I have been an interested reader of financial information for the the past 40 years. My uncle was an avid stock market investor when I was a kid and he got me interested in reading the Value Line investment survey. I still read it and base some of my decisions on it. Over the years I have had some degree of success in investing, but it hasn't all been good. One of my greatest successes was a defensive maneuver that resulted in me not losing anything during the stock market crash of 2008. I have been a subscriber at one time or another to most of the significant investment magazines and newspapers in the United States.
It has been interesting to observe what has happened to what has come to be known as the financial services industry over my investing career because it has implications for the increasing business control over medicine. I have already alluded to many on these implications on this blog including treating knowledge workers like production workers and creating an unhealthy work environment that results in a lack of empathy for the patients being treated. But there are even larger implications. Financial services industry friendly legislation has probably been the single largest contributor to the idea that the privacy of individuals is relative to the advantages gained by establishing credit reporting. Credit reporting agencies were born out of the idea that data could be collected under a Social Security Number and released to any financial institution without the consent of the person behind that SSN. That single idea violated a previous promise by Congress that SSNs would not be used as any type of national identifier and was single handedly responsible for creating a multi-billion dollar industry that basically buys and sells credit information and the identity theft industry - both the criminal side and the services to protect people from the criminals. It is much harder to be an identity thief in a world that does not have credit information centralized on a SSN.
The driving force behind businesses everywhere is to create leverage that results in people needing to buy a product or service and make it so they can't get it anywhere else. We hear a lot about competition and its importance in capitalism, but there is plenty of evidence that capitalism is not only lacking but that measures are often in place to severely restrict it. It results in an industry that is set up to optimize gain from consumers while keeping them all at risk. As an example, one of the "low risk" strategies for investing with some of these companies is to investment in index funds. As retirement nears, the recommendation can be to put funds into an annuity or with an advisor who can determine withdrawal rates, reallocation, and future investment decisions. In many cases the retiree is charged up to 1% for that service on top of whatever service charges and transaction fees are associated with the funds that are invested in. There is always the disclaimer that there is no guarantee of income from the account and this is compounded by the fact that interest on cash and money market funds is at an all time low. Very few investors can fund their retirement by interest on so-called safe investments and in the last decade we have witnessed the first losses on money market funds. All things considered, regulation at all levels seems like it is clearly set up to favor the financial services industry. They have a license to warn you that you can lose money even though you may be paying them to protect it - and that's OK. In some extreme examples, investment banks have recommended purchases to customer that they were actively betting against.
I don't know how many people can see the trend, but it is pretty obvious to me. As medical information gets more like financial information - it moves farther away from any reality basis and it becomes a vehicle for manipulation. The whole point of collecting data from a medical and scientific standpoint is to look at underlying meaning specifically implications for health care. The best example is lab data. If I look at a patient's CBC with differential count and chemistry profile, I have about 40 data points, any one of which could have significant health implications for the care of that individual. If I look at various quality markers and screening scores that are being collected for business purposes that data varies from questionable to clearly invalid and yet physicians are being held "accountable" for what is essentially business quality data. In other words, data that has no scientific basis and can be manipulated for a specific result. The usual intent is to maximize business profits and make it seem like the business is much more critical to the provision of health care than the health professionals it hires. As absurd as that last sentence looks, it is without a doubt one of the goals of most health care businesses.
Business information collected and manipulated for the sake of furthering business interests in the health care industry is no more valid than what happens in the financial services industry. Both types of information have evolved to place the consumer at risk all of the time and give them no clear reason for a making a decision in their own interest. And in both cases, consumers have no choice but to participate. We have a government mandated retirement industry that provides a windfall to financial services. We now have a government mandated health care industry that is set to provide a windfall the large health care and pharmaceutical companies. In both cases it is underwritten by the American consumer who is placed at financial risk all of the time in an economy of stagnant wages and significant unemployment.
