National Behavioral Health Quality Framework - Ultimate Oxymoron?

As I pointed out in a previous post, the Substance Abuse and Mental Health Services Administration (SAMHSA) a branch of the U.S. Department of Health and Human Services is currently working with the managed care industry.  They are also the object of criticism by E. Fuller Torrey in his recent editorial and upcoming book for promoting non evidence based care of people with severe mental illnesses and in fact at many levels dismantling existing care.   With that kind of a backdrop, their e-mail to me this morning suggesting that I should review the National Behavioral Health Quality Framework (NBHQF) and provide comments as an interested member of the public should not have been very surprising.  I thought I would put that commentary here rather than letting it be buried on a government website that nobody would read.

To set the appropriate tone for my comments, the introduction section of this document identifies the major entity that the government is working with here as the managed care industry.  I consider the NCQA (or NQF) to be a proxy for the managed care industry.  That is their history as I recall it and I am not aware of any physician professional group that says otherwise.  In fact, I cannot find the American Psychiatric Association as a member of the NQF, but I am fairly certain that they used to be a member of NCQA..

Getting back to the document - six goals are identified with a page each dedicated to currently available measures and a second page that is described as "future targeted measures that are deemed important to advancing the behavioral health quality measurement."  An example of what that involves is illustrated in "NBHQF Goal 1: Effective - Promote the most effective prevention, treatment, and recovery practices for behavioral health disorders."  Not to be too much of a stickler here, but I don't really know what a "behavioral health disorder" is.  The most precise definition would be "whatever mental or psychiatric disorder that a managed care company has decided that they will pay for".  Behavioral health is basically a business term with no medical or psychological meaning.  As far as I can tell, it was designed to disenfranchise psychiatrists and other mental health providers and yet the rationale for denying treatment was always proprietary "medical necessity" criteria.   Moving beyond that we basically see a number of screening interventions for "Provider/Practitioners", a number of completely unproven interventions and quality markers, and at least 30% of the cells in the matrix are left "intentionally blank".  What exactly is there to comment on?  In the second page "payers using payment incentives to increase the use of EBP (evidence based practices)" is actually considered a quality marker.  That is a conflict of interest much greater than any pharmaceutical company scandal.  To translate, that means that managed care companies nation wide have another way to deny payment and save money based on what they consider to be an "evidence based practice." but they are rationalizing it as a quality marker.

Let me suggest how the depression assessment and screening should be done in this matrix.  First of all the screening test in this case the PHQ-9 does need to be validated as a diagnostic and outcome measure in populations.  The  current literature is extremely limited and there is no evidence that population screening for depression accomplished anything other than exposing a lot of people to antidepressants that the FDA has identified as potentially arrhythmogenic.  The cost of prescribing SSRIs to a large population as well as the electrocardiogram abnormalities is unknown.

I will briefly comment on the additional goals.  "Goal 2: Person-Centered Care".  As previously explained, this is the goal of every physician who has ever been trained in medical school.  It appears here basically as rhetoric that is designed to disenfranchise professionals and make it seem like managed care companies invented individualized care.  "Goal 3: Encourage effective coordination within behavioral health".  What jumps out of the page at me under this sparsely populated matrix is "Ratio of detox to outpatient admissions".  It is well known that managed care tactics have essentially destroyed the availability of medical detox in most communities.  I can recall being told that medical detox was not "medically necessary" by managed care reviewers.  I guess the hope was that the cost of detox could be transferred from managed care companies to non-medical county facilities.  Quality care for addictions means that there needs to be a spectrum of care.  I don't know what ratio is implied by this quality marker but I can assure you that it will favor managed care companies.

"Goal 5: SAFE - make behavioral health care safer."  Suicide, injury and death, treatment for overdoses after hospitalization, and discharges on multiple antipsychotic drugs are suggested as quality markers.  There is no evidence of what it takes to make the assessment and treatment.  To capture any problems in these areas you need a quality process, not a piecemeal check box that can be gamed so that it appears that you are providing quality care.  Measuring these variables in the absence of defining a quality process is meaningless.

"Goal 6: Affordable/Accessible: Foster affordable high quality behavioral health care...".  This continues to be an absurd priority of the partnership between the government and the managed care system. There is no more "cost effective" approach than what passes for behavioral health care.  Mental health treatment in the US has been decimated by 20 years of managed care to the point it is practically non-existent.  During that same time there has been an addition of trillions of dollars in Cardiology, Intensive Care, and Oncology infrastructure.  Even if that were not true, what is the evidence that cost effectiveness has to do with quality?  It is certainly not reflected in the previous specialties that I just listed.

Are there problems with this approach?  It turns out there are major problems and here are just a couple:

1.  Administrative data - administrators have significant biases that seem to impact on so called quality markers across the board.  They don't seem to understand their biases and the major biases include not really knowing anything about medical quality,  thinking that medical quality can be derived from what is basically administrative data (length of stay, readmissions, etc.) and at this point in time having so much political leverage from government backing that they don't really have to pay attention to the considerable number of people out there who know a lot more about quality.  As I have documented on this blog this is a thirty year trend and all of that is captured in the NBHQF.  Any who has followed quality markers over the last two decades will probably have made the observation that business heavy entities like managed care systems are information averse.  By that - I mean that they collect a large amount of data  but it is really not enough data or the right data.  Great examples are HEDIS data and PHQ-9 scores.  Is it really possible to collapse medical quality in to what are really simplified demographic parameters?  No more than knowing that 50% of 85 year old men have coronary artery disease.

2.  Business practices trumping medical practice -  on this blog I have also reviewed these practices and will focus on one this glares in this report - "person-centered care".  For years HMOs and their administrators were focused on "population based care".  They scoffed at the notion that people or patients needed to be treated on an individual basis.  This was at the peak time when they were deciding that everyone with a certain condition should be hospitalized for a the same number of days and it was a "quality problem" if the length of stay in the hospital was too long.  Nobody ever complained if the length of stay was too short.  Many of the thought leaders in managed care go to that position by basically promoting these ideas.  Why is the managed care industry suddenly behind "person centered care".  You won't see the history recorded anywhere but a lot of it goes back to the primary care physician as gatekeeper.  If you assume that you can managed populations of people with the same interventions, you can tell your subscribers that they have to get "referrals" from their primary care physician for any tests or consultations that are viewed outside of the population norm.  This was happening on a large scale in the 1980s and 1990s but subscribers rebelled against it.  After all they were paying good money for insurance coverage and not seeing it back in what they were interested in for health care.  The gatekeeper function disappeared and suddenly even managed care subscribers could directly seek consultations and referrals that they were interested in.  Patient centered care from the managed care industry was basically determined by the market and the failed theory of their thought leaders about managing populations rather than treating individual people.

Physicians have always been taught that patient care is highly individualized.  The question is will they continue to let the government, business entities, and non-evidence based practices masquerade as quality.  Looking at the quality of physician commentary in the media, in journals, and on blogs is not very hopeful.  It is clear that physicians would prefer to blame themselves or one up one another rather than look at the true problems with the health care system and what bureaucrats and businessmen are calling quality.

George Dawson, MD, DFAPA

SAMHSA.  National Behavioral Health Quality Framework (NBHQF)

Observations from Amazon on DSM-5 sales

As anyone reading the newspapers has heard, the DSM-5 went on sale earlier this year amidst a cacophony of DSM bashing and bashing of the profession in general.  The most vehement critics also exhorted the public to not buy this evil book that would lead to the squandering of billions of healthcare dollars and leave millions hopelessly misdiagnosed and taking expensive unnecessary drugs.  In some cases that I have recorded on this blog the criticism was even more extreme.  Now that the DSM-5 has been out for several months I asked myself what the outcome of all of that bad press has been?  Like thousands of my colleagues, I have picked up a copy and glanced at it from time to time.  It certainly has not lead to any revolution in psychiatric practice or changed anyone's clinical interviewing or diagnostic process.  In fact I have talked with many psychiatrists in the past several months and none of my conversations has touched on the DSM-5.  What are the facts of the release after all of the pre-release spin?

First of all, the predicted apocalypse has not happened.  I should say the apocalypse happened but it was 30 years ago when the managed care industry essentially converted mental illness into "behavioral health" and began to restrict access to psychiatric care, inpatient and medical care, psychotherapy, and certain medications to people with severe mental illnesses.  The predicted apocalypse in response to the DSM-5 did not happen because as I have been saying all along, the DSM has never been the problem.  Mental health care can be denied as easily on the basis of a DSM-5 diagnosis as a DSM-IV diagnosis.  A diagnostic manual is partially relevant only for people who are trained to use it.

That said, is there any way to estimate whether people are buying it or not?  I heard a sales estimate e-mailed by a colleague that suggested brisk sales, but did not have permission to quote him so I started to look for public sources of data on DSM-5 sales.  I went to the usual New York Times Bestseller List and could not find it listed.  I could not really find any academic books listed there so I wonder if there is not another list.  I thought that Amazon would be the next logical stopping point and I did find some data there.  I was looking for data in number of units actually sold and I could only find that as proprietary data that somebody would sell to me.  I did find it as # 8 in Best Sellers of 2013 so far.  This link shows it has been in the Top 100 books for 167 days but that it has fallen to the number 4 position.  Interestingly the Publication Manual of the American Psychological Association had been on the same list 8 times as long.  I also found it in a sequential list of DSM-5 products and related variants including 2 books about the DSM-5 by Allen Frances, MD.  It made me think about obvious conflict of interest considerations in the psychiatry criticism industry that are never mentioned when they get free press.  If somebody can suggest that I have been getting a free lunch from a pharmaceutical company when I haven't seen a drug rep in over 25 years, they should at least point out that somebody can currently make money - possibly even a good amount of money by criticizing psychiatry regardless of whether or not that criticism is remotely accurate.

That is all I have so far.  If you have reliable public data on the actual sales of this manual and would like me to post it here, please send me the information.   I have requested the actual sales figures in an APA forum but I doubt that anyone will provide them to me.  The APA is a very conservative organization and I doubt that they would want you to see those sales figures posted here, even if if this is probably the only public forum that takes a very skeptical look at all of the critics of the DSM-5 and psychiatry in general.

George Dawson, MD, DFAPA

A Poem About Grandiosity

I came across this poem as part of the Breaking Bad series on AMC.  It applies to their plot line, but it is also a testament to grandiosity as a reaction to the existential concerns about death and meaningfulness.  As I drove in to work this morning I thought about the fact that the physical monuments to people, especially the ones that are personally erected in one's own honor rarely stand the test of time.  There is imagery at several levels in the poem from the archaeological to the psychological and the impact that culture has on that psychology.

Thoughts, ideas, and deeds are the best way to be remembered.  And the people who are remembered in this way would not be interested in monuments in their honor.  A good example is the focus on Shelley's poem nearly 200 years after it was originally published.

Ashes to ashes........


Ozymandias

by Percy Bysshe Shelley

I met a traveller from an antique land
Who said: Two vast and trunkless legs of stone
Stand in the desert. Near them, on the sand,
Half sunk, a shattered visage lies, whose frown,
And wrinkled lip, and sneer of cold command,
Tell that its sculptor well those passions read
Which yet survive, stamped on these lifeless things,
The hand that mocked them and the heart that fed:
And on the pedestal these words appear:
"My name is Ozymandias, king of kings:
Look on my works, ye Mighty, and despair!"
Nothing beside remains. Round the decay
Of that colossal wreck, boundless and bare
The lone and level sands stretch far away.



Should existential themes be important to a psychiatrist?  I answered that question for myself over 20 years ago when I picked up a copy of Yalom's Existential Psychotherapy.  At that time I was working in a pediatric setting and talking with residents and staff who actually seemed interested in talking with a prospective psychiatrist.  Two of the physicians in the group had the rare experience of seeing motorcycle accidents on the freeway and being first responders and saving the crash victims.  We discussed Yalom's conceptualization of death anxiety and how it might apply and it made sense to both of them.  Since then I have found it much easier to talk about these themes when they occur rather than trying to elicit specific symptoms since they are very important themes associated with anxiety and depression.  The meaning of those symptoms is still important to most people whether that happens from a psychodynamic, cognitive behavioral or existential perspective.

And yes - I have recognized the grandiose adaptation to death anxiety and meaningfulness, many times.


George Dawson, MD, DFAPA

Bryan Cranston's dramatic read of Ozymandias.  The graphics may not mean much unless you have watched the television series.

Jim Amos, MD.  Did Ozymandias Weep?  The Practical Psychosomaticist Blog.  Jim Amos has been thinking about this poem a lot longer than me.  Read his associations to it at this link.

Psychiatry - Science and Pseudoscience

I finished the first chapter in Philosophy of Pseudoscience: Reconsidering the Demarcation Problem by Pigliucci and Boudry.  I became aware of Massimo Pigliucci and his work back in 2002 when I read his book on Intelligent Design and since then have discovered his blog Rationally Speaking where he has recently posted his best papers from his careers as a scientist and a philosopher.  He writes very clearly on the philosophy of science and has such a command of the field that he can include a history lesson of relevant references.  He also does not shy away from controversy or the apparent lack of a clean solution to a problem.  One of the central concepts in his chapter is this chart of empirical knowledge versus theoretical understanding. (click to enlarge)

The purpose of this essay is to look at possible boundaries between science and pseudoscience as well as a couple of interesting observations as they apply to psychiatry.  One of his key concepts is that the lines of demarcation are not necessarily sharp and the variables are not necessarily linear.  He uses the above graph of empirical knowledge versus theoretical understanding as an example.   Starting in the upper right corner of the diagram we have hard sciences with particle physics given as the most clear cut hard science.  I like to think about my undergraduate chemistry experience as being hard science.  Even introductory chemistry exposes the student to an amazing array of facts, observations, and theories that are incredibly accurate.  From there, chemistry majors build on their ability to measure specific compounds, synthesize them and study the theory in Physical Chemistry.   I don't think that there is any doubt that chemistry as a field is not too far removed from particle physics in terms of empirical knowledge or theoretical understanding.  String physics has much theory but is low in terms of empirical support.  He refers to evolutionary psychology,  scientific history and Search for Extraterrestrial Intelligence (SETI) as a "proto-quasi science" cluster with decreased amounts of theory and empirical support.  Other fields like the so-called "soft sciences" of sociology, economics, and psychology have a fair amount of empirical knowledge but less theoretical understanding.  The true pseudosciences are in the zone with astrology, HIV denialism, and Intelligent Design.  From the history of psychiatry - Freudian psychoanalysis and Adlerian psychology would also be included here but there is also a list of theories from general medicine and surgery that would also qualify.

In psychology and psychiatry a central philosophical problem is the so-called hard problem or the explanatory gap between the neurobiology of conscious states and subjective experience.  This is exactly where psychiatry resides.  A lot of political criticism of psychiatry involves the ability to parse these states and accurately classify different conscious states.  Resolving the hard problem would move psychiatry and psychology firmly to the right in the demarcation diagram but probably not nearly as far as particle physics or maybe not even as far as molecular biology.

The relevant question for me of course is where psychiatry fits on the plane of empirical knowledge x theoretical understanding.  What about medicine in general?  Could we plot a plane of medical and surgical sub specialties on this plane instead of the hard and soft sciences?  Does medicine and surgery have theories or practices end up in the same zone as Freudian psychoanalysis.  Of course they do.  A great example from my days as a medicine intern was highlighted by Ghaemi as "The cult of the Swan-Ganz catheter."  In the places where I trained, anyone with moderately serious cardiopulmonary problems was at risk for placement of a Swan-Ganz catheter.  The actual person inserting the catheter could be a medicine resident, a cardiologist, or an anesthesiologist.  Since the intern is responsible for doing the initial history and physical exam, I witnessed the placement of a large number of these catheters.  Once placed they gave an impressive number of parameters on ICU monitors.  We were routinely grilled about the meaning of these parameters by attending physicians on rounds.  It all seemed very scientific.  The cult of the Swan-Ganz catheter was subsequently disproved by randomized clinical trials.  This standard of care from the 1980s and 1990s disappeared much faster than Freud.

The best way to plot medicine and psychiatry on Pigliucci's empirical knowledge versus theoretical understanding plane would be to consider the clinical basic sciences taught in the first two years of medical school.  In my experience that was anatomy, neuroanatomy, histology, microbiology, biochemistry/molecular biology, genetics, pathology, physiology, pharmacology, epidemiology, and statistics.  Practically all clinical specialties carry these basic sciences forward in one form or another.  The research literature in any particular specialty in full of theory and techniques from these basic sciences.  The psychiatric literature cuts across all of the basic sciences in the same way as other specialties.  At the minimum, some of psychiatry will be at the level of molecular biology on the diagram in some areas and at the level of psychology in others.  Hopefully the unscientific theories will be relegated to the lower left hand corner of the diagram as unscientific and not stand the test of time.

I think that Professor Pigliucci's conceptualization is a very useful one.  I expect that he will continue to refine these ideas.  I think that measurement precision and categorization may be important dimensions to add to these concepts.  As Merskey has pointed out both the phone book and the periodic table are much more accurate forms of categorization than any scheme of medical classification.  I think that probably says a lot about the underlying scientific dimensions and how measurement is done.


George Dawson, MD, DFAPA

Ghaemi SN.  A Clinician's Guide to Statistics and Epidemiology in Mental Health.  (2009) Cambridge University Press, Cambridge, UK.  p. 91.

First Episode Psychosis

There is an interesting study in the July JAMA Psychiatry on the treatment of first episode psychosis (FEP).  The authors conclude that this is the first study that shows major advantages of an antipsychotic discontinuation strategy over maintenance therapy.  FEP has always been a topic of interest to me because for 22 years I ran an inpatient unit and about 10% - 20% of the admission were patients with FEP.  For the purposes of the study FEP encompassed the diagnoses of schizophrenia, schizophreniform   disorder, schizoaffective disorder, brief reactive psychosis, delusional disorder and psychotic disorder not otherwise specified (NOS).  There were no diagnoses of mood disorders or organic disorder with psychotic symptoms.  Thirty six percent had a comorbid alcohol or substance use disorder.  In the original study 7 years earlier, 128 patients were randomized into a DR (dose reduction/discontinuation) and MT(maintenance treatment) arms.  A few things are striking as I look at this study.  The first is the relatively small N of patient in the study and the diagnostic heterogeneity.  In the subgroup analysis at 7 years (Figure 3.) there were a total of 5, 6, 8, and 14 patients in the subgroups.  Some of the diagnostic categories imply more chronicity than others.  

From an experimental standpoint I have concerns about the addition of that last three categories - delusional disorder, brief psychotic disorder, and psychotic disorder-NOS.  In my experience, delusional disorder is often not associated with much functional impairment and patients often do not benefit from or want to take any medications.  They can be engaged in psychotherapy but maintaining them in therapy is often problematic unless there is an associated crisis in their lives.   Brief psychotic disorders also have a good prognosis.  I recall presenting data to families concerned about this problem based on a review of what was primarily Scandinavian literature from the 1980s suggesting that up to 50% of patients with a diagnosis of "brief reactive psychosis" experienced remissions.  Schizoaffective disorder has similar problems with the manic subtype having a course and prognosis similar to bipolar disorder and the depressive subtype having a course and prognosis similar to schizophrenia.  In clinical practice it is extremely common to see bipolar patients misdiagnosed with schizoaffective disorder and I have always wondered how that impacts on the studies of course and prognosis.  At any rate, adding these diagnostic categories (31% of the total sample) biases this study toward better outcomes.

The dose of haloperidol is interesting.  I started to practice inpatient psychiatry in an era of very high dose antipsychotic medication.  It did not take long to figure out that this was a bad idea.  It also did not take long to look at the basic science behind antipsychotic medication dosing.  A key figure in the early days of dopamine receptor pharmacology was Phillip Seeman, PhD who wrote an excellent review in American College of Neuropsychopharmacology's The Fourth Generation of Progress.  His graph of D2 receptor dissociation constants versus free neuroleptic in plasma water correlated well with antipsychotic dose provided a sound rationale for lower doses and also monitoring plasma levels of antipsychotics.  In my experience the only people who need higher doses of antipsychotics are rapid metabolizers of a particular drug with lower than expected levels.  With haloperidol that usually translates to a dose of 2-4 mg/day.  That is consistent with the dose ranges in the diagram in Figure 2 of this paper.  There is also a distinct group of people who have such neurotoxicity from antipsychotic medications that they should probably never take them.  That is also why I am member of the Movement Disorder Society.

Another interesting aspect of this paper is the psychopathology ratings.  When I noticed the diagnostic heterogeneity and the likelihood of remission, the logical question is what the ratings show.  In this study the  Positive and Negative Syndrome Scale (PANSS).  I had experience   with the brief versions of these scales.  Each dimension is rated on a 7 point Likert scale from 1 (normal) to 7 (extremely severe).  The PANSS is widely accepted as being psychometrically valid.  There is not a consensus on the interpretation of scoring and what might mean remission.  In this study we have to track back to the original description of the sample (3) and we observe the average baseline PANSS P score as 9.9 for the DR groups and 10.7 for the MT group.  The average PANSS N score was 13.1 for the DR group and 14.0 for the MT group.  For the purpose of contrast, the authors of this article expressed their concern about the interpretation of PANSS scores illustrate their concern by presenting ratings for an agitated patient with schizophrenia and paranoia.  The PANSS P score of 28 had improved to 24 by the end of the study and the PANSS N score was unchanged at 22.  

The overall context for the references here are important to keep in mind.  The authors original experiment (3) was an 18 month follow up of FEP following 6 months of remission of positive symptoms according to the PANNS.  It basically showed at that point that only 20% of patients can discontinue medications in the acute phase and that the relapse rate was twice as high with the DR than the MT strategy (43 versus 21%).  The current article (2) recruited members of the original trial and did the same intervention after 6 months of remission and assigned them to DR and MT groups and showed that the DR patients had twice the symptomatic and functional recovery rate than the MT patients (40.4 vs. 17.6%).  Looking at the baseline and study completion PANNS score for both studies yields the following:

All PANNS scores are  mean(SD)	Study 1				Study 2
	Baseline		End of Trial		Baseline		End of Trial
	DR	MT	DR	MT	DR	MT	DR	MT
PANNS P	9.9(2.8)	10.7(3.0)	11(4.3)	10.8(3.8)	9.79(2.96)	10.78(3.15)
PANNS N	13.1(4.6)	14.0(5.6)	12.1(5.2)	13.3(6.2)	12.87(4.8)	13.96(5.51)
PANNS G	24.6(6.2)	26.4(6.9)	24.7(7.3)	24.9(6.7)	25.27(6.44)	26.45(6.62)

Although I could not find PANNS scores for the end of the second study, the scores in all categories across studies are strikingly similar.  PANNS, BPRS, and CGI scores have recently been investigated by Leucht, et al who conclude that a change of a 10 point reduction of a PANSS score was the equivalent of mild clinical improvement and a 50% reduction was consistent with “much improvement” in an acutely ill non-refractory sample (5).

I think the reasonable conclusions from this study are:

1.  Mildly symptomatic populations with FEP may be cautiously tapered off low dose antipsychotics over time and experience better functional recovery.  Tapering earlier in the course has a higher risk of relapse.

2.  The treatment recommendation for low dose antipsychotic medication in mildly symptomatic populations is sound practice according to this report.  Another important aspect is that minimal side effects were reported in standard measures in this study.  It is still common to find patients discharged from hospitals on the equivalent of 10-20 mg haloperidol and show up for their first outpatient visit with metabolic or neurological side effects.

3.  FEP needs further study.  I suppose we can wait for a large initiative and I may have missed one in progress, but the best approach at this time would be for large clinics and hospital based programs to all develop FEP clinics staffed by interested staff and networked to share information.  This study highlights that following the remission of psychotic symptoms is not enough and the common practice of following people in an outpatient “medication management” visit is not enough to restore functional capacity or quality of life.  There is also the question of the availability of psychotherapy for people who can successfully taper off antipsychotic medications and for those who cannot.  I have found that psychotherapy is often a useful treatment for people who cannot tolerate low dose antipsychotic medication.

4.  The authors describe reasonable concerns about their study including that fact that they may have selected the “best half” of the subjects from the original trial.  The subjects that were nonparticipants in the second study were described at “functioning at a lower level, less adherent to therapy and more difficult to engage.” But it is difficult to see that in the rankings at baseline.  They also point out that the raters were not blind and suggest that probably would not account for the degree of difference.  Based on studies of clinics that deal well with certain chronic disease (like cystic fibrosis) motivated clinicians with a stake in the treatment method and outcome clearly can make a difference and that might be reflected in ratings.  They discuss a mechanism to account for gains in functional capacity in the DR arm and that is basically less impairment of dopamine signaling and possible impairment in drive, motivation and functional capacity.  They recommend follow up studies of up to 7 years “or longer” in duration to look at these trends.

Finally, there is really no reason why principles discovered in an FEP study or a psychotherapy study of psychosis cannot be applied to patients who have histories of recurrent psychotic episodes.  Highly motivated clinicians can apply these treatment modalities if they have the opportunity.  It is really no different than large scale (but much better funded) efforts in other specialties where the treatments and outcomes are in a state of flux.  A good example would be electrophysiological ablation of atrial fibrillation.  There has been some opinion about the implications of this study for the idea of life-long maintenance therapy but it is equally damning for the model of seeing patients in 15 minute visits and asking them about positive symptoms and medication side effects.  There has always been a need for a much broader focus on cognition and functional capacity.

George Dawson, MD, DFAPA

1: McGorry P, Alvarez-Jimenez M, Killackey E. Antipsychotic Medication During the

Critical Period Following Remission From First-Episode Psychosis: Less Is More.
JAMA Psychiatry. 2013 Jul 3. doi: 10.1001/jamapsychiatry.2013.264. [Epub ahead of print   PubMed PMID: 23824206. 

2: Wunderink L, Nieboer RM, Wiersma D, Sytema S, Nienhuis FJ. Recovery in

Remitted First-Episode Psychosis at 7 Years of Follow-up of an Early Dose

Reduction/Discontinuation or Maintenance Treatment Strategy: Long-term Follow-up

of a 2-Year Randomized Clinical Trial. JAMA Psychiatry. 2013 Jul 3. doi:

PubMed PMID: 23824214. 10.1001/jamapsychiatry.2013.19. [Epub ahead of print]

3: Wunderink L, Nienhuis FJ, Sytema S, Slooff CJ, Knegtering R, Wiersma D. Guided

discontinuation versus maintenance treatment in remitted first-episode psychosis:

relapse rates and functional outcome. J Clin Psychiatry. 2007 May;68(5):654-61.

PubMed PMID: 17503973.

              

4:  Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome scale (PANSS)

for schizophrenia. Schizophr Bull. 1987;13(2):261-76. PubMed PMID: 3616518.

5: Leucht S, Kane JM, Etschel E, Kissling W, Hamann J, Engel RR. Linking the

PANSS, BPRS, and CGI: clinical implications. Neuropsychopharmacology. 2006

Oct;31(10):2318-25. Epub 2006 Jul 5. PubMed PMID: 16823384.

Happy Labor Day II - To All of the Docs on the Assembly Line

Last year I posted a Labor Day greeting to all of the docs laboring in American medicine.  I used the assembly line metaphor for obvious reasons - physicians were no longer being treated like knowledge workers but were being treated like assembly line workers.  Circumscribed patient visits were the widgets.  In the case of proceduralists the procedure was the widget.  One of my friends referred to himself as a "scope monkey" based on the expectation for the number of procedures he was supposed to produce every year.  Have there been any substantial changes in the last year?

The bad news is that there have not been. Managed care continues to consolidate its monopoly.  The final product under the Affordable Care Act (PPACA) will result in unprecedented leverage on the part of that industry over physicians and patients.  I often compare the healthcare industry to the financial services industry when it comes to an example of government determined monopolies.  The 401K is a great example of how this works.  The 401K was sold to the American public as a great way to save for retirement.  When the choices in 401K were limited it was sold as a way to simplify the 401K for most people.  The truth about 401Ks is that they have not been a very successful investment vehicle.  They put trillions of dollars of retiree savings at risk and the fees they charge are even more outrageous than medical fees.  I just looked at a bond fund prospectus this morning that shows on an investment of $10,000 I could expect to pay $1,000 in fees every 10 years.  Considering that there are about $9 trillion dollars in 401Ks and IRAs that generates about a trillion dollars in fees (about $90 billion a year) for the financial services industry.  Those fees are generated independent of the general goal of retirement funds - actually having money for retirement.  My prospectus has the usual disclaimer: "The value of your investment in the fund can go up or down.  You can lose money by investing money in the fund."  As many baby boomers found out that can be 30-40% of your principal.

How does managed care compare?  The most interesting game has been the idea that all fees will increase substantially with the implementation of the PPACA.  This bill allows for unprecedented merger and efficiencies.  It allows for only 80% of the health care premium to be devoted to the actual provision of health care services.  It is logical to assume that a greater percentage of the health care dollar devoted to health care would also decrease premiums.  There will be significant hidden savings associated with a model of care that is integrated and minimizes the amount of physician billing.  Insurance company rhetoric suggests that provided additional services to the uninsured with no limitations on pre-existing conditions will more than cancel out the monopoly advantages.  If that was true why lobby for large monopolies?

One of the indicators to me of just how much leverage the managed care industry has is the expected out of pocket costs for a retired couple on Medicare.   That number is currently $220,000 not including nursing home costs.  That is roughly more than four times the average retirement savings for most Americans.

The financial services industry and the medical industry are basically government mandated hidden taxes on the American people.  In exchange for that huge subsidy we get an industry that charges us significant fees to place our retirement funds at risk all of the time and another industry that rations health care and charges whatever they want in order to make money.  In the case of the medical industry the overriding philosophy is not consistent with an enlightened approach to employees that probably know a lot more about the provision of quality medical services than the administrators.

That conflict of interest is central to the deterioration of the practice environment and a diminished focus on quality care and a continued focus of the study and academic aspects of medicine.   Having medical care dictated by administrators using business guidelines or managed care reviewers using the same approach is demoralizing.  Unless this conflict of interest is adequately addressed - the focus of health care will be turning out widgets.  Only the widget producers will be valued.  Administrators making arbitrary decisions run the whole show.

All of this remains decidedly grim in terms of the practice environment where most physicians work.  It is only fair to consider some solutions.  I will try to avoid the political decisions I have advanced in APA and other medical forums over the past 20 years.  Physicians are uniquely oblivious to the fact that the science of medicine is routinely trumped by business and politics.  Are there any possible solutions?  For many years private practice was always considered an option.  With the PPACA that route will be more difficult because the solo practitioners and groups will probably be off the network and professionally isolated, but some will be able to practice in this environment.  There is still niche work where physicians can be paid professional salaries and still have adequate time to complete all of the administrative tasks and focus on quality work, but they are rare.

A single exciting model that I think can disrupt the usual managed care and government restrictions that I expect to flow from the PPACA comes from the University of Wisconsin and their Memory Clinics approach.  This is a statewide network of clinics focused on providing state-of-the-art and quality care across a number of settings.  Guidelines, continuing education, and consultation is provided from a University based department and there is a minimum requirement for for ongoing education every year.  I don't see why this model cannot be widely applied across psychiatry and all other medical specialties.  It brings the academic focus back into medicine instead of the current focus by governments and business.  The practice environment of medicine needs this academic focus and it would greatly enhance the practice environment and get us out of widget production.

That is my hope between this Labor Day and the next.

George Dawson, MD, DFAPA

Response to Dr. Lieberman on the Changing Times for Psychiatry

Jeffrey Lieberman, MD is the current President of the American Psychiatric Association (APA).  He came out today with the first in a series of three statements on the changing profession of psychiatry.  He starts out with an uneven historical recap of the first 200 years of the profession.  I am probably sensitized to his use of Freud as an inflection point with my recent study of the philosophy of science.  Freudian psychoanalysis and Adlerian psychology were Popper's original example of fields that did not meet logical criteria as a science.  They were not falsifiable and therefore were unscientific.  At the same time the neuropsychiatric movement based on phenomenology and neuroanatomy associated with German asylums is not mentioned.  I suppose that a historical context is appropriate when considering all of the inflection points for the profession but let's face it - the first 150 of those 200 years are irrelevant to any scientifically based psychiatry and can be disregarded.  He added a few paragraphs on the advent of psychopharmacology and the DSM as additional innovations and ends with his idea that the rising cost of health care and the pace of scientific discovery will be the two forces that shape the profession of psychiatry going forward.

My first problem with this statement is that there seems to be no role for psychiatrists or their professional organization in shaping the profession.  We are there to be buffeted by rising costs and scientific discovery.  Like most fields of medicine innovation has been driven by the clinicians and researchers in the field.   When Len Stein, MD and his collaborators noticed that patients at the Mendota State Mental Health Institute were residing there in appalling conditions, they invented community psychiatry and community support teams and moved them out.   There have been a long list of innovators in psychotherapy, psychopharmacology, neuroscience and in the general methods of psychiatry.

Taking Dr. Lieberman's points individually and starting with the rising cost of healthcare - what does that mean exactly and what does it mean in terms of psychiatric services?  Thirty years ago some health plans covered unlimited psychotherapy.  Many psychiatric trainees underwent psychoanalysis as part of their training and it was covered by health insurance.  Today they would likely get a brief evaluation or a checklist and the offer of antidepressant medication if they scored high enough on a rating scale.  If they were very fortunate they might see a crisis counselor for two or three sessions.   How could this change in care possibly be related to rising costs?  Psychiatric care has never been cheaper.  The rising costs in medicine have to do with services that have pricing power and that never involves mental health.  The real challenge here is a political one.  It is very apparent that political systems and their partners in the business community will do everything possible to restrict access to psychiatric services - no matter how cheap they are.  In the general scope of actual payments to providers there are no services that are more cost effective than psychiatry and until very recently that was essentially guaranteed by special billing codes that reimbursed psychiatry less.

The impact of rationing of psychiatric services by managed care companies, state and federal governments go beyond the purely economic.  When psychiatric services are easily rationed, evidence based services that are more expensive like Assertive Community Treatment can simply be made a non covered service.  There are few functional detoxification facilities for people with severe drug and alcohol problems.  Most people are sent home from an emergency department with medications to "self detox" or sent to a county run facility with no medical services.  They are readmitted when that fails or when they develop complications that require intensive care such as seizures or delirium tremens.  The majority have no chance to achieve sobriety from outpatient detox of significant addictions.  The hospital evaluation and treatment of severe disorders that often take weeks or months to assess and treat are restricted to a few days.  The actual admission and discharge decisions from hospitals and treatment centers are no longer medical decisions but they are based on arbitrary guidelines made up by business organizations.  Entire hospital and clinic environments are run by administrators with no psychiatric training.  There are actually situations where administrators seem to believe that they can design treatment programs that target behavioral problems when they are not clinicians.  The "rising cost of health care" rhetoric is frequently used to rationalize a nationwide approach to mental illness that is totally nonfunctional.  This has been the result of a series of "reforms" that basically turned the field over to the managed care industry.

Psychiatric research and the neuroscience research that applies to psychiatry is vast.  When physicians are trained we are all taught to value ongoing education.  At some point the education of physicians also became a political football.  There are initiatives to teach physicians how to treat pain.  A decade later there are initiatives to retrain physicians who are prescribing too many opioids - despite the fact that the original initiative had a goal of appropriate assessment and treatment.  Specialty boards and the oversight board unilaterally decided that the public wanted board certification to be time limited.  They came up with a Maintenance of Certification (MOC) procedure despite the lack of evidence that it was necessary.  That allowed several states to consider tying medical licensing to these costly and unnecessary exams.  The best way to educate physicians is an active collaboration at both the clinical and basic science levels like many specialty boards were doing at the time of the new idea about MOC.

These are the dimensions that shape my world as a psychiatrist every day.  They have been responsible for the deterioration of the practice environment and decreased quality of care across most treatment settings.  Contrary to Dr. Lieberman's points there has been no reform and there certainly is no enlightenment.  Despite all of the research and expanding knowledge clinical psychiatry is in the Dark Ages as external forces suppress psychiatrists and limit creativity and innovation.

George Dawson, MD, DFAPA



Jeffrey Lieberman, MD.  Change, Challenge, and Opportunity: Psychiatry in Age of Reform and Enlightenment.  Psychiatric News August 29, 2013