Friday, December 14, 2012
Guns Are Not Cooling Off Between Mass Shootings
I have previously posted my concerns about mass shootings and the general paralysis on dealing with this problem. The gun lobby has unquestionable political power on this issue, but that is also due to judicial interpretation of the Second Amendment as it is written. Today's New York Times describes a mass shooting at an elementary school in Connecticut. At the time I am typing this, the death toll is 20 children, 6 adults, and the gunman. This incident occurs three days after a shopping mall shooting in Oregon.
Most people would think that nothing would be more motivating for major societal changes than children being attacked in this manner. Unfortunately this is not the first time that children have been victimized by mass shooters. On October 2, 2006 a gunman shot 10 girls and killed 5 before committing suicide. According to the Wikipedia article that was the third school shooting that week. Altogether there have been 31 school shootings since the Columbine incident on April 20, 1999.
My question and the question I have been asking for the past decade is what positive steps are going to be taken to resolve this problem? How many more lives need to be lost? How many more children need to be shot while they are attending school? Some may consider these questions to be provocative, but given the dearth of action and the excuses we hear from public health officials and politicians, I am left in the position of continuing to sound an alarm that should have been heard a couple of decades ago. After all, the elections are over. The major parties don't have to worry about alienating the pro-gun or the pro-gun control lobbyists and activists. This will not be solved as a Second Amendment or political issue. I have said it before and I will say it again - the basic approach to the problem is a scientific one and a proactive public health one that involves the following sequence of action:
1. Get the message out that homicidal thoughts - especially thoughts that involve random violence toward strangers are abnormal and treatable. The public health message should include what to do when the thoughts have been identified.
2. Provide explanations for changes in thought patterns that lead to homicidal thinking.
3. Provide a discussion of the emotional, personal and economic costs of this kind of violence.
4. Emphasize that the precursors to homicidal thinking are generally treatable and provide accessible treatment options and interventions.
5. The cultural symbol of the lone gunman in our society is a mythical figure that needs to go. There needs to be a lot of work done on dispelling that myth. I don't think that this repetitive behavior by individuals with a probable psychosis is an accident. Delusions do not occur in a vacuum and if there is a mythical explanation out there for righting the wrongs of a delusional person - someone will incorporate it into their belief system. The lone gunman is a grandiose and delusional solution for too many people. If I am right it will affect even more.
6. Study that sequence of events and outcomes locally to figure out what modifications are best in specific areas.
One of the main problems here may be the deterioration in psychiatric services over the past three decades largely as a result of government and managed care manipulations. Ironically being a danger to yourself or others is considered the main reason for being in an inpatient psychiatric unit these days. I wonder how much of the inertia in dealing with the problem of mass homicide comes from the same forces that want to restrict access to psychiatric care? Setting up the remaining inpatient units to deal with a part of this problem would require more resources for infrastructure, staff training, and to recruit the expertise needed to make a difference.
The bottom line here is that the mass homicide epidemic will only be solved by public health measures. This is not a question of good versus evil. This is not a question of accepting this as a problem that cannot be solved, grieving, and moving on. This is a question of identifiable thought patterns changing and leading to homicidal behavior and intervening at that level.
George Dawson, MD, DFAPA
Wednesday, December 12, 2012
ADHD and Crime
There has been a lot of commentary on the NEJM article on the association between stimulant treatment of Attention Deficit Hyperactivity Disorder (ADHD) and less crime in a cohort of patients with ADHD. Two of my favorite bloggers have commented on the study on the Neuroskeptic and Evolutionary Psychiatry blogs. As a psychiatrist who treats mostly patients with addictions who may have ADHD and teaches the subject in lectures - I thought that I would add my opinion.
Much of my time these days is spent seeing adults who are also being treated for alcoholism or addiction. I also teach the neurobiological aspects of these problems to graduate students and physicians. In the clinical population that I work with - ADHD is common and so is stimulant abuse/dependence and diversion. Cognitive enhancement is a widely held theory on college campuses and in professional schools. That theory suggests that you can study longer, harder, and more effectively under the influence of stimulants. They are easy to obtain. Stimulants like Adderall are bought, sold, and traded. It is fairly common to hear that a feeling of enhanced cognitive capacity based on stimulants acquired outside of a prescription is presumptive evidence of ADHD. It is not. It turns out that anyone (or at least most people) will have the same experience even without a diagnosis of ADHD.
There is very little good guidance on how to treat ADHD when stimulant abuse or dependence may be a problem. Some literature suggests that you can treat people in recovery with stimulants - even if they have been previously addicted to stimulants. Anyone making the diagnosis of ADHD needs to makes sure that there is good evidence of impairment in addition to the requisite symptoms. Ongoing treatment needs to assure that the stimulants are not being used in an addictive manner. I would define that as not accelerating the dose, not taking medications for indications other than treating ADHD (cramming for an exam, increased ability to tolerate alcohol, etc), not attempting to extract, smoke, inject, or snort the stimulant, not obtaining additional medication from an illegal source, and not using the stimulant in the presence of another active addiction. Addressing this problem frequently requires the use of FDA approved non stimulant medication and off-label approaches.
With the risk of addiction that I see in a a population that is selected on that dimension, why treat ADHD and more specifically why treat with medications? The literature on the treatment of ADHD is vast relative to most other drugs studied in controlled clinical trials. There have been over 350 trials and the majority of them are not only positive but show very robust effects in terms of treatment response. The safety of these medications is also well established.
Enter the article from the NEJM on criminality and the observation that stimulants treatment may reduce the criminality rate. This was a Swedish population where the research team had access to registries containing data on all persons convicted of a crime, diagnosed with ADHD, getting a prescription for a stimulant, and to assign 10 age, sex, and geography matched controls to each case. Active treatment was rather loosely defined as any time interval between two prescriptions as long as that interval did not exceed six months. The researchers found statistically significant reductions during the time of active treatment for both men (32%) and women (41%).
I agree that this is a very high quality article from the standpoint of epidemiological research - but my guess is the editors of the NEJM already knew that. This study gets several style points from the perspective of epidemiological research. That includes the large data base and looking for behavioral correlates of another inactive medication for ADHD - serotonin re-uptake inhibitors or SSRIs. There is a robust correlation with stimulants but not with self discontinued SSRIs. They also analyzed the data irrespective of the order of medications status to rule out a reverse causation effect (treatment was stopped because of criminal behavior) and found significant correlations independent of order.
Apart from the usual analysis clinical and researchers in the field ranging from neurobiologists to researchers doing long term follow up studies do not find these results very surprising. The Medline search below gives references of varying quality dating back for decades. The pharmacological treatment certainly goes back that far. The accumulating data suggests that where the disorder persists, it requires treatment on an ongoing basis. A limited number of studies suggest that cognitive behavioral therapy (CBT) may be useful for adults with ADHD but not as useful for children or adolescents. The practice of "drug holidays" prevalent not so long ago - no longer makes sense when the diagnosis is conceptualized as a chronic condition needing treatment to reduce morbidity ranging from school failure to decreased aggression to better driving performance.
One of the typical criticisms of epidemiological research of this design is that association is not causality, I think it is time to move beyond that to what may be considered causal. In fact, I think it may be possible at this time to move beyond the double blind placebo controlled trial to an epidemiological standard and I will try to pull together some data about that approach.
George Dawson, MD, DFAPA
Lichtenstein P, Halldner L, Zetterqvist J, Sjölander A, Serlachius E, Fazel S, Långström N, Larsson H. Medication for attention deficit-hyperactivity disorder and criminality. N Engl J Med. 2012 Nov 22;367(21):2006-14. doi: 10.1056/NEJMoa1203241.
Criminality and ADHD: Medline Search
Much of my time these days is spent seeing adults who are also being treated for alcoholism or addiction. I also teach the neurobiological aspects of these problems to graduate students and physicians. In the clinical population that I work with - ADHD is common and so is stimulant abuse/dependence and diversion. Cognitive enhancement is a widely held theory on college campuses and in professional schools. That theory suggests that you can study longer, harder, and more effectively under the influence of stimulants. They are easy to obtain. Stimulants like Adderall are bought, sold, and traded. It is fairly common to hear that a feeling of enhanced cognitive capacity based on stimulants acquired outside of a prescription is presumptive evidence of ADHD. It is not. It turns out that anyone (or at least most people) will have the same experience even without a diagnosis of ADHD.
There is very little good guidance on how to treat ADHD when stimulant abuse or dependence may be a problem. Some literature suggests that you can treat people in recovery with stimulants - even if they have been previously addicted to stimulants. Anyone making the diagnosis of ADHD needs to makes sure that there is good evidence of impairment in addition to the requisite symptoms. Ongoing treatment needs to assure that the stimulants are not being used in an addictive manner. I would define that as not accelerating the dose, not taking medications for indications other than treating ADHD (cramming for an exam, increased ability to tolerate alcohol, etc), not attempting to extract, smoke, inject, or snort the stimulant, not obtaining additional medication from an illegal source, and not using the stimulant in the presence of another active addiction. Addressing this problem frequently requires the use of FDA approved non stimulant medication and off-label approaches.
With the risk of addiction that I see in a a population that is selected on that dimension, why treat ADHD and more specifically why treat with medications? The literature on the treatment of ADHD is vast relative to most other drugs studied in controlled clinical trials. There have been over 350 trials and the majority of them are not only positive but show very robust effects in terms of treatment response. The safety of these medications is also well established.
Enter the article from the NEJM on criminality and the observation that stimulants treatment may reduce the criminality rate. This was a Swedish population where the research team had access to registries containing data on all persons convicted of a crime, diagnosed with ADHD, getting a prescription for a stimulant, and to assign 10 age, sex, and geography matched controls to each case. Active treatment was rather loosely defined as any time interval between two prescriptions as long as that interval did not exceed six months. The researchers found statistically significant reductions during the time of active treatment for both men (32%) and women (41%).
I agree that this is a very high quality article from the standpoint of epidemiological research - but my guess is the editors of the NEJM already knew that. This study gets several style points from the perspective of epidemiological research. That includes the large data base and looking for behavioral correlates of another inactive medication for ADHD - serotonin re-uptake inhibitors or SSRIs. There is a robust correlation with stimulants but not with self discontinued SSRIs. They also analyzed the data irrespective of the order of medications status to rule out a reverse causation effect (treatment was stopped because of criminal behavior) and found significant correlations independent of order.
Apart from the usual analysis clinical and researchers in the field ranging from neurobiologists to researchers doing long term follow up studies do not find these results very surprising. The Medline search below gives references of varying quality dating back for decades. The pharmacological treatment certainly goes back that far. The accumulating data suggests that where the disorder persists, it requires treatment on an ongoing basis. A limited number of studies suggest that cognitive behavioral therapy (CBT) may be useful for adults with ADHD but not as useful for children or adolescents. The practice of "drug holidays" prevalent not so long ago - no longer makes sense when the diagnosis is conceptualized as a chronic condition needing treatment to reduce morbidity ranging from school failure to decreased aggression to better driving performance.
One of the typical criticisms of epidemiological research of this design is that association is not causality, I think it is time to move beyond that to what may be considered causal. In fact, I think it may be possible at this time to move beyond the double blind placebo controlled trial to an epidemiological standard and I will try to pull together some data about that approach.
George Dawson, MD, DFAPA
Lichtenstein P, Halldner L, Zetterqvist J, Sjölander A, Serlachius E, Fazel S, Långström N, Larsson H. Medication for attention deficit-hyperactivity disorder and criminality. N Engl J Med. 2012 Nov 22;367(21):2006-14. doi: 10.1056/NEJMoa1203241.
Criminality and ADHD: Medline Search
Friday, December 7, 2012
Paradigm Shift or Typical Rhetoric?
"Humanism and science cannot be based on rhetoric and wishful thinking. They require hard work and dedication to both scientific methodology and humanistic concerns." - Akiskal and McKinney - 1973
Well I decided to interrupt a post I was working on to respond to more noise about everything that is wrong with psychiatry - at least according to one blogger and an author that he is reviewing. The basic argument is that there is a push to "remedicalize" psychiatry because of pressure on psychiatrists from non physician providers. Apparently psychiatrists are an expensive commodity- especially if they really don't know anything. That argument is so poorly thought out - it is difficult to know where to start.
The medical basis of psychiatry is well recorded starting in European asylums. At one point German psychiatry was firmly focused on brain studies and Alzheimer, Nissl and others were searching for the neuroanatomical basis of mental illnesses in the late 19th century. Psychiatrists were the first physicians responsible for the large scale treatment of epilepsy and neurosyphilis. Whenever a previously intractable condition became more treatable it seems like it was no longer under the purview of psychiatry.
If anything there was a push to demedicalize psychiatry with the advent of Freudian and later therapies - that for the most part were good literary efforts but seem to offer very little in terms of modern treatment apart from a few very broad guideposts. It probably persisted right up to the heyday of biological psychiatry in the US and I would put that sometime in the early 1980s. A well read friend of mine suggested that when Freud was waiting for a call from the Nobel committee, it probably should have been the committee on Literature rather than Medicine. Given Freud's subsequent impact on English literature - I think that was a keen observation. It certainly had little to do with medicine.
The medical basis of psychiatry is well documented and all I have to do is spin around in my chair and look at the texts I have on my book shelves.
The original work on delirium by Lipowski. Three editions of Lishman's Organic Psychiatry. Countless texts on consultation liaison psychiatry, geriatric psychiatry, addiction psychiatry, sleep medicine, psychosomatic medicine, and specialty volumes on Alzheimer's disease and other brain conditions. Classic chapters in Lahita's Systemic Lupus Erythematosus on the cognitive and psychiatric aspects of SLE. Every psychiatrist needs to know if there is a medical cause for the psychiatric problem being evaluated, if it is safe to treat a person given their medical comorbidity, and how to assure the medical and psychological safety of that patient they are treating. That has always included the ability to make common and rare medical diagnoses, interpret physical findings, and interpret test results. That last sentence is frequently minimized but it requires the ability to recognize patterns and manage information that is on par with any other specialist.
The idea that psychiatry requires "remedicalization" or has been "remedicalized" is another myth of the ill informed, but it does have a basis. The basis is in how the managed care cartel has taken over and dumbed down the field. Managed care companies would like nothing more than psychiatrists sitting in offices doing cursory interviews and handing out antidepressants. Reviewers from managed care companies have essentially disclosed this to me over the years with comments like: "Psychiatrists are not supposed to manage delirum". My reply: "That's funny because the Medicine service transferred me this patient as 'medically stable' and with no delirium diagnosis." Who in the hell else is going to manage delirious bipolar patients with hepatic or renal failure?
Of course I realize that managed care companies really don't care about my patients and in this case it was fairly explicit that they could save the "behavioral health" cost center a lot if they could shame me into transferring the patient back to Medicine. My response was basically - you convince them to accept the patient and I will transfer them back. It never happened.
The only "paradigm shift" required here is to let psychiatrists practice medicine at the level they are competent to provide, rather than rationing their services. The quality of care will dramatically improve and that includes associated medical care and diagnoses determined based on the ability of psychiatrists to communicate with patients. What is probably difficult to accept by the "paradigm shifters" no matter who they may be is that psychiatry is a difficult field. You do have to know plenty of medicine and like all other medical specialties you need to know the theory. When I trained in in medical school there was plenty of theory that we had to learn that never made it into mainstream practice. Much of the neuroscience and genetics that applies to psychiatry already exceeds the applicability of what I was taught about theophylline in medical school.
The most difficult part about psychiatry is that you always have to be patient centered and know how to talk to people. That falls flat if you don't have the expertise to recognize all of their their illnesses and help them get better. The only real crisis in psychiatry is that it is being starved into non existence by the government and managed care companies. They don't care what psychiatrists know and what they can do. They don't want you to see one.
George Dawson, MD, DFAPA
Akiskal HS, McKinney WT Jr. Psychiatry and pseudopsychiatry. Arch GenPsychiatry 1973 Mar;28(3):367-73.
Thursday, November 29, 2012
Freedom of Information is Not Exactly Free
I am still trying to figure out how to access information from the Freedom of Information Act (FOIA). Some data acquired through this act has proven to be valuable from a research standpoint. I first became aware of this data a a research technique in the excellent studies by Kahn, looking at the issue of suicide in placebo controlled drug trials of antidepressant and antipsychotic medications. These were excellent studies and I am surprised that they are not widely referred to whenever the issue of suicidal behavior secondary to a medication or suicidal behavior in drug trials is discussed. Kahn, et al accessed their raw data through FOIA requests through the FDA.
I have been trying for a long time to access data from the FBI on the basis of an FOIA request. I started out about 10 years ago and asked them for specific data pertaining to their pre-911 role of auditing physicians billing practices and determining whether or not a physician had committed "fraud" based on a mismatch between the billing statement and the document of the clinical visit. I know that they had specific documents about this practice and even briefly published a journal detailing their strategies and tactics. At one point that data was online and then it disappeared. In order to have a closer look at FBI activity in the area of health care fraud I filed the original request that resulted in no data. This year, I looked at the FBI reading room again and it discussed the wide availability of information in that venue that could also be copied and sent at a cost to the requester. Using the FBI form and broadening the request to data pertaining to health care fraud, I completed the following form on the FBI web site on September 1, 2012 (click graphic to expand):
I think that it is fairly clear that I am interested in activities pertaining to health care fraud. I received the following reply today (click graphic to expand):
That is quite a price tag. $66,702.50 for 667,125 pages or $7,985 for 533 CDs. I can't imagine that there is a lot of relevant data contained in these pages. The documents I am looking for comprise no more than 200 pages. Using their rates that is $20 of information. The result when I specifically ask for information that I am certain they have is a denial. If I try to broaden the search and look for myself they offer to send me what could be a small directory off a hard drive. Figuring 14 kB per page that converts to about 8.9 GB. The fact that they are willing to send CDs suggests to me that it is already sitting on a hard drive. My point here is that all of this data could be sitting on a hard drive somewhere in a federal building and I could be searching it from home for free.
If data is declassified and available to the public, why jump through all of these hoops to get it? If the data was available, I don't think it would be too hard to trace the FBI activity in health care fraud against physicians and get all of the facts out on the table. As it stands both price tags in this FOIA request are too steep for me and that story will have to be written at another time. As with many problems that occur with our government that time is usually when anyone who cared about the issue, all of the politicians responsible for it, and the bureaucrats who actually administered it are long gone.
George Dawson, MD, DFAPA
I have been trying for a long time to access data from the FBI on the basis of an FOIA request. I started out about 10 years ago and asked them for specific data pertaining to their pre-911 role of auditing physicians billing practices and determining whether or not a physician had committed "fraud" based on a mismatch between the billing statement and the document of the clinical visit. I know that they had specific documents about this practice and even briefly published a journal detailing their strategies and tactics. At one point that data was online and then it disappeared. In order to have a closer look at FBI activity in the area of health care fraud I filed the original request that resulted in no data. This year, I looked at the FBI reading room again and it discussed the wide availability of information in that venue that could also be copied and sent at a cost to the requester. Using the FBI form and broadening the request to data pertaining to health care fraud, I completed the following form on the FBI web site on September 1, 2012 (click graphic to expand):
If data is declassified and available to the public, why jump through all of these hoops to get it? If the data was available, I don't think it would be too hard to trace the FBI activity in health care fraud against physicians and get all of the facts out on the table. As it stands both price tags in this FOIA request are too steep for me and that story will have to be written at another time. As with many problems that occur with our government that time is usually when anyone who cared about the issue, all of the politicians responsible for it, and the bureaucrats who actually administered it are long gone.
George Dawson, MD, DFAPA
Friday, November 23, 2012
Mayo Clinic Counterpoint to FDA on Citalopram
The Mayo Clinic came out with their recommendations on what to do about the FDA's warning about citalopram. By their own description they are more liberal with regard to their citalopram recommendations and more conservative regarding escitalopram. I have previously reviewed the problem here and concluded that there is really a lack of data available on the likelihood of electrocardiogram abnormalities during normal clinical use and if citalopram is as cardiotoxic as the FDA is describing it - we should treat it more like a standard antiarrhythmic drug and used flecanide as an example.
For all practical purposes that would include baseline ECGs, ECGs at the max dose and taking it up one more level from either the Mayo Clinic or the FDA - a stress test looking for QTc prolongation at higher heart rates. The other elements in the Mayo recommendations based on history and physical examination and expecting some physician knowledge of drug metabolism are fairly standard. I thought it was interesting that they did not mention checking plasma levels of the drug especially in complex cases (eg. a patient with cirrhosis) who only responds to higher than recommended doses of the drug. Regarding the statements: "Selective serotonin reuptake inhibitors cannot simply be substituted for one another, not even escitalopram for citalopram." That is generally true and where are these guys in the battle against PBMs saying that these drugs are all equivalent? I have not found any patient that responded selectively to citalopram and not escitalopram. I have generally been able to convert patients to an equivalent amount of escitalopram the next day.
Both the Mayo Clinic and the FDA are silent on molecular approaches to solving this problem and screening patient for potential risk before they are started on either drug. The Mayo Clinic offers testing for cytochrome P450 genotypes. The genetic basis for hereditary prolonged QTc intervals has been a hot topic of research over the past decade. It is probably time to expand the search for additional genotypes that place people at risk during specific drug therapies. Until then we have only very approximate methods of determining the at - risk population and keeping them safe and the Mayo recommendations are more reality based than the FDA.
I think it would also be possible to estimate the risk associated with taking citalopram across the entire population. In fact, at this point the FDA seems to have the data to estimate the risk of any QTc effect at all to the risk of torsade de pointes - the most significant arrhythmia. I think it is very important for patients making the decision to have this number and if I can provide numbers on rare but serious antidepressant complications like serotonin syndrome, a federal agency with more perfect information and no patient care responsibility can do better.
George Dawson, MD, DFAPA
Sheeler RD, Ackerman MJ, Richelson E, Nelson TK, Staab JP, Tangalos EG, Dieser LM, Cunningham JL. Considerations on safety concerns about citalopram prescribing. Mayo Clin Proc. 2012 Nov;87(11):1042-5.
FDA Drug Safety Communication: Revised recommendations for Celexa (citalopram hydrobromide) related to a potential risk of abnormal heart rhythms with high doses.
For all practical purposes that would include baseline ECGs, ECGs at the max dose and taking it up one more level from either the Mayo Clinic or the FDA - a stress test looking for QTc prolongation at higher heart rates. The other elements in the Mayo recommendations based on history and physical examination and expecting some physician knowledge of drug metabolism are fairly standard. I thought it was interesting that they did not mention checking plasma levels of the drug especially in complex cases (eg. a patient with cirrhosis) who only responds to higher than recommended doses of the drug. Regarding the statements: "Selective serotonin reuptake inhibitors cannot simply be substituted for one another, not even escitalopram for citalopram." That is generally true and where are these guys in the battle against PBMs saying that these drugs are all equivalent? I have not found any patient that responded selectively to citalopram and not escitalopram. I have generally been able to convert patients to an equivalent amount of escitalopram the next day.
Both the Mayo Clinic and the FDA are silent on molecular approaches to solving this problem and screening patient for potential risk before they are started on either drug. The Mayo Clinic offers testing for cytochrome P450 genotypes. The genetic basis for hereditary prolonged QTc intervals has been a hot topic of research over the past decade. It is probably time to expand the search for additional genotypes that place people at risk during specific drug therapies. Until then we have only very approximate methods of determining the at - risk population and keeping them safe and the Mayo recommendations are more reality based than the FDA.
I think it would also be possible to estimate the risk associated with taking citalopram across the entire population. In fact, at this point the FDA seems to have the data to estimate the risk of any QTc effect at all to the risk of torsade de pointes - the most significant arrhythmia. I think it is very important for patients making the decision to have this number and if I can provide numbers on rare but serious antidepressant complications like serotonin syndrome, a federal agency with more perfect information and no patient care responsibility can do better.
George Dawson, MD, DFAPA
Sheeler RD, Ackerman MJ, Richelson E, Nelson TK, Staab JP, Tangalos EG, Dieser LM, Cunningham JL. Considerations on safety concerns about citalopram prescribing. Mayo Clin Proc. 2012 Nov;87(11):1042-5.
FDA Drug Safety Communication: Revised recommendations for Celexa (citalopram hydrobromide) related to a potential risk of abnormal heart rhythms with high doses.
Why I No Longer Support NAMI
For the past several years my wife and I have been regular donors to our state branch of the National Alliance on Mental Illness (NAMI). We decided to do it initially as a memorial to family members who suffered from mental illness. I just got two letters in the mail encouraging me to donate again. One was a "Dear Friend" letter from NAMI reminding me of the plight of the mentally ill. The other was from the Medical Director and CEO of the American Psychiatric Association. Dr. Scully apparently thinks he is reminding me of how fragmented the system of care is and "The treatment system that confronts families seeking care is too often fragmented, unorganized and, despite the efforts of many, is uneven at best in its quality." After working in that "system" for over 25 years and witnessing its decimation by the managed care industry - both letters are insulting.
The only time I was impressed with NAMI was during an attempt to secure resources for a patient in another state. At that time I contacted NAMI in Illinois and was almost immediately faxed, about 50 pages of resources that my social worker and I could use to come up with a discharge plan. The fragmented system often resulted in us spending long stress filled hours trying to piece together a plan that we hoped would work while we were being pressured to discharge the person to the street. Managed care companies were not helpful. I can still recall a patient with complicated problems. The managed care company did not acknowledge the serious nature of the problem and wanted immediate discharge. When we tried to get a discharge appointment for the patient the earliest appointment was 6 months away and they refused to give any priority based on the recent hospital discharge.
A local NAMI walk for fund raising was disappointing. Psychiatrists tended to walk with their own organizations, but the dimension that was unnerving to me was the corporate presence. It seems that the no free lunch movement for doctors is not as concerned about corporate sponsorship of NAMI and any conflicts of interest that might arise. Why would anyone raise the issue of conflict of interest? There are two obvious issues. NAMI has long been an advocate for access to psychiatric care and psychiatrists. The managed care companies listed as sponsors have been the primary drivers in restricting access not just to psychiatric care but any kind of evaluation or treatment for mental illness or addiction. In the Twin Cities they currently use case managers to control admissions and discharges. Those case managers make those decisions based on proprietary guidelines that have little to do with the modern practice of psychiatry.
A second issue is pharmaceutical sponsors. Psychiatry has been singled out for the appearance of conflict of interest whenever there have been sponsorship or payment of researchers or speakers by pharmaceutical companies. The real effect of this sponsorship is on the public. There is no clearer example than National Depression Screening Day. This event began across the country over 20 years ago. I was the organizer for two years for the Minnesota Psychiatric Society. The event was sponsored nation wide by the company who had the most expensive and widely known antidepressant on the market. It was a field day for the idea that antidepressant medications treat depression. That bias is still present today and is probably one of the single greatest reasons why treatment of mental illness is typically reduced to a cure in a pill.
Despite my reservations, I decided to support NAMI with an annual check and was listed as a professional member of the organization. NAMI is a politically powerful organization and I often heard that they had interests that were similar to psychiatric professional organizations. Then a few months ago Minnesota Public Radio came out with a story on the Minnesota Security Hospital. It is the state facility that is used to house and treat patients with severe mental illnesses who are also dangerous on an ongoing basis. Most of the patients are there because they have been adjudicated after committing a violent crime or they are there for an evaluation. There have been severe administrative problems that have resulted in the resignation of most of the psychiatric staff and an increased number of injuries to staff.
According to that report:
"Sue Abderholden, the executive director of the mental health advocacy group NAMI Minnesota, said despite the concerns, she thinks Barry and other officials are doing a good job of addressing serious, long-standing issues at the facility. She said the decrease in the number of psychiatrists is not necessarily a problem, as long as the facility hires qualified nurse practitioners. Ideally, she said, patients would always see the same provider, but she said that's not realistic for most facilities."
The opinion given in that story is certainly at odds with my opinion. The state and NAMI seem to believe that psychiatrists are there to prescribe medications and can be easily replaced in that department. I don't see anything that reflects psychiatric training in how to treat aggressive patients (what else is needed besides medication?) and what needs to happen from a systems or administrative standpoint. Psychiatrists are the only staff with that kind of training and I wonder about whether they can use that training in a system that seems to suggest that an administrator can develop programs to deal with aggression. The executive director's opinion seems quite consistent with that approach. Wasn't that the problem in the first place?
I don't expect any support from NAMI. Psychiatrists should be able to support their own positions and members. At the same time, I don't see any benefit to financially supporting an organization that has radically different goals than my professional goals and sees psychiatrists as easily replaced by people with much less training. As far as the position of administrators dictating clinical care goes, that is a psychiatrist replaced by someone with no training. If anyone can act like a physician - then physicians become superfluous. It is tantamount to running the place with a managed care company and creating the illusion that serious care is being done by seeing people for a few minutes and talking about their medications.
The time has come to not renew my professional membership in NAMI. With mental health parity still in question, any advocacy organization needs to have higher standards than a managed care company.
George Dawson, MD, DFAPA
Madeleine Baran. More injured employees, fewer doctors at Minnesota Security Hospital. August 29. 2012.
The only time I was impressed with NAMI was during an attempt to secure resources for a patient in another state. At that time I contacted NAMI in Illinois and was almost immediately faxed, about 50 pages of resources that my social worker and I could use to come up with a discharge plan. The fragmented system often resulted in us spending long stress filled hours trying to piece together a plan that we hoped would work while we were being pressured to discharge the person to the street. Managed care companies were not helpful. I can still recall a patient with complicated problems. The managed care company did not acknowledge the serious nature of the problem and wanted immediate discharge. When we tried to get a discharge appointment for the patient the earliest appointment was 6 months away and they refused to give any priority based on the recent hospital discharge.
A local NAMI walk for fund raising was disappointing. Psychiatrists tended to walk with their own organizations, but the dimension that was unnerving to me was the corporate presence. It seems that the no free lunch movement for doctors is not as concerned about corporate sponsorship of NAMI and any conflicts of interest that might arise. Why would anyone raise the issue of conflict of interest? There are two obvious issues. NAMI has long been an advocate for access to psychiatric care and psychiatrists. The managed care companies listed as sponsors have been the primary drivers in restricting access not just to psychiatric care but any kind of evaluation or treatment for mental illness or addiction. In the Twin Cities they currently use case managers to control admissions and discharges. Those case managers make those decisions based on proprietary guidelines that have little to do with the modern practice of psychiatry.
A second issue is pharmaceutical sponsors. Psychiatry has been singled out for the appearance of conflict of interest whenever there have been sponsorship or payment of researchers or speakers by pharmaceutical companies. The real effect of this sponsorship is on the public. There is no clearer example than National Depression Screening Day. This event began across the country over 20 years ago. I was the organizer for two years for the Minnesota Psychiatric Society. The event was sponsored nation wide by the company who had the most expensive and widely known antidepressant on the market. It was a field day for the idea that antidepressant medications treat depression. That bias is still present today and is probably one of the single greatest reasons why treatment of mental illness is typically reduced to a cure in a pill.
According to that report:
"Sue Abderholden, the executive director of the mental health advocacy group NAMI Minnesota, said despite the concerns, she thinks Barry and other officials are doing a good job of addressing serious, long-standing issues at the facility. She said the decrease in the number of psychiatrists is not necessarily a problem, as long as the facility hires qualified nurse practitioners. Ideally, she said, patients would always see the same provider, but she said that's not realistic for most facilities."
The opinion given in that story is certainly at odds with my opinion. The state and NAMI seem to believe that psychiatrists are there to prescribe medications and can be easily replaced in that department. I don't see anything that reflects psychiatric training in how to treat aggressive patients (what else is needed besides medication?) and what needs to happen from a systems or administrative standpoint. Psychiatrists are the only staff with that kind of training and I wonder about whether they can use that training in a system that seems to suggest that an administrator can develop programs to deal with aggression. The executive director's opinion seems quite consistent with that approach. Wasn't that the problem in the first place?
I don't expect any support from NAMI. Psychiatrists should be able to support their own positions and members. At the same time, I don't see any benefit to financially supporting an organization that has radically different goals than my professional goals and sees psychiatrists as easily replaced by people with much less training. As far as the position of administrators dictating clinical care goes, that is a psychiatrist replaced by someone with no training. If anyone can act like a physician - then physicians become superfluous. It is tantamount to running the place with a managed care company and creating the illusion that serious care is being done by seeing people for a few minutes and talking about their medications.
The time has come to not renew my professional membership in NAMI. With mental health parity still in question, any advocacy organization needs to have higher standards than a managed care company.
George Dawson, MD, DFAPA
Madeleine Baran. More injured employees, fewer doctors at Minnesota Security Hospital. August 29. 2012.
Thursday, November 15, 2012
ADHD - The Scientific Evidence versus the Political Hype
I attended a day long seminar by Russell Barkley, PhD. It is part of my ongoing mission of seeing the experts in person who I have read and collected in my library over the past 30 years. My earliest exposure to Dr. Barkley's work was the book Hyperactive Children that I acquired while I was in Medical School and used when I was treating children in the first clinic I worked in as a psychiatrist. Interestingly he was working at the same medical school I had attended. Dr. Barkley has an impressive surveillance system for current literature and in the seminar was presenting work that had literally been published or put into prepublication the day before. His scholarship is impressive and he is one of the most widely published authors in the field. He has a clear scientific approach and does not recommend treatments that have not gone through randomized and blinded clinical trials. He gave many examples of ADHD treatments that seemed effective until the raters were blinded to the treatment or the methods were used by researchers who had no vested interest in the outcome.
All of his information was presented on PowerPoint as is the standard. His PowerPoint slides were information dense, frequently presenting dimensions and data points from several studies on the same line.
A few of the highlights that you will not read in the New York Times:
1. On the "overdiagnosis" issue - at this time about 40% of kids and 10% of adults with the disorder are treated.
2. On the DSM issue - the categories of ADHD are going away. Like categories of schizophrenia and autism spectrum disorder they are not unique entities. This of course runs counter to the usual DSM criticism that there is a proliferation of diagnostic categories Another positive was that the age of onset criteria is changing from age 7 to age 12. Barkley points out that an age cutoff for a developmental process is arbitrary and suggested a further change to "onset in childhood or adolescence". On the other hand, it does appear that the committee in charge is responding to political pressure from the government and insurance companies to not make any changes that would increase the prevalence of the disorder. He presented clear criteria that would improve the diagnosis of ADHD in adults that will apparently not be included or possibly on a parenthetical basis.
3. The problem with the treatment of children is not overtreatment, but that fact that most children who need treatment discontinue their medications as teenagers.
4. The resulting complications of untreated ADHD are significant from an educational, public health, and psychiatric perspective. As one example, untreated ADHD is associated with high risk of dropping out of school. Every person who drops out and does not complete school represents a cost of $450K to the community.
5. Stimulant medications have a 40 year record of use and there have been over 350 studies documenting the efficacy and safety. They have the greatest effect size of any psychiatric medications and that includes up to 90% response rates across all stimulants.
6. Response to treatment is robust and the best of any psychiatric disorder. Evidence based studies show that patients treated with stimulants show improved outcomes across 20 parameters and that treatment with atomoxetine is associated with improvement across 23 parameters.
7. These medications have an unprecedented safety record.
8. There is a potential steep cost in many areas of not adequately treating the disorder.
It is very disappointing to hear that the DSM committee may be yielding to political pressure when it comes to implementing new evidence based DSM criteria particularly give the poor quality of these arguments. A professional organization should be above political influence when it comes to scientific findings and this revision of criteria was supposed to be based on science. The APA does have a long history of not providing any resistance to the managed care industry or government initiatives to reduce the quality of psychiatric care in favor of the managed care industry. If true it will be ironic that the ADHD section of the DSM5 will be be directly influenced by the usual managed care forces and that they are aligned with all of the media rhetoric about the proliferation diagnoses and increased prevalence.
So the usual media hype is wrong - psychiatrists and pharmaceutical companies are not plotting to put more people on medication. The government, managed care companies, and the anti-biological antipsychiatrists are trying to keep them off even when they are indicated. In that political divide - the science is left out.
George Dawson, MD, DFAPA
Dr. Russell A. Barkley, PhD. Official Web Site.
Dr. Russel A. Barkley, PhD. Professional Workshop on ADHD. ADHD Across the Life Span: Diagnosis, Life Course, Management, and Comorbidity. Minnetonka, Minnesota. Thursday November 15, 2012.
International Consensus Statement on ADHD (excerpt) - read this statement signed by scientists explaining that this diagnosis is not controversial and that the percentage of patients treated is about the same in the past decade.
All of his information was presented on PowerPoint as is the standard. His PowerPoint slides were information dense, frequently presenting dimensions and data points from several studies on the same line.
A few of the highlights that you will not read in the New York Times:
1. On the "overdiagnosis" issue - at this time about 40% of kids and 10% of adults with the disorder are treated.
2. On the DSM issue - the categories of ADHD are going away. Like categories of schizophrenia and autism spectrum disorder they are not unique entities. This of course runs counter to the usual DSM criticism that there is a proliferation of diagnostic categories Another positive was that the age of onset criteria is changing from age 7 to age 12. Barkley points out that an age cutoff for a developmental process is arbitrary and suggested a further change to "onset in childhood or adolescence". On the other hand, it does appear that the committee in charge is responding to political pressure from the government and insurance companies to not make any changes that would increase the prevalence of the disorder. He presented clear criteria that would improve the diagnosis of ADHD in adults that will apparently not be included or possibly on a parenthetical basis.
3. The problem with the treatment of children is not overtreatment, but that fact that most children who need treatment discontinue their medications as teenagers.
4. The resulting complications of untreated ADHD are significant from an educational, public health, and psychiatric perspective. As one example, untreated ADHD is associated with high risk of dropping out of school. Every person who drops out and does not complete school represents a cost of $450K to the community.
5. Stimulant medications have a 40 year record of use and there have been over 350 studies documenting the efficacy and safety. They have the greatest effect size of any psychiatric medications and that includes up to 90% response rates across all stimulants.
6. Response to treatment is robust and the best of any psychiatric disorder. Evidence based studies show that patients treated with stimulants show improved outcomes across 20 parameters and that treatment with atomoxetine is associated with improvement across 23 parameters.
7. These medications have an unprecedented safety record.
8. There is a potential steep cost in many areas of not adequately treating the disorder.
It is very disappointing to hear that the DSM committee may be yielding to political pressure when it comes to implementing new evidence based DSM criteria particularly give the poor quality of these arguments. A professional organization should be above political influence when it comes to scientific findings and this revision of criteria was supposed to be based on science. The APA does have a long history of not providing any resistance to the managed care industry or government initiatives to reduce the quality of psychiatric care in favor of the managed care industry. If true it will be ironic that the ADHD section of the DSM5 will be be directly influenced by the usual managed care forces and that they are aligned with all of the media rhetoric about the proliferation diagnoses and increased prevalence.
So the usual media hype is wrong - psychiatrists and pharmaceutical companies are not plotting to put more people on medication. The government, managed care companies, and the anti-biological antipsychiatrists are trying to keep them off even when they are indicated. In that political divide - the science is left out.
George Dawson, MD, DFAPA
Dr. Russell A. Barkley, PhD. Official Web Site.
Dr. Russel A. Barkley, PhD. Professional Workshop on ADHD. ADHD Across the Life Span: Diagnosis, Life Course, Management, and Comorbidity. Minnetonka, Minnesota. Thursday November 15, 2012.
International Consensus Statement on ADHD (excerpt) - read this statement signed by scientists explaining that this diagnosis is not controversial and that the percentage of patients treated is about the same in the past decade.
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