As any reader of this blog can recall one of my foci is to expose the anti DSM 5 rhetoric for what is was. One the the main points by DSM detractors was diagnostic proliferation or more total diagnoses. This implies more diagnoses, more prescriptions, and more money for psychiatrists and pharmaceutical companies. Another spin was that it was the intent of organized psychiatry to "pathologize" the population. I put up a table on this issue in a previous post and at that time did not have the final number of diagnoses. As of today I have the final number and it is 157. According to the presenter that means that a total of 15 diagnoses were eliminated from DSM-IV to DSM 5. The total diagnoses in DSM 5 did not increase as the detractors predicted - they decreased by 15.
I was at a conference today put on by the University of Wisconsin Department of Psychiatry entitled Annual Update and Advances In Psychiatry. The Introduction by Art Walaszek, MD acknowledged that this was the first in a series that replaces a long tradition of courses run by John H. Greist, MD and James W. Jefferson, MD: "Jeff Jefferson and John Greist ran this conference for 31 years." That is an amazing track record and record of achievement and a contribution to psychiatry in the Midwest. I don't know of many psychiatrists who were not aware of this conference with the alliterative titles like: "Quaffing Quanta of Quality from Quick Witted Quinessentialists" or the Door County Course they regularly taught. They have been a model of scholarship and professionalism and continue to be.
The first speaker today was Alan Schatzberg, MD. He posted the information about the total diagnostic categories in DSM 5 an other important changes and how they occurred. Per my previous post about the DSM 5 lectures by Jon Grant, MD the DSM 5 effort was outlined in addition to some critical information on how stigma affects psychiatric diagnosis. For example, when the DSM 5 work group wanted to add mild neurocognitive disorder a well known historian of psychiatry came out and said it would add countless people who had normal memory impairment associated with aging. When neurologists added mild cognitive disorder to their diagnostic nomenclature (an equivalent diagnosis) no such claims were made about neurologists. In terms of the effort, Dr. Schatzberg pointed out that there were 13 conferences from 2003-2008 that produced 10 monographs and over 200 journal articles.
Dr. Schatzberg and his colleagues presented a ton of information today on what really happened with DSM 5 development. I will try to summarize and post additional comments when I can post from a more user friendly computer. I wanted to keep the post more on the scientific and debunk another common refrain from the naysayers before the DSM 5 was printed. That involved the so called "bereavement exclusion" that basically says that a person cannot be diagnosed with major depression if they are seen during an episode of grief. One question that was never brought up in the popular press "Where did this convention came into the diagnostic criteria in the first place?" I quoted a text from about the same time (see third from last paragraph) that makes this convention seem even more arbitrary. It turns out the original bereavement exclusion began in DSM-III not from any research basis but from convention that was subjectively determined by the authors of DSM-III. Contrast that with the research done by Zisook, et al. You would think that some of the self proclaimed level headed skeptics out there would have referred to this critical paper on the issue rather than speculative attacks on the field. Incorporating these scientific findings was one of the reasons that the DSM was updated.
Stay tuned for more of the hard data and insider info on DSM 5.
George Dawson, MD, DFAPA
1: Zisook S, Corruble E, Duan N, Iglewicz A, Karam EG, Lanouette N, Lebowitz B, Pies R, Reynolds C, Seay K, Katherine Shear M, Simon N, Young IT. The bereavement exclusion and DSM-5. Depress Anxiety. 2012 May;29(5):425-43. doi: 10.1002/da.21927. Epub 2012 Apr 11. Review. Erratum in: Depress Anxiety. 2012 Jul;29(7):665. PubMed PMID: 22495967.
Supplementary 1: The DSM-5 Guidebook by Donald W. Black, MD and Jon E. Grant, MD came out in March 2014. Table 1. (p. xxiii) lists the total diagnoses is DSM-5 as 157 excluding "other specified and unspecified disorders".
Saturday, October 12, 2013
Sunday, October 6, 2013
"Some Sort of Mental Health Issue"
I was getting ready for work yesterday morning and watching The Today Show in the background as usual. Suddenly there was the story of a young woman trying to ram the security barriers at the White House and then being pursued in a high speed chase down Pennsylvania Avenue. It eventually showed a direct confrontation with law enforcement and them opening fire on her through the window of her vehicle. There was an initial report saying that she had fired shots but she was unarmed. The police discovered her one year old daughter in the car and removed her. The acute reaction captured on film was surreal. There were descriptions of some of her recent behavior and thoughts. A police official commented that the security barriers "worked" as though this was an assault by a terrorist. A different official commented how her daughter was "rescued" by the police. People were talking as though this was an actual assault by a terrorist. The last person I heard was a politician who made the quote at the top of this post and finally suggested the real problem.
Confrontation between people with severe mental illnesses and law enforcement are very common. During my years of acute inpatient work I have talked with many people who have been injured in every imaginable way during these confrontations. In some cases they were themselves engaged in very dangerous and aggressive behavior as the direct result of a mood disorder or a psychosis. In other cases law enforcement just misinterpreted their behavior. That happened most commonly when the person refused to comply with what the officer wanted them to do. These confrontations are always high risk situations because most people in society know that it is in their best interest to be law abiding and comply with the police. The people who don't are criminals or people with impaired judgment due to mental illness or intoxication states. Even if the police can make that distinction rapidly that does not mean they can easily use a different approach to the person with mental illness. Police officers have been injured or killed in these situations.