George Dawson, MD, DFAPA
Monday, March 24, 2014
Friday, March 21, 2014
Compassion Fatigue? Or Sometimes You Eat The Shark And Sometimes The Shark Eats You
I passed a pamphlet for a conference on Compassion Fatigue today and thought to myself: "Why haven't I ever encountered the term compassion in medical school or at any point in my medical or professional training?" If you look it up in a real dictionary there seems to be multiple meanings ranging from: "A feeling of wanting to help someone who is sick, hungry, in trouble, etc." to "a feeling of deep sympathy and sorrow for another who is stricken by misfortune, accompanied by a strong desire to alleviate suffering." None of these definitions seems to capture what happens in medicine and how physicians are trained. It seems like an undisciplined emotional reaction to human suffering. That may seem a bit calloused to someone outside the field but would you want your surgeon operating on you in the throes of an emotional reaction? Would you want your internist or psychiatrist recommending medication for you during an emotional episode? On the other hand, depending on what part of the definition I focus on, I have already pointed out that in my opinion the overprescribing of medications is motivated at some level by "a strong desire to alleviate suffering." More evidence that compassion may not be the best basis for medical decisions.
I can still recall the first patient that I was responsible for. The very first patient I evaluated on Internal Medicine as a third year medical student. He was not much older than me, but at that point he had a much harder life. As he explained his symptoms to me and we did the examination, I found myself getting more and more anxious. I realized that he had a very serious illness that he was not going to recover from. I pulled all of the test results and x-rays together so I could present it in our team meeting in the morning. I could barely get the information out to my chief resident and attending. I was overcome with emotion. My voice cracked. I was tearing up. My head was spinning. I was focused on how unfair life was. He was a young guy, just like me with the usual hopes, dreams, and relationships that we all have and through no fault of his own, he had developed a terminal illness. I certainly wanted to help him, but there was nothing that could be done. That happens so frequently in medicine, using the most emotional definition of compassion would render most physicians nonfunctional. It tends to alter your focus. The focus has to be on what is happening right here and right now and not the unfairness of the process. The focus needs to be on the technical details or you can't provide competent care and tell people what they need to know. As I have gotten older, I have an image for the process of unpredictable disease and death. It reminds me of the war movie where the fleet is sunk and everyone is bobbing in the Pacific Ocean wearing life preservers. Suddenly the sharks appear and people start to die on a random basis. Whoever the sharks decide to kill. A random horrific process. That is my image.
It may explain the reaction of one of my attendings when I was a resident on a busy inpatient psychiatric unit. I was reading the description of one of our consultants to him and the consultant used the adjective "unfortunate" to describe all of the medical problems the patient had sustained. My attending glared at me and said: "Why is he unfortunate?" It seemed like an obvious descriptor to me. Anyone with all of these severe medical problems could be described as unfortunate, but I could not respond to him at the time. It seems to me if the sharks get you or there is a near miss, unfortunate in the bad luck sense may be a good description. He may have been thinking of another definition. But I think he was most likely giving me the message that it is best to not even recognize the random walk through life and the fact that the shark can eat you at any time. Without that element of denial, how can you function? How can you function as a physician?
After you have talked with thousands of people about their traumas and adversities, you realize that most people suffer. Personal biases make some people want to alleviate the suffering of some more than others. Nobody wants to see children suffer. There are some people who attract the ill wishes of others. They are generally unlikable or they have perpetrated some kind of shocking crime. There seems to be a likeability bias with compassion and that also makes it less useful for physicians. Physicians are obliged to perform competent medical care irrespective of how well the person is liked. There are often errors on the side of people who are very likeable. Sometimes physicians and medical staff get very attached to person based on their personality, physical characteristics, or demeanor. You may want to help that likeable person more, but that doesn't translate into whether you can or not.
