol comes in many forms.  It can be a perception of a physical property of the actual compound itself such as the taste, odor, appearance or consistency.  It can be physical acts associated with its use and a common example there is a feeling that cigarette smokers get when they feel like they need to do something with their hands after they stop smoking.  It can be cue induced like being offered a drug or being in a place where previous drug transactions occurred.  It can be recall of the first intense and protracted euphoric experience of using the drug even though that has long passed related to tolerance.  The overwhelming affect associated with craving is anxiety and fear because of the sign on an impending withdrawal or relapse.  The negative reinforcement that keeps addictions going after the initial states of positive reinforcement due to the euphorigenic effects of the drug is avoiding withdrawal.  Craving may be a signal that acute withdrawal is imminent or that there is a state of chronic withdrawal.

Craving has had an uncertain place in the field of addiction and the diagnosis of addictive states, largely because of the broad range of experiences associated with craving.  This diagrammatic summary shows that various groups have considered the definition to be too vague.  In other cases there was no consensus that craving was a universal enough phenomenon to be considered a diagnostic criterion.  That changed this spring when the DSM-5 added craving and eliminated legal consequences of drug and alcohol use as a diagnostic criterion.  Medications used to eliminate cravings probably led to that consideration, but people with cravings are more likely to relapse and have significant distress during recovery.

The addition of cravings to the DSM-5 opens up a whole new area of focus during encounters with people who have addictions.  Prior to this change the two major texts on addiction devoted about 3-4 pages to craving phenomena.  Addiction psychiatrists and addictionologists may have already been focused on this area, but I think that overall it makes ongoing assessments more dynamic because it is an intervention point for physicians and there are a number of medical and non-medical interventions that are possible.  Omar Manejwala, MD reviews the options in his very readable book entitled Craving.  This book is interesting because it gives a number of practical tips on how to counter cravings based on the substance involved as well as the importance of psychosocial interventions like 12-step recovery and how that might work.  Addiction science has probably been at the cutting edge of neurobiology for at least the past decade and with this focus there is often the implicit understanding that we are searching for some medication that will be an immediate solution to craving.  In some cases we have that medication, but I always emphasize that cravings at some point disappear and that there are non medication approaches to addressing them.

George Dawson, MD, DFAPA

Manejwala O.  Craving: Why We Can't Seem To Get Enough.  Hazelden, Center City, MN, 2013.

Definitions:

Neuropsychopharmacology The Fifth Generation of Progress (2002):  Craving is a powerful, "must-have" pull that causes addicted people to risk and sometimes lose, their relationships, families, money, possessions, jobs and even their lives. (p.1575)

No - I Don't Have Generalized Anxiety Disorder

I was reading a copy of JAMA the other day and a story written by a transplant surgeon Jeremy M. Blumberg, MD.  It was an excellent description of surgical training to the point of autonomy and then the nagging uncertainty of whether the surgery you have trained for years to do will go well.  Will you avoid mistakes?  He describes his first transplant as an attending:

"This operating room was new to me; the nurses were friendly but foreign.  The instruments were familiar, but somehow felt different - was there just a barely palpable increase in tension in the muscles of my hand causing this effect?  The patient's blood vessels were hard, thickened from years of dialysis and diabetes.  She bled more than usual when we reperfused the kidney.  It felt as if every last molecule of epinephrine had rushed out of my glands and nerves, squeezing my blood vessels and taunting my intestines to detonate...."  (p. 1676)

I hear you brother.  I thought that level of anxiety over the balance between doing the impossible and not doing harm might fade away over the years but it has not.  In psychiatry a lot of it depends on the level of complexity that your patients have.  It can be an acute situation but more often than not - it is a problem throughout the day that you take home with you.  Additional medical conditions, non psychiatric medications, polypharmacy, and difficult to treat disorders all compound the problem.  I have designed a hierarchy to illustrate what I mean.  It turns out that when I think about it, the acute problems seen by psychiatrists are not at the top.  The problems at the top are typically problems where there is no good guidance, where you are on your own, left with biologically determined probabilities and you need to come up with your best estimate of what will happen given current circumstances.  The problems encompass both psychiatry and the medicine associated with psychiatry.

Let me provide an example of both.  In the case of the psychiatric problem the usual scenario is a case of impaired judgment.  Is the person at risk for death or self injury?  Are they able to cooperate with the assessment and treatment plan.  Do they seem changed to the point that you can no longer accept their responses as being accurate?  Are you treating them for acute and chronic suicidal ideation and behavior?  Any acute care psychiatrist ends up assessing thousands of the situations across the course of their career.  It is often much more complex than an acute assessment.  Many of these scenarios unfold in the context of ongoing psychotherapy and in order for the patient to be able to improve some risk is taken.  In other cases there are calls to warn people and in extreme cases - calls to the police to check on a person who might be in trouble.  I have not seen it studied but the stress of these situations for the psychiatrist involved is well known.   Overthinking the situation in order to avoid the unexpected call that one of your patients has suicided or killed someone is common.  In my conversations with medical students over the years, one of the main deterrents to psychiatric residency is the worry about suicide prediction.

The medical situations are as complex and they frequently have no clear solution.  A common scenario is that the person has a severe mental illness and they develop a problem that leads to to rethinking the medication they are taking.  A common scenario is a person on maintenance therapy who suddenly develops a renal or hepatic problem necessitating a change in therapy.  The best example is bipolar disorder and lithium therapy.  Lithium remains the drug of choice for many people with bipolar disorder and it can be highly effective.  When I first started to practice it was common to see people who had repeated institutionalizations for bipolar disorder suddenly stabilized on lithium.  Their functional capacity was restored and they were able to return to work and establish families.  In those early days, the issue of lithium nephrotoxicity was not clearly observed.  There was a major study of people on lithium maintenance for decades that showed no difference in renal function.  In the last 15-20 years most nephrologists agree that lithium can lead to renal insufficiency and failure in a minority of patients on lithium therapy.  In the case of a person that lithium has been working well for 30 years, there is no guarantee that anything else will work as good.  That translates to no hospitalizations in a long time to frequent hospitalizations every year.  Monitoring that therapy and in some cases following the patient while they are in dialysis or after transplantation is on example of a situation that you can't leave at the office.

In many ways, the stress and anxiety in psychiatric practice is a measure of attempting to predict the unpredictable.  Psychiatry has accurately said that psychiatrists can't predict future behavior or rare events to explain why all suicides and homicides cannot be prevented.  But some sort of probability statement is inherent in all medical practice.  I would estimate it still happens to me about every three weeks.  Something isn't right and I don't have an exact answer.  It becomes an obsession to an extent.  Laying awake in bed.  Getting up to do some additional research but realizing ahead of time that the yield is low.  Realizing that no matter what decision you make - all of the outcomes are probably going to be suboptimal.  You always get to the point where you  can feel the adrenaline molecules rushing and your heart pounding.  You know you are tense and starting to break into a light sweat.  You readjust yourself in bed and realize your back and shoulders are as tight as a frozen hydraulic jack.  You might actually check your pulse and blood pressure and find that  they are elevated.  It goes on like this until something happens and the intellectual crisis abates.  Sometimes that takes a while - at one point months and a beta blocker to break up the stress induced tachycardia and hypertension.

No I don't have generalized anxiety disorder - I am a doctor trying to deal with the uncertainties of being human.

George Dawson, MD, DFAPA

APA Continues to Hype Managed Care

This YouTube video is fresh off my Facebook feed this morning from the APA.  It features American Psychiatric Association (APA) President Jeffrey Lieberman, MD discussing the advantages of a so-called collaborative care model that brings psychiatrists into primary care clinics.  I have critiqued this approach in the past and will continue to do so because it is basically managed care taken to its logical conclusion.  As opposed to Dr. Lieberman's conclusion, the logical conclusion here is to simply take psychiatrists out of the picture all together.

A prototypical example of what I am talking about is the Diamond Project in Minnesota.  It is an initiative by a consortium of managed care companies to use on of these models to monitor and treat depression in primary care clinics in the state of Minnesota.  In this model, patients are screened and monitored using the PHQ-9 a rating scale for depressive symptoms.  Their progress is monitored by a care manager and if there is insufficient progress as evidence by those rating scales, a psychiatrist is consulted about medication doses and other potential interventions.  The model is described in this Wall Street Journal article.  As is very typical of articles praising this approach it talks about the "shortage" of psychiatrists and how it will require adjustments.  In the article for example, the author points out that there would no longer be "one-to-one"  relationships.  There are two major problems with this approach that seem to never be not considered.

The first is the standard of care.  There are numerous definitions but the one most physicians would accept is care within a certain community that is the agreed upon standard provided by the same physician peers.  In this case care provided by all psychiatrists for a specific condition like depression.  There are professional guidelines for the care of depression and in the case of primary care guidelines for care provided by both family physicians and internal medicine specialists.  One of the tenants of this care is that physicians generally base treatment of an assessment that they have done and documented.  The only exception to that is an acceptable surrogate like a colleague in the same group covering a physician's patients when they are not available.  That colleague generally has access to the documented assessment and plan to base decisions on.  This is the central feature of all treatment provided by physicians and is also the basis for continuity of care.  As such it also forms the basis of disciplinary action by state medical boards and malpractice claims for misdiagnosis and maltreatment.  An example of disciplinary action based on this standard of care is inappropriate prescribing with no documented assessment or plan - a fairly common practice in the 1980s.

In all of my professional life, the standard of care has been my first and foremost consideration.  It is basically a statement of accountability to a specific patient and that is what physicians are trained to be.  Curiously it is not explicit in ethics literature and difficult to find in many state statutes regulating medical practice.  That may be due to the entry of managed care and the introduction of business ethics rather than medical ethics.  It also may be due in part to an old community mental health center practice of hiring psychiatrists essentially to refill prescriptions rather than assess patients.  This is addressed from a malpractice perspective by Gutheil and Appelbaum in their discussion of malpractice considerations and how they changed with the advent of managed care:

"Managed care is one omnipresent constraint.  Patients and clinicians must work together to fashion an appropriate treatment plan to take into account available resources and given the contingencies faced by the patient.  If that plan-properly implemented-fails to prevent harm to the patient, the clinician should not face liability as a result." (p 164).

They go on to explain how ERISA - the Employee Retirement Income Security Act of 1974 indemnifies managed care companies and their reviewers from the same liability that individual physicians have.  They cannot be sued for negligence and the resulting harm.  So managed care can take risks without concern about penalties as opposed to physicians who are obliged to discuss risks with the patient.  Managed care organizations can also implement broad programs like depression screening and treatment without a physician assessment and consider that their standard of care.

The second problem with the so-called collaborative care approach is that there is no evidence that it is effective on a large scale.  I pointed out this criticism by a group of co-authors including one of the most frequently cited epidemiologists in the medical literature.  That group has the common concern that a rating scale is a substitute for an actual diagnosis and everything that involves and given the recent FDA warning on citalopram.

Both of these concerns bring up an old word that nobody uses anymore - quality.  It is customary today to use a blizzard of  euphemisms instead.  Words like "behavioral health", "managed care", accountable care organizations", "evidence-based", "cost-effective" and now "collaborative care".  According to Orwell, the success of such political jargon and euphemism requires

"an uncritical or even unthinking audience.  A 'reduced state of consciousness' as he put it, was 'favorable to political conformity'." (3 p. 124)

Dr. Lieberman uses a lot of that language in his video.  The critics of psychiatry in the business community do the same.  There appears to be a widespread uncritical acceptance of these euphemisms by politicians, businesses and even professional organizations.

An actual individualized psychiatric diagnosis and quality psychiatric care gets lost in that translation.


George Dawson, MD, DFAPA

1.  Beck M.  Getting mental health care at the doctor's office.  Wall Street Journal September 24, 2013.

2.  Gutheil TG, Appelbaum PS.  Clinical Handbook Of Psychiatry And The Law. 3rd edition. Philadelphia: Lippincott Williams & Wilkens.  2000, p 164.

3.  Nunberg G.  Going Nucular: language, politics, and culture in confrontational times.  Cambridge: Perseus Books Group, MA 2004.

4.  American Psychiatric Association Principles of Medical Ethics with Annotations Espcially Applicable to Psychiatry.  2009 version.

SNL Keeps the Stigma Going

I suppose I was one of millions of disappointed viewers who tuned in to Saturday Night Live last night. One of the skits was to show the first used car commercial.  The commercial uses the familiar "crazy" motif, implying that the business uses an irrational pricing strategy that favors the customer.  Practically every television market has a business that uses this approach for selling cars, appliances, stereos, you name it.  I suppose that some comedians would suggest that this is commentary on these commercials as a rationale for the video.  In the same show there was a skit about a drunk uncle.  At one point the drunk uncle introduces meth nephew - portrayed by an actor for the AMC series Breaking Bad.  I can recall the comedic placement of an alcoholic dating back to The Andy Griffith Show's Otis.

Associating comedy with mental illness is stigmatizing.  That is not an original thought and I am sure that some people have written about it before.  I am sure there is a thesis somewhere submitted for degree requirements that looks at the rationale and the pros and the cons.  For me the straightforward analysis is that it is a reflection of the disproportionate noise in the media about psychiatry and mental health.   That is closely followed by the fact that  there are no similar comedic approaches to other diseases.  Where are the skits about an uncle with cirrhosis, chronic pancreatitis or cancer?  Or the uncle in prison for vehicular homicide while intoxicated?

I also can't help but notice if you were not laughing at the Tina Fey character in the commercial what were you thinking?  I was thinking about a situation where a family might notice a personality change or a change in thinking like the one described in this skit and what they would do about it.  There are no clearly defined public health approaches to these problems.  People get concerned, they get very uneasy, they don't know what to do about it, and complications happen.  They may actually bring their relative down to the local Emergency Department only to find that they are declared "not imminently dangerous" and discharged with a number to call for an outpatient appointment.  If their family member is in need of medical detoxification from alcoholism, they may be discharged with a bottle of lorazepam and instructed on how to detox them at home.  I was thinking about the millions of Americans out there who have had this happen, have inadequate treatment, and never recover.  Their role in the family is permanently altered or disrupted.

I was thinking about the legal approach to some of these problems and the issue of criminal responsibility.  That dovetails with the lack of a public health approach because one of the possible complications is that a crime gets committed during an episode of mental illness.  Of course it is a crime based on the assumption that the person is able to appreciate what they are doing and that it is unlawful.  In the majority of cases it is not likely that a severe crime will be understood that way and the defendant will typically get psychiatric treatment in prison or a county jail.  The civil legal approach is as problematic.  An actual or practical "imminent dangerousness" standard for treatment leaves huge numbers of people untreated and acutely mentally ill.

For all of these reasons, these skits were not funny to me.  I like Tina Fey and think that she is a comedic genius, but I didn't crack a smile.  I think it will be a test of mental health advocacy groups everywhere to see what they say about this.  Some have criticized SNL before but I have not seen anything about this skit so far.  All of the discussions about the problems with the lack of adequate mental health treatment in this country and the associated public health disasters have no traction as long as we continue to think of mental illnesses and addictions as comedy.

George Dawson, MD, DFAPA

UW Update - the Rest of the Story

I am back at my usual computer tonight and feeling much better after attending the UW Psychiatric Update. It was well attended and I estimate there were about 400 people there - mostly psychiatrists.  The conference brought in several people who were instrumental in the DSM-5 to talk about the thinking and research that went into it.  The resulting story is one that you will never hear in the press or other media.  The story is based on science as opposed to the irrational criticisms in the media and that science is written about and discussed by brilliant people.  I will try to post a few examples, and wish that it had been presented to the public.  The discussion produced for public consumption was not close to reality and it was a further example of how stigmatization of the profession prevents relevant information from reaching the public.  It seems that the most we can hope for is an actual expert being placed in a staged debate or responding to some off-the-wall criticism - hoping to interject a few valid points.  That is a recipe for selling the sensational and leaving out the scientific and rational.  Just how far off the media is on this story is a mark of how skewed that perspective is.

Let me start with the disclosures.  There were 14 presenters and 10 of them had no potential conflicts of interest to report.  That included one work group chair.  One of the presenters suggested that the political backlash against psychiatrists affiliated with the industry and the DSM limit on the amount of money that could be earned from the industry limited access to some experts and probably limits drug development.  His question to the audience was:  "What if it means that 10 years from, all we have to prescribe is generic paroxetine and generic citalopram?  What if we have no better drugs?"  It would be interesting to know who was specifically not able to participate in the process due to these restrictions.  There were primarily 2 presenters with extensive industry support primarily in their role as consultants to the industry.  One of them joked about his level of involvement: "Based on my disclosures you should probably not believe a thing that I say."  He went on to give an excellent presentation replete with references to peer reviewed research.



Before I go on to talk about specific speakers I want to address another frequent illusion about psychiatrists and that is that they are primarily medication focused and have minimal interest in other treatments.  That is convenient rhetoric if you are trying to build a case that psychiatrists are all dupes for the pharmaceutical industry and that drives most of their waking decisions.  During the presentation of the pharmacological treatment of obsessive compulsive disorder, the presenter clearly stated: "It could probably be said that we are still waiting for an effective medication for obsessive compulsive disorder."  Certainly, the section on autism spectrum disorder presented the current AACAP practice parameters and the fact that there is no medication that treats the core features but some that that have a "mild to modest" effect on some features or comorbidities.   Three of the four breakout sessions in the early afternoon of day 1 were psychotherapy focused.  I attended Mindfulness Based Cognitive Therapy and Recurrent Major Depression with about 200 other participants.  We were guided through two interventions that could be used in follow up individual sessions as well as groups.  The efficacy of preventing recurrent major depression with this modality alone was discussed.  The Psychotherapeutic Treatment of Insomnia and Pediatric Post Traumatic Stress Disorder were discussed in parallel sessions.  In the PTSD lecture, it was pointed out that there is no FDA approved medication for the treatment of this disorder and that the gold standard of treatment is Trauma Focused Cognitive Behavior Therapy (CBT).  That's right a psychiatric conference where the treatment of choice is psychotherapy and not medications.

What about he individual presentations on the thinking behind the DSM?  I was thoroughly impressed by Katharine A. Phillips, MD Chair of the DSM-5 Anxiety, Obsessive-Compulsive Spectrum, Post Traumatic Stress Disorder Work Group.  Reviewing the structure of the DSM-5 as opposed to the DSM-IV shows that all of these disorder previously considered anxiety disorders are now all broken out into their own categories.  She discussed the rationale for that change as well as the parameters that were considered in grouping disorders in chapters - clearly an advance over DSM-IV.  She talked about the two new disorders Hoarding and Excoriation (Skin Picking) Disorder and why they were OCD spectrum disorders.  She talked  about insight and how it varies in both OCD and Body Dysmorphic Disorder (BDD).   She discussed the new OCD Tic-Related Specifier and its importance.  Most importantly she discussed how the decisions of the Workgroup will improve patient care.  The most obvious example, is the case of BDD where both the delusional and non-delusional types respond to SSRIs and those are the drugs of choice and not antipsychotics.  By grouping BDD in with Obsessive Compulsive Disorder and Related Disorders recognition and appropriate treatment will probably be enhanced.  Dr. Phillips is the researcher who initially discovered the treatment response of BDD to SSRIs.  She is also a rare lecturer who does not pay much attention to the PowerPoint slides but speaks extemporaneously and authoritatively on the subject in a parallel manner.

Susan E. Swedo, MD was the Chair DSM-5 Neurodevelopmental Disorder Work Group.  She talked in detail about the elimination of the Pervasive Developmental Disorders diagnosis  and how the Autism Spectrum Disorder diagnosis reflected current terminology in the field over the past ten years and how it basically eliminated 5 DSM-IV diagnoses (Autistic Disorder, Asperger Disorder, Pervasive Developmental Disorder, Childhood Disintegrative Disorder, and Rett Disorder).  She pointed out that the Workgroup could only locate 24 cases of anyone who had ever been diagnosed with Childhood Disintegrative Disorder and that the CDC's epidemic of Autism was probably related to diagnostic confusion and overlap between PDD-NOS and Attention Deficit Hyperactivity Disorder. She gave a detailed response to the "publicized concerns about DSM-5" including decreased sensitivity to improve specificity, the loss of the uniqueness of the Asperger Diagnosis, and the fact that pre/post research in this area won't be comparable.  She showed a detailed graphic and comparison of DSM-IV and DSM-5 criteria to show why that is not accurate.

I came away from this conference refreshed and more confident than ever about the reason for writing this blog.  I had just seen some of the top scientists and minds in the field and why the DSM was really changed - not what you read in the New York Times.  If you are a psychiatrist - there were plenty of reasons for a DSM-5 and if you read this far, it is only the tip of the iceberg.

George Dawson, MD, DFAPA

DSM 5 Total Diagnoses Revealed

As any reader of this blog can recall one of my foci is to expose the anti DSM 5 rhetoric for what is was.  One the the main points by DSM detractors was diagnostic proliferation or more total diagnoses.  This implies more diagnoses, more prescriptions, and more money for psychiatrists and pharmaceutical companies.  Another spin was that it was the intent of organized psychiatry to "pathologize" the population.  I put up a table on this issue in a previous post and at that time did not have the final number of diagnoses.  As of today I have the final number and it is 157.  According to the presenter that means that a total of 15 diagnoses were eliminated from DSM-IV to DSM 5.  The total diagnoses in DSM 5 did not increase as the detractors predicted - they decreased by 15.

I was at a conference today put on by the University of Wisconsin Department of Psychiatry entitled Annual Update and Advances In Psychiatry.  The Introduction by Art Walaszek, MD acknowledged that this was the first in a series that replaces a long tradition of courses run by John H. Greist, MD and James W. Jefferson, MD: "Jeff Jefferson and John Greist ran this conference for 31 years."  That is an amazing track record and record of achievement and a contribution to psychiatry in the Midwest.  I don't know of many psychiatrists who were not aware of this conference with the alliterative titles like:  "Quaffing Quanta of Quality from Quick Witted Quinessentialists" or the Door County Course they regularly taught.  They have been a model of scholarship and professionalism and continue to be.

The first speaker today was Alan Schatzberg, MD.  He posted the information about the total diagnostic categories in DSM 5 an other important changes and how they occurred.  Per my previous post about the DSM 5 lectures by Jon Grant, MD the DSM 5 effort was outlined in addition to some critical information on how stigma affects psychiatric diagnosis.  For example, when the DSM 5 work group wanted to add mild neurocognitive disorder a well known historian of psychiatry came out and said it would add countless people who had normal memory impairment associated with aging.  When neurologists added mild cognitive disorder to their diagnostic nomenclature (an equivalent diagnosis) no such claims were made about neurologists.  In terms of the effort, Dr. Schatzberg pointed out that there were 13 conferences from 2003-2008 that produced 10 monographs and over 200 journal articles.

Dr. Schatzberg and his colleagues presented a ton of information today on what really happened with DSM 5 development.  I will try to summarize and post additional comments when I can post from a more user friendly computer.  I wanted to keep the post more on the scientific and debunk another common refrain from the naysayers before the DSM 5 was printed.  That involved the so called "bereavement exclusion" that basically says that a person cannot be diagnosed with major depression if they are seen during an episode of grief.  One question that was never brought up in the popular press "Where did this convention came into the diagnostic criteria in the first place?"  I quoted a text from about the same time (see third from last paragraph) that makes this convention seem even more arbitrary.  It turns out the original bereavement exclusion began in DSM-III not from any research basis but from convention that was subjectively determined by the authors of DSM-III.  Contrast that with the research done by Zisook,  et al. You would think that some of the self proclaimed level headed skeptics out there would have referred to this critical paper on the issue rather than speculative attacks on the field.  Incorporating these scientific findings was one of the reasons that the DSM was updated.

Stay tuned for more of the hard data and insider info on DSM 5.

George Dawson, MD, DFAPA

1: Zisook S, Corruble E, Duan N, Iglewicz A, Karam EG, Lanouette N, Lebowitz B, Pies R, Reynolds C, Seay K, Katherine Shear M, Simon N, Young IT. The bereavement exclusion and DSM-5. Depress Anxiety. 2012 May;29(5):425-43. doi: 10.1002/da.21927. Epub 2012 Apr 11. Review. Erratum in: Depress Anxiety. 2012 Jul;29(7):665. PubMed PMID: 22495967.

Supplementary 1:  The DSM-5 Guidebook by Donald W. Black, MD and Jon E. Grant, MD came out in March 2014.  Table 1.  (p.  xxiii) lists the total diagnoses is DSM-5 as 157 excluding "other specified and unspecified disorders". 

"Some Sort of Mental Health Issue"

I was getting ready for work yesterday morning and watching The Today Show in the background as usual.  Suddenly there was the story of a young woman trying to ram the security barriers at the White House and then being pursued in a high speed chase down Pennsylvania Avenue.  It eventually showed a direct confrontation with law enforcement and them opening fire on her through the window of her vehicle.  There was an initial report saying that she had fired shots but she was unarmed.  The police discovered her one year old daughter in the car and removed her.  The acute reaction captured on film was surreal.  There were descriptions of some of her recent behavior and thoughts.  A police official commented that the security barriers "worked" as though this was an assault by a terrorist.  A different official commented how her daughter was "rescued" by the police.  People were talking as though this was an actual assault by a terrorist.  The last person I heard was a politician who made the quote at the top of this post and finally suggested the real problem.

Confrontation between people with severe mental illnesses and law enforcement are very common.  During my years of acute inpatient work I have talked with many people who have been injured in every imaginable way during these confrontations.  In some cases they were themselves engaged in very dangerous and aggressive behavior as the direct result of a mood disorder or a psychosis.  In other cases law enforcement just misinterpreted their behavior.  That happened most commonly when the person refused to comply with what the officer wanted them to do.  These confrontations are always high risk situations because most people in society know that it is in their best interest to be law abiding and comply with the police.  The people who don't are criminals or people with impaired judgment due to mental illness or intoxication states.  Even if the police can make that distinction rapidly that does not mean they can easily use a different approach to the person with mental illness.  Police officers have been injured or killed in these situations.

There seems to be a great deal of misunderstanding and continued bias about how these situations can occur.  It can happen as rapidly as waking up one morning finding out that your entire state of consciousness has changed.   That  gas company truck across the street is there to monitor you and direct microwaves at you.  The phones and your computer are bugged.  Going to work that morning you decide you need to take evasive action because it seems like you are being followed.  Your anxiety levels build all day and that night at home you can't sleep.  You decide you need to move the refrigerator in front of the door because you had the thought that it would be too easy for government agents to kick the door down and grab you.  You do a Google search on microwaves and decide these people are trying to do a lot more than harass you - they are trying to kill you.  You start to make plans on that basis.

That is how paranoid delusions evolve and how they change your behavior.  You are no longer making rational assessments of the environment.  Your brain has come up with a theory and you are now interpreting all of the environmental information according to that theory.  When I approach the problem psychotherapeutically, I generally explain that delusional thoughts are very low probability explanations or interpretations of an event in the environment.  I illustrate this by asking the question:  "If we had 100 people in the room right now - how many of them would agree with what you just told me?"    Many people know that hardly anyone would agree with them, but that doesn't stop them from continuing to misinterpret the data or trying to cast me with everyone else who either doesn't believe them or is just saying that they are "crazy".

Before I outline an approach to the problem of people experiencing episodes of psychosis or mania and running into problems with law enforcement consider what gets in the way of any of early intervention?  Keeping with my cardiology comparison from a previous post - most people know that chest pain is a warning sign for a possible heart attack.  With continued public health interventions most people know cardiac risk factors.  Public health intervention has been so effective that the current campaign is focused on decreasing the denial in women and decreasing cardiac sudden death in women.  Two generations of public health intervention are associated with a decreasing rate of cardiac mortality.

How does that compare with psychosis and mania?  I have never seen a public service ad advising about the warning signs of psychosis or mania.  There are countless euphemisms for acute changes in a persons mental status.  The public treats it like a mystery.  When a tragedy occurs there is often no explanation or an inadequate one like "some sort of mental illness."  The cultural approach is an obstacle to a rational approach to helping affected individuals.  Stigma is considered to be a factor, but it could as easily be an artifact of the process.  What would be a better approach?

I have been advocating a public health approach to the problem for a long time now.  At a political level there is a lot of confusion about whether this is a firearms issue.  Firearms are just a subset of the problem.  The overriding public health goal is to get people the help that they need as soon as possible.  Our current system of care is set up to provide minimal care to people with severe mental illnesses.  The level of care and condition of the facilities where the care occurs is widely known in communities and most people do not want to access these facilities for help.    I hear a lot about the concern that someone is going to be stigmatized by treatment at a psychiatric facility.  I think it is as likely that many facilities are substandard physical plants that are poorly managed.  Based on the length of stay policies alone, nobody wants to bring their relative to a facility that has a reputation for discharging partially stabilized people back into the community.  The long term goal needs to be improving the quality of psychiatric facilities in addition to changing the culture about severe mental illness.

I thought of a public service announcement that would potentially have the same advertising power as some of the more popular health spots like the "7 warning signs of cancer".  I call it the 4 warning signs of severe mental illness.  A concerted effort to focus on severe mental illnesses that can potentially lead to errors in judgment is a logical way to approach this problem.  Based on my previous paragraph it takes a much more enlightened approach to treating the problem.  Health care systems in general are not friendly to people with severe mental illnesses.  There are no specialty centers designed to cater to their needs like the high margin businesses get.  Many of these health care organizations sponsor walks for mental illness and other programs like National Depression Screening day.  But none of them say - if you have these symptoms we want to see you and treat you in a hospitable environment.

That attitude has to change to prevent the loss of innocent lives as the direct result of severe mental illness.

George Dawson, MD, DFAPA