There seems to be a great deal of misunderstanding and continued bias about how these situations can occur. It can happen as rapidly as waking up one morning finding out that your entire state of consciousness has changed. That gas company truck across the street is there to monitor you and direct microwaves at you. The phones and your computer are bugged. Going to work that morning you decide you need to take evasive action because it seems like you are being followed. Your anxiety levels build all day and that night at home you can't sleep. You decide you need to move the refrigerator in front of the door because you had the thought that it would be too easy for government agents to kick the door down and grab you. You do a Google search on microwaves and decide these people are trying to do a lot more than harass you - they are trying to kill you. You start to make plans on that basis.
That is how paranoid delusions evolve and how they change your behavior. You are no longer making rational assessments of the environment. Your brain has come up with a theory and you are now interpreting all of the environmental information according to that theory. When I approach the problem psychotherapeutically, I generally explain that delusional thoughts are very low probability explanations or interpretations of an event in the environment. I illustrate this by asking the question: "If we had 100 people in the room right now - how many of them would agree with what you just told me?" Many people know that hardly anyone would agree with them, but that doesn't stop them from continuing to misinterpret the data or trying to cast me with everyone else who either doesn't believe them or is just saying that they are "crazy".
Before I outline an approach to the problem of people experiencing episodes of psychosis or mania and running into problems with law enforcement consider what gets in the way of any of early intervention? Keeping with my cardiology comparison from a previous post - most people know that chest pain is a warning sign for a possible heart attack. With continued public health interventions most people know cardiac risk factors. Public health intervention has been so effective that the current campaign is focused on decreasing the denial in women and decreasing cardiac sudden death in women. Two generations of public health intervention are associated with a decreasing rate of cardiac mortality.
How does that compare with psychosis and mania? I have never seen a public service ad advising about the warning signs of psychosis or mania. There are countless euphemisms for acute changes in a persons mental status. The public treats it like a mystery. When a tragedy occurs there is often no explanation or an inadequate one like "some sort of mental illness." The cultural approach is an obstacle to a rational approach to helping affected individuals. Stigma is considered to be a factor, but it could as easily be an artifact of the process. What would be a better approach?
I have been advocating a public health approach to the problem for a long time now. At a political level there is a lot of confusion about whether this is a firearms issue. Firearms are just a subset of the problem. The overriding public health goal is to get people the help that they need as soon as possible. Our current system of care is set up to provide minimal care to people with severe mental illnesses. The level of care and condition of the facilities where the care occurs is widely known in communities and most people do not want to access these facilities for help. I hear a lot about the concern that someone is going to be stigmatized by treatment at a psychiatric facility. I think it is as likely that many facilities are substandard physical plants that are poorly managed. Based on the length of stay policies alone, nobody wants to bring their relative to a facility that has a reputation for discharging partially stabilized people back into the community. The long term goal needs to be improving the quality of psychiatric facilities in addition to changing the culture about severe mental illness.
I thought of a public service announcement that would potentially have the same advertising power as some of the more popular health spots like the "7 warning signs of cancer". I call it the 4 warning signs of severe mental illness. A concerted effort to focus on severe mental illnesses that can potentially lead to errors in judgment is a logical way to approach this problem. Based on my previous paragraph it takes a much more enlightened approach to treating the problem. Health care systems in general are not friendly to people with severe mental illnesses. There are no specialty centers designed to cater to their needs like the high margin businesses get. Many of these health care organizations sponsor walks for mental illness and other programs like National Depression Screening day. But none of them say - if you have these symptoms we want to see you and treat you in a hospitable environment.
That attitude has to change to prevent the loss of innocent lives as the direct result of severe mental illness.
George Dawson, MD, DFAPA
Confrontation between people with severe mental illnesses and law enforcement are very common. During my years of acute inpatient work I have talked with many people who have been injured in every imaginable way during these confrontations. In some cases they were themselves engaged in very dangerous and aggressive behavior as the direct result of a mood disorder or a psychosis. In other cases law enforcement just misinterpreted their behavior. That happened most commonly when the person refused to comply with what the officer wanted them to do. These confrontations are always high risk situations because most people in society know that it is in their best interest to be law abiding and comply with the police. The people who don't are criminals or people with impaired judgment due to mental illness or intoxication states. Even if the police can make that distinction rapidly that does not mean they can easily use a different approach to the person with mental illness. Police officers have been injured or killed in these situations.
There seems to be a great deal of misunderstanding and continued bias about how these situations can occur. It can happen as rapidly as waking up one morning finding out that your entire state of consciousness has changed. That gas company truck across the street is there to monitor you and direct microwaves at you. The phones and your computer are bugged. Going to work that morning you decide you need to take evasive action because it seems like you are being followed. Your anxiety levels build all day and that night at home you can't sleep. You decide you need to move the refrigerator in front of the door because you had the thought that it would be too easy for government agents to kick the door down and grab you. You do a Google search on microwaves and decide these people are trying to do a lot more than harass you - they are trying to kill you. You start to make plans on that basis.
That is how paranoid delusions evolve and how they change your behavior. You are no longer making rational assessments of the environment. Your brain has come up with a theory and you are now interpreting all of the environmental information according to that theory. When I approach the problem psychotherapeutically, I generally explain that delusional thoughts are very low probability explanations or interpretations of an event in the environment. I illustrate this by asking the question: "If we had 100 people in the room right now - how many of them would agree with what you just told me?" Many people know that hardly anyone would agree with them, but that doesn't stop them from continuing to misinterpret the data or trying to cast me with everyone else who either doesn't believe them or is just saying that they are "crazy".
Before I outline an approach to the problem of people experiencing episodes of psychosis or mania and running into problems with law enforcement consider what gets in the way of any of early intervention? Keeping with my cardiology comparison from a previous post - most people know that chest pain is a warning sign for a possible heart attack. With continued public health interventions most people know cardiac risk factors. Public health intervention has been so effective that the current campaign is focused on decreasing the denial in women and decreasing cardiac sudden death in women. Two generations of public health intervention are associated with a decreasing rate of cardiac mortality.
How does that compare with psychosis and mania? I have never seen a public service ad advising about the warning signs of psychosis or mania. There are countless euphemisms for acute changes in a persons mental status. The public treats it like a mystery. When a tragedy occurs there is often no explanation or an inadequate one like "some sort of mental illness." The cultural approach is an obstacle to a rational approach to helping affected individuals. Stigma is considered to be a factor, but it could as easily be an artifact of the process. What would be a better approach?
I have been advocating a public health approach to the problem for a long time now. At a political level there is a lot of confusion about whether this is a firearms issue. Firearms are just a subset of the problem. The overriding public health goal is to get people the help that they need as soon as possible. Our current system of care is set up to provide minimal care to people with severe mental illnesses. The level of care and condition of the facilities where the care occurs is widely known in communities and most people do not want to access these facilities for help. I hear a lot about the concern that someone is going to be stigmatized by treatment at a psychiatric facility. I think it is as likely that many facilities are substandard physical plants that are poorly managed. Based on the length of stay policies alone, nobody wants to bring their relative to a facility that has a reputation for discharging partially stabilized people back into the community. The long term goal needs to be improving the quality of psychiatric facilities in addition to changing the culture about severe mental illness.
I thought of a public service announcement that would potentially have the same advertising power as some of the more popular health spots like the "7 warning signs of cancer". I call it the 4 warning signs of severe mental illness. A concerted effort to focus on severe mental illnesses that can potentially lead to errors in judgment is a logical way to approach this problem. Based on my previous paragraph it takes a much more enlightened approach to treating the problem. Health care systems in general are not friendly to people with severe mental illnesses. There are no specialty centers designed to cater to their needs like the high margin businesses get. Many of these health care organizations sponsor walks for mental illness and other programs like National Depression Screening day. But none of them say - if you have these symptoms we want to see you and treat you in a hospitable environment.
That attitude has to change to prevent the loss of innocent lives as the direct result of severe mental illness.
George Dawson, MD, DFAPA
Friday, October 4, 2013
The Dog Quadrant
Before anyone gets the wrong idea, this post is not about pet therapy. It is not about the purported advantages of owning a dog. It is not even about the new research on dog intelligence that I was frankly surprised by, especially the research showing how easily dogs can beat non-human primates on specific tasks. So much for that massive frontal cortex conferring supreme advantage over the animal kingdom. No - this is about managed care and using the term "dog" in its pejorative context.
Several years ago, I was burned out and suffering from the type of large scale mismanagement that is so common in organizations that run on managed care principles. I attempted to approach the problem with humor by reading Dilbert cartoons. Read the first few pages in the Dogbert Management Handout to see what I mean. I soon realized that this stuff was too close to the truth about health care management and decided to look for other management styles.
I happened across the work of Peter Drucker and his ideas about managing knowledge workers that were considered revolutionary. There was certainly nothing like that going on in health care. The managed care approach to managing physicians was to actually treat them like they were not knowledge workers but assembly line workers. Drucker's stroke of genius was in recognizing that managers know much less about products and processes than knowledge workers and that the business was essentially the product of the knowledge workers. Managed care techniques are diametrically opposed and are based on the fact that business guidelines are somehow relevant to medical care and even may actually be called medical quality. There is no health care process more autocratic and primitive than managed care. I have reviewed how this bizarre set of circumstances evolved in several posts on this blog.
Along the way, I also interviewed a health care business management expert and asked him if there were any definitive texts that are used to train business people about managing health care and he referred me to the text Strategic Management of Health Care Organizations. I started to read and study the text, initially trying to find out why Drucker was completely ignored by health care managers. That was when I encountered the BCG Analysis for a Health Care Institution (p 254). BCG is an abbreviation for Boston Consulting Group who came up with this technique for analyzing products and services. In this case, there was a four quadrant graph that differences in market growth rate and relative market share position. I don't have permission to reproduce it here so I will do my best to describe it briefly. The high growth/high market share quadrant was termed "Stars" and contained services like orthopedics, cardiology, oncology, and women's service. The medium/high and high/low quadrants were called "Cash Cows" and "Problem Children". The lower right hand quadrant of the graphic were the "Dogs" and they included psychiatry, ENT, pediatrics and others.
I am no financial analyst, but what is wrong with this picture? Let me give you a hint. If you have a portfolio of medical services and one of them is selected for rationing and the others are not - it should easily end up in the Dog quadrant. The selective rationing of psychiatric and mental health services is a known fact for the last 30 years. When you ration a service you naturally slow its growth and reduce the market share. The market share is reduced even more precipitously when you start shutting down bed capacity and hospitals. Early in the course of all of these events some high profile teaching units in hospitals affiliated with prestigious medical schools were shut down and it was described as being secondary to a lack of reimbursement from companies using managed care models. If you are in a business that severely distorts the market by controlling growth and market share it makes little sense to pretend that you can analyze portfolios across an imaginary market and make decisions about resource allocation in an organization.
If you were a physician unlucky enough to be trapped in this process it played out in several ways. There were endless meetings that formed the base of misinformation. There was the suggestion that productivity was the only fair way to reimburse physicians and the implication that some physicians were much less productive than others. That was a good way to provoke the competitive, even though in practically all cases that was not true. Then there was the usual barrage of financial information. Overhead figures from who knows where. The suggestion that physicians may need to cover the salaries of any physician assistants working with them. It was an unending painful process designed to give the appearance that physicians had a say in the business, except at every critical decision they did not. In the end all there were was a long series of Dogbert management PowerPoints.
I have not seen the latest edition of the book and I wonder if there have been any additional pejorative classifications for mental health or psychiatry. One thing is for sure. You don't end up in the Dog quadrant because of lack of real demand or free markets. You end up in the Dog quadrant because of managed care and their supporters in the government.
And then they can use this analysis to remove even more resources.
George Dawson, MD, DFAPA
Thursday, October 3, 2013
Psychotherapy Has No Image Problem - Psychotherapy Has a Managed Care Problem
There was an opinion piece in the New York Times a few days ago entitled "Psychotherapy's Image Problem". The author goes on to suggest that despite empirical evidence of effectiveness and a recent study showing a patient preference for psychotherapy - it appears to be in decline. He jumps to the conclusion that this is due to an image problem, namely that primary care physicians, insurers, and therapists are unaware of the empirical data. That leads to a lack of referrals and for some therapists use of therapies that are not evidence based - further degrading the field. He implicates Big Pharma in promoting the image of medications and that the evidence base for medication has been marketed better. He implicates the American Psychiatric Association in promoting medications and suggests that the guidelines are biased against psychotherapies.
I am surprised how much discussion this post has received as though the contention of the author is accurate. Psychotherapy has no image problem as evidenced by one the references he cites about the fact that most patients prefer it. It wasn't that long ago that the famous psychotherapy journal Consumer Reports surveyed people and concluded that not only were psychotherapy services preferred, they were found as tremendously helpful by the majority of people who used them. That study was not scientifically rigorous but certainly was effective from a public relations standpoint.
The idea that psychiatry is promoting drugs over psychotherapy seems erroneous to me. The APA Guidelines certainly suggest psychotherapy as first line treatments and treatments that are part of selecting a therapeutic approach to the patient's problems. Psychopharmacology is also covered and in many cases there are significant qualifications with the psychopharmacology. Further there are a number of psychiatrists who lecture around the country who are strong advocates for what are primarily psychotherapeutic approaches to significant disorders like borderline personality disorder and obsessive compulsive disorder. Psychiatrists have also been leaders in the field of psychotherapy of severe psychiatric disorders and have been actively involved in that field for decades. Even psychopharmacology seminars include decision points for psychotherapy either as an alternate modality to pharmacological approaches or a complementary one. What is omitted from the arguments against psychiatry is that many payers do not reimburse psychiatrists for doing psychotherapy.
The author's action plan to politically promote the idea that psychotherapy is evidence based and deserves more utilization is doomed to fail because the premises of his argument are inaccurate. There is no image problem based on psychiatry - if anything the image is enhanced. There is definitely a lack of knowledge about psychotherapy by primary care physicians and it is likely that is a permanent deficit. Primary care physicians don't have the time, energy, or inclination to learn about psychotherapy. In many cases they have therapists in their clinic and just refer any potential mental health problems to those therapists. In other cases, the health plan that primary care physicians work for has an algorithm that tells them to give the patient a 2 minute depression rating scale and prescribe them an antidepressant or an anxiolytic.
And that is the real problem here. Psychotherapists just like psychiatrists are completely marginalized by managed care and business tactics. If you are a managed care company, why worry about insisting that therapists send you detailed treatment plans and notes every 5 visits for a maximum of 20 visits per year when you can just eliminate them and suggest that you are providing high quality services for depression and anxiety by following rating scale scores and having your primary care physicians prescribe antidepressants?. The primary care physicians don't even have to worry if the diagnosis is accurate anymore. The PHQ-9 score IS the diagnosis. Managed care tactics have decimated psychiatric services and psychotherapy for the last 20 years.
It has nothing to do with the image of psychotherapy. It has to do with big business and their friends in government rolling over professionals and claiming that they know more than those professionals. If you really want evidence based - they can make up a lot of it. Like the equation:
rating scale + antidepressants = quality
If I am right about the real cause of the decreased provision of psychotherapy, the best political strategy is to expose managed care and remember that current politicians and at least one federal agency are strong supporters of managed care.
George Dawson, MD, DFAPA
Brandon A. Guadiano. Psychotherapy's Image Problem. New York Times September 29, 2013.
I am surprised how much discussion this post has received as though the contention of the author is accurate. Psychotherapy has no image problem as evidenced by one the references he cites about the fact that most patients prefer it. It wasn't that long ago that the famous psychotherapy journal Consumer Reports surveyed people and concluded that not only were psychotherapy services preferred, they were found as tremendously helpful by the majority of people who used them. That study was not scientifically rigorous but certainly was effective from a public relations standpoint.
The idea that psychiatry is promoting drugs over psychotherapy seems erroneous to me. The APA Guidelines certainly suggest psychotherapy as first line treatments and treatments that are part of selecting a therapeutic approach to the patient's problems. Psychopharmacology is also covered and in many cases there are significant qualifications with the psychopharmacology. Further there are a number of psychiatrists who lecture around the country who are strong advocates for what are primarily psychotherapeutic approaches to significant disorders like borderline personality disorder and obsessive compulsive disorder. Psychiatrists have also been leaders in the field of psychotherapy of severe psychiatric disorders and have been actively involved in that field for decades. Even psychopharmacology seminars include decision points for psychotherapy either as an alternate modality to pharmacological approaches or a complementary one. What is omitted from the arguments against psychiatry is that many payers do not reimburse psychiatrists for doing psychotherapy.
The author's action plan to politically promote the idea that psychotherapy is evidence based and deserves more utilization is doomed to fail because the premises of his argument are inaccurate. There is no image problem based on psychiatry - if anything the image is enhanced. There is definitely a lack of knowledge about psychotherapy by primary care physicians and it is likely that is a permanent deficit. Primary care physicians don't have the time, energy, or inclination to learn about psychotherapy. In many cases they have therapists in their clinic and just refer any potential mental health problems to those therapists. In other cases, the health plan that primary care physicians work for has an algorithm that tells them to give the patient a 2 minute depression rating scale and prescribe them an antidepressant or an anxiolytic.
And that is the real problem here. Psychotherapists just like psychiatrists are completely marginalized by managed care and business tactics. If you are a managed care company, why worry about insisting that therapists send you detailed treatment plans and notes every 5 visits for a maximum of 20 visits per year when you can just eliminate them and suggest that you are providing high quality services for depression and anxiety by following rating scale scores and having your primary care physicians prescribe antidepressants?. The primary care physicians don't even have to worry if the diagnosis is accurate anymore. The PHQ-9 score IS the diagnosis. Managed care tactics have decimated psychiatric services and psychotherapy for the last 20 years.
It has nothing to do with the image of psychotherapy. It has to do with big business and their friends in government rolling over professionals and claiming that they know more than those professionals. If you really want evidence based - they can make up a lot of it. Like the equation:
rating scale + antidepressants = quality
If I am right about the real cause of the decreased provision of psychotherapy, the best political strategy is to expose managed care and remember that current politicians and at least one federal agency are strong supporters of managed care.
George Dawson, MD, DFAPA
Brandon A. Guadiano. Psychotherapy's Image Problem. New York Times September 29, 2013.
Tuesday, October 1, 2013
What JAMA Psychiatry Doesn't Know About Patient Dumping
JAMA Psychiatry recently posted commentary on a form of patient dumping that I described in a previous post as Greyhound therapy. The authors' post an impressive chart of state mental health budget cuts and some of the associated problems. Their solution to the problem "opening a dialogue among providers, funding agencies, and Congress" is a non solution that suggests a lack of appreciation for the details of the problems and how the system of care for people with serious mental illnesses has been systematically dismantled and is no longer capable of providing quality or innovative psychiatric care. To illustrate my point consider the following 8 points:
1. The myth of dangerousness is all encompassing. At some point the government and the managed care industry wanted to make the rationale for admissions to psychiatric units as difficult as possible to ration inpatient psychiatric care. The standard question is: "Is this person a danger to themselves or anyone else." This bias has completely disrupted inpatient care. We now have desperate people who should have been admitted who are lying about suicidal ideation in order to get admitted. We have people who don't need to be admitted saying they are suicidal and getting admitted. The point is that this criteria is irrelevant for a whole range of indications for inpatient treatment. As an example, anyone with a familiy member who has severe mental illness recognizes that there are times when they are completely unable to function due to their illness. Leaving that person at home to fend for themselves in that condition is not only a bad idea it is inhumane and yet they may not meet somebody's criteria for "dangerousness".
2. Length of stay in all community based psychiatric units is based on DRG payments. That means there is a set reimbursement for a diagnosis related stay independent of how long the patient is in the hospital. As an example a psychosis DRG is one of the commonest DRGs and the last reliable figure I have is that it pays $4,500 per DRG. That is set by the federal regulatory agency for Medicare reimbursement but practically every managed care and insurance company pays the same way either per admission or per discharge. If the patient stays 5 days that is nearly the mythical "$1,000/day" that most people believe the hospital is reimbursed. If the stay is 30 days that is $150/day and less that the cost of most board and care homes. This is a strong financial incentive for the hospital to discharge the patient as soon as possible.
3. Despite an emphasis on biological treatments in inpatient settings, there really are no biological treatments that work in the 5 days. That is the length of stay most hospitals want their patients discharged in. Most inpatient experts will tell you that severe mental illnesses (as opposed to crisis intervention) often require at least 2 - 4 weeks for stabilization.
4. Available social service providers have no incentive to assist the hospital with placement irrespective of whether there is adequate housing or not. The hospital is the least expensive place to house the patient, even if they are stable for discharge.
5. The economic incentives result in a large patient population that circulates from homelessness to emergency departments to inpatient care. These same incentives result in the patient being exposed to no single environment that results in their stabilization. In fact providing thousands of dollars of discharge medications to people who will probably never take them is a massive inefficiency that creates an illusion that inpatient treatment has done something. My personal conversations and correspondence with many outpatient psychiatrists confirms that most of them consider inpatient care to be a complete waste of time and they acknowledge that they have no good place to send their patients anymore for stabilization.
6. The same managed care companies that denied hospital claims many years ago currently own the facilities. They now have case managers essentially running their inpatient treatment and telling the physicians there when a patient must be discharged. If the doctors working in that environment don't go along they can be forced out or placed in an uncomfortable enough position that they quit. Managed care companies frequently have proprietary and arbitrary guidelines that dictate when people are discharged. It is not a coincidence that the suggested lengths of stay are expected to maximize profits and have nothing to do with quality psychiatric care.
7. Utilization reviewers still exist. Their job is basically to argue with inpatient physicians and harass them enough so that they discharge the patient. These physicians were supposed to be "peers" but in my experience talking with them over the years, it was apparent that I was not talking with anyone who had actually worked in an inpatient unit. Their job was clearly to force me to get the person out of the hospital or play the trump card by denying payment and getting the hospital to force me to get the patient out. You might ask yourself why they are necessary if their company is paying a fixed fee for inpatient care and I think that is a good question.
8. The trivial reimbursement for inpatient care deincentivizes access to other assessment and treatment modalities that the patient may need such as specialty consultation, brain imaging, and electroencepaholgraphy. Patients may be told to come back for outpatient appointments when the treating psychiatrist knows that patient will not return for the necessary appointments and will probably be readmitted soon with the exact same medical problem.
All of these issues combined are why people are discharged to the street or put on a bus. You can see that the common theme here is actually the rationing of services by the government and managed care industry as well as psychiatry's inability to deliver the quality of care that psychiatrists are trained to provide in this restricted environment. The suggested solutions in the authors article seem to be written by Joint Commission bureaucrats and will have little impact.
This is a problem that can be solved by psychiatrists but it has to start with a quality approach. Inpatient specialty training in psychiatry with a focus on providing state of the art assessment and care is necessary. It is an ideal place to begin to attend to the cognitive dimension of psychotic disorders and mood disorders. Civil commitment laws need to be reformed with a focus on treatment rather than dangerousness. There needs to be an appropriate hand-off from the hospital team to a community team and a housing team. It is the time to stop demanding "cost effective" treatment from a system that has been practically rationed into non-existence. It is time to invest in quality to the point that patients with severe mental illness and their families can expect that there will be psychiatric services available as a resource on par with the cardiology services they expect for any middle aged person with chest pain.
George Dawson, MD, DFAPA
1. Das S, Fromont SC, Prochaska JJ. Bus Therapy: A Problematic Practice in Psychiatry. JAMA Psychiatry. 2013 Sep 25. doi: 10.1001/jamapsychiatry.2013.2824. [Epub ahead of print] PubMed PMID: 24068366.
1. The myth of dangerousness is all encompassing. At some point the government and the managed care industry wanted to make the rationale for admissions to psychiatric units as difficult as possible to ration inpatient psychiatric care. The standard question is: "Is this person a danger to themselves or anyone else." This bias has completely disrupted inpatient care. We now have desperate people who should have been admitted who are lying about suicidal ideation in order to get admitted. We have people who don't need to be admitted saying they are suicidal and getting admitted. The point is that this criteria is irrelevant for a whole range of indications for inpatient treatment. As an example, anyone with a familiy member who has severe mental illness recognizes that there are times when they are completely unable to function due to their illness. Leaving that person at home to fend for themselves in that condition is not only a bad idea it is inhumane and yet they may not meet somebody's criteria for "dangerousness".
2. Length of stay in all community based psychiatric units is based on DRG payments. That means there is a set reimbursement for a diagnosis related stay independent of how long the patient is in the hospital. As an example a psychosis DRG is one of the commonest DRGs and the last reliable figure I have is that it pays $4,500 per DRG. That is set by the federal regulatory agency for Medicare reimbursement but practically every managed care and insurance company pays the same way either per admission or per discharge. If the patient stays 5 days that is nearly the mythical "$1,000/day" that most people believe the hospital is reimbursed. If the stay is 30 days that is $150/day and less that the cost of most board and care homes. This is a strong financial incentive for the hospital to discharge the patient as soon as possible.
3. Despite an emphasis on biological treatments in inpatient settings, there really are no biological treatments that work in the 5 days. That is the length of stay most hospitals want their patients discharged in. Most inpatient experts will tell you that severe mental illnesses (as opposed to crisis intervention) often require at least 2 - 4 weeks for stabilization.
4. Available social service providers have no incentive to assist the hospital with placement irrespective of whether there is adequate housing or not. The hospital is the least expensive place to house the patient, even if they are stable for discharge.
5. The economic incentives result in a large patient population that circulates from homelessness to emergency departments to inpatient care. These same incentives result in the patient being exposed to no single environment that results in their stabilization. In fact providing thousands of dollars of discharge medications to people who will probably never take them is a massive inefficiency that creates an illusion that inpatient treatment has done something. My personal conversations and correspondence with many outpatient psychiatrists confirms that most of them consider inpatient care to be a complete waste of time and they acknowledge that they have no good place to send their patients anymore for stabilization.
6. The same managed care companies that denied hospital claims many years ago currently own the facilities. They now have case managers essentially running their inpatient treatment and telling the physicians there when a patient must be discharged. If the doctors working in that environment don't go along they can be forced out or placed in an uncomfortable enough position that they quit. Managed care companies frequently have proprietary and arbitrary guidelines that dictate when people are discharged. It is not a coincidence that the suggested lengths of stay are expected to maximize profits and have nothing to do with quality psychiatric care.
7. Utilization reviewers still exist. Their job is basically to argue with inpatient physicians and harass them enough so that they discharge the patient. These physicians were supposed to be "peers" but in my experience talking with them over the years, it was apparent that I was not talking with anyone who had actually worked in an inpatient unit. Their job was clearly to force me to get the person out of the hospital or play the trump card by denying payment and getting the hospital to force me to get the patient out. You might ask yourself why they are necessary if their company is paying a fixed fee for inpatient care and I think that is a good question.
8. The trivial reimbursement for inpatient care deincentivizes access to other assessment and treatment modalities that the patient may need such as specialty consultation, brain imaging, and electroencepaholgraphy. Patients may be told to come back for outpatient appointments when the treating psychiatrist knows that patient will not return for the necessary appointments and will probably be readmitted soon with the exact same medical problem.
All of these issues combined are why people are discharged to the street or put on a bus. You can see that the common theme here is actually the rationing of services by the government and managed care industry as well as psychiatry's inability to deliver the quality of care that psychiatrists are trained to provide in this restricted environment. The suggested solutions in the authors article seem to be written by Joint Commission bureaucrats and will have little impact.
This is a problem that can be solved by psychiatrists but it has to start with a quality approach. Inpatient specialty training in psychiatry with a focus on providing state of the art assessment and care is necessary. It is an ideal place to begin to attend to the cognitive dimension of psychotic disorders and mood disorders. Civil commitment laws need to be reformed with a focus on treatment rather than dangerousness. There needs to be an appropriate hand-off from the hospital team to a community team and a housing team. It is the time to stop demanding "cost effective" treatment from a system that has been practically rationed into non-existence. It is time to invest in quality to the point that patients with severe mental illness and their families can expect that there will be psychiatric services available as a resource on par with the cardiology services they expect for any middle aged person with chest pain.
George Dawson, MD, DFAPA
1. Das S, Fromont SC, Prochaska JJ. Bus Therapy: A Problematic Practice in Psychiatry. JAMA Psychiatry. 2013 Sep 25. doi: 10.1001/jamapsychiatry.2013.2824. [Epub ahead of print] PubMed PMID: 24068366.
Sunday, September 29, 2013
A Familiar Story - Another Shooting
The story is familiar and the media writes about it the same way. A mass shooting and the shooter has anger control problems, social problems, and finally probable symptoms of psychosis. The "ELF" considerations here were interesting. ELF is extremely low frequency as specified in this Wiki primer that covers most of the relevant facts. I grew up about 30 miles away from the original ELF site in Clam Lake, Wisconsin and there were plenty of conspiracy theories and environmental concerns right in the area at the time that surrounded this project including the effect of ELF on the residents.
The usual interviews with politicians about gun access and psychiatrists about whether or not violence can be predicted. It is a very familiar sequence of events. The White House is less vocal this time because I think everyone realizes that the government has no interest in solving the problem. You can click on mass homicide and mass shooting and see my previous posts on the matter for a more complete elaboration. There seems to be nothing new in the response to this mass shooting other than the question of security at American military installations.
My response is also the same and it is basically the following:
1. Mass homicide is a public health problem that can be addressed with public health interventions.
2. Violence and homicide prevention can occur even in the absence of firearm legislation.
3. Violence and homicide prevention does not require prediction of future events but the capacity to recognize markers of violence and psychiatric disorders and respond to them appropriately.
4. There need to be accessible speciality programs for the safe assessment and treatment of people with severe mental illnesses and aggressive behavior. That includes the assessment of threats since they are the precursors to the actual violence.
5. A standardized legal approach to the problem of the potentially dangerous person and whether or not mental illness is a factor is necessary.
6. A comprehensive policy that addresses the issues of progressively inadequate mental health funding is necessary to reverse these trends will provide the funding.
All of the above elements require a standardized approach to the care of the aggressive person and there are several clear reasons why that does not happen. The so-called mental health systems is fragmented and it has been for decades. It is basically designed to ration rather than provide care. That is a massive conflict of interest. Until that is acknowledged by the politicians and advocates nothing will be accomplished. It is very hard for politicians to acknowledge when they are backing a national agency that essentially endorses rationing and managed care. You can also compare my writing and suggested solutions to this problem to a recent "call to action" by American Psychiatric Association President Jeffrey A. Lieberman, MD.
How many "calls to action" does the APA need?
George Dawson, MD, DFAPA
The usual interviews with politicians about gun access and psychiatrists about whether or not violence can be predicted. It is a very familiar sequence of events. The White House is less vocal this time because I think everyone realizes that the government has no interest in solving the problem. You can click on mass homicide and mass shooting and see my previous posts on the matter for a more complete elaboration. There seems to be nothing new in the response to this mass shooting other than the question of security at American military installations.
My response is also the same and it is basically the following:
1. Mass homicide is a public health problem that can be addressed with public health interventions.
2. Violence and homicide prevention can occur even in the absence of firearm legislation.
3. Violence and homicide prevention does not require prediction of future events but the capacity to recognize markers of violence and psychiatric disorders and respond to them appropriately.
4. There need to be accessible speciality programs for the safe assessment and treatment of people with severe mental illnesses and aggressive behavior. That includes the assessment of threats since they are the precursors to the actual violence.
5. A standardized legal approach to the problem of the potentially dangerous person and whether or not mental illness is a factor is necessary.
6. A comprehensive policy that addresses the issues of progressively inadequate mental health funding is necessary to reverse these trends will provide the funding.
All of the above elements require a standardized approach to the care of the aggressive person and there are several clear reasons why that does not happen. The so-called mental health systems is fragmented and it has been for decades. It is basically designed to ration rather than provide care. That is a massive conflict of interest. Until that is acknowledged by the politicians and advocates nothing will be accomplished. It is very hard for politicians to acknowledge when they are backing a national agency that essentially endorses rationing and managed care. You can also compare my writing and suggested solutions to this problem to a recent "call to action" by American Psychiatric Association President Jeffrey A. Lieberman, MD.
How many "calls to action" does the APA need?
George Dawson, MD, DFAPA
Saturday, September 28, 2013
Lessons About Clarity and Boundaries from a Sound Engineer
I read Jason Kottke's blog on a regular basis, probably because he posts a lot of stuff that is just interesting from the standpoint of human communication and analysis. The latest item that caught my eye was this 20 year old letter to the band Nirvana by their prospective sound engineer - Steve Albini. To set the context for this letter, Nirvana had released one of the the highest selling rock albums of all time two years earlier, so at the time this letter was penned the group was huge. There is also a documentary out there about the production of that album with commentary from that sound engineer (Butch Vig) and his analysis of the group and the recording that is very interesting. So the group was huge and they probably had access to the same sound engineer who made the most successful rock album of all time. I looked at my copy of In Utero and confirmed that the band did in fact hire Albini. The hiring and ultimate product was not without controversy and there are 48 references to Albini in the Wiki piece on In Utero, some of them referring back to the original letter. I thought it was a remarkable document about providing service, the parameters of that service and the associated philosophy. I will use a brief excerpt of this letter as an example:
"#2: I do not consider recording and mixing to be unrelated tasks which can be performed by specialists with no continuous involvement. 99 percent of the sound of a record should be established while the basic take is recorded. Your experiences are specific to your records; but in my experience, remixing has never solved any problems that actually existed, only imaginary ones. I do not like remixing other engineer's recordings, and I do not like recording things for someone to remix. I have never been satisfied with either version of that methodology......"
This letter does contain the rough language that you would expect to hear from young men before they recognize the value of language that never needs to be censored, but there are potentially important lessons.
I have had the privilege of talking with people in considerable detail about their medical, psychiatric, social and family histories since about 1978. That is a long time by anybody's standard. There are some things that jump out of those interviews that seem to not change over time. I am always surprised by the implicit rather than explicit agreements between physicians and their patients. That is especially true since managed care companies started dictating the practice parameters of their physician employees on a large scale basis. I wonder if things might be a lot better if the relationship between a doctor and his/her patient was not spelled out as clearly as the letter from this sound engineer. I thought I would compose a parallel letter. It might go something like this .
That is my first attempt to write a letter about what you might expect in seeing me for psychiatric treatment. I intentionally wrote it in a manner similar to Steve Albini when he described what it might be like to employ him as a sound engineer. The whole idea of being very clear with people about what they can expect and how they need to interact with psychiatrists in treatment has never been more critical. For all of my career (so far) I have been an employee of a healthcare organization. In that situation that adds a dimension to the treatment contract. For example, do the organization that employs you have the same priorities and the same approach to patient care? If not, it might be very difficult for you to pen a sample letter like the one I have written. You can't really talk about psychotherapy or even lengthy evaluations if your organization allows you to see patients in 10-20 minute appointments to refill their medications.
I am very interested in hearing what other psychiatrists would add or subtract to what I have so far. I would also be interested in hearing about any existing letters. I think they would also be very useful for psychiatrists starting out of residency or psychiatrists going into private practice after years of working as an employee.
George Dawson, MD, DFAPA
If you send me a letter, with your permission I will scan them into Dropbox and post the links right here with any title that you want me to use including "anonymous":
"#2: I do not consider recording and mixing to be unrelated tasks which can be performed by specialists with no continuous involvement. 99 percent of the sound of a record should be established while the basic take is recorded. Your experiences are specific to your records; but in my experience, remixing has never solved any problems that actually existed, only imaginary ones. I do not like remixing other engineer's recordings, and I do not like recording things for someone to remix. I have never been satisfied with either version of that methodology......"
This letter does contain the rough language that you would expect to hear from young men before they recognize the value of language that never needs to be censored, but there are potentially important lessons.
I have had the privilege of talking with people in considerable detail about their medical, psychiatric, social and family histories since about 1978. That is a long time by anybody's standard. There are some things that jump out of those interviews that seem to not change over time. I am always surprised by the implicit rather than explicit agreements between physicians and their patients. That is especially true since managed care companies started dictating the practice parameters of their physician employees on a large scale basis. I wonder if things might be a lot better if the relationship between a doctor and his/her patient was not spelled out as clearly as the letter from this sound engineer. I thought I would compose a parallel letter. It might go something like this .
That is my first attempt to write a letter about what you might expect in seeing me for psychiatric treatment. I intentionally wrote it in a manner similar to Steve Albini when he described what it might be like to employ him as a sound engineer. The whole idea of being very clear with people about what they can expect and how they need to interact with psychiatrists in treatment has never been more critical. For all of my career (so far) I have been an employee of a healthcare organization. In that situation that adds a dimension to the treatment contract. For example, do the organization that employs you have the same priorities and the same approach to patient care? If not, it might be very difficult for you to pen a sample letter like the one I have written. You can't really talk about psychotherapy or even lengthy evaluations if your organization allows you to see patients in 10-20 minute appointments to refill their medications.
I am very interested in hearing what other psychiatrists would add or subtract to what I have so far. I would also be interested in hearing about any existing letters. I think they would also be very useful for psychiatrists starting out of residency or psychiatrists going into private practice after years of working as an employee.
George Dawson, MD, DFAPA
If you send me a letter, with your permission I will scan them into Dropbox and post the links right here with any title that you want me to use including "anonymous":
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