If you are trained to render assistance, save lives when you can and alleviate suffering where does the compassion that you had before medical school go? Without invoking defense mechanisms it gets converted to other things that are adaptive in the profession. Empathy and technical skill are good examples. Empathy is probably a more accurate emotional appreciation of what is occurring in a person you are trying to help. It is focused on that person and their emotional state and if reflected back to that person they would agree with the observations. A better measure of burnout for physicians especially psychiatrists would be empathy fatigue rather than compassion fatigue. Seeing people as collections of symptoms and having no appreciation for the emotional side of their experience would be one example. Seeing patients as an endless stream of problems that you need to fix rather than unique individuals would be another. As the days get longer there are also the comparisons physicians make about how much time they spend taking care of others compared to how much time they spend with their families. As the family time gets shorter it may be harder to empathize with increasing numbers of patients.
Whether it is compassion fatigue or burnout, these seminars all seem to teach the same things. It is fashionable to refer to the skills as "tools". Mindfulness techniques, cognitive behavioral therapy. relaxation techniques, meditation, diet, sleep, and exercise are all parts of the "toolkit." Nobody ever seems to address the severely deteriorated work environment as a cause and ongoing factor. Productivity demands on physicians in terms of the number of patients seen, the amount of documentation that needs to be done and the other aspects of being a good corporate citizen are a recipe for burnout and that is probably the most common job scenario for physicians these days. Professional organizations seem to ignore that fact that if physicians are going to function the way they should and treat the whole person, a work environment without adequate time to talk with patients in one of the fast paths to burnout.
No amount of "tools" can reverse that.
George Dawson, MD, DFAPA
Supplementary 1: In talking with people over the years and trying to help them stay on the job, the most significant problem is unreasonable employers. People work in jobs where the job directly impacts their health. The best example is alternating shifts and never being able to establish a regular sleep routine. Hospitals are some of the worst offenders. They have adopted policies that allow them to tell nursing staff that they need to work "mandatory doubles" when there are shortages. The policies that have hospitalists working 7 days on and 7 days off are no better. I have interviewed hospitalists about their cognitive efficiency on day 6 and 7 and have been told that it generally plummets. They are taking twice as long to do the documentation and it is difficult to think. I was in a similar position one year when I was running a 20 bed inpatient service with assistance of a physician's assistant. I had to see everyone, everyday and managed both the medical and psychiatric diagnoses. When I decided to stop doing that, I was replaced by two full time psychiatrists and an internal medicine specialist to take care of all of the medical problems. Eventually those two psychiatrists felt it was too much work and a third psychiatrist was added to cover 4 of the 20 patients. The adverse effect of a business model on employee health that operates on personnel expenses cut to the bone can not be overemphasized. Hospitals and clinics will happily work medical staff to the point that it adversely impacts their health and lifestyle, adversely impacts their cognitive abilities at work, leads to burnout, and leaves them in a state where empathy is a thing of the past.
The only reason I quit running a 20 bed inpatient unit by myself was a colleague of mine who told me he did it for years - right up to the point he had his first heart attack.
I can still recall the first patient that I was responsible for. The very first patient I evaluated on Internal Medicine as a third year medical student. He was not much older than me, but at that point he had a much harder life. As he explained his symptoms to me and we did the examination, I found myself getting more and more anxious. I realized that he had a very serious illness that he was not going to recover from. I pulled all of the test results and x-rays together so I could present it in our team meeting in the morning. I could barely get the information out to my chief resident and attending. I was overcome with emotion. My voice cracked. I was tearing up. My head was spinning. I was focused on how unfair life was. He was a young guy, just like me with the usual hopes, dreams, and relationships that we all have and through no fault of his own, he had developed a terminal illness. I certainly wanted to help him, but there was nothing that could be done. That happens so frequently in medicine, using the most emotional definition of compassion would render most physicians nonfunctional. It tends to alter your focus. The focus has to be on what is happening right here and right now and not the unfairness of the process. The focus needs to be on the technical details or you can't provide competent care and tell people what they need to know. As I have gotten older, I have an image for the process of unpredictable disease and death. It reminds me of the war movie where the fleet is sunk and everyone is bobbing in the Pacific Ocean wearing life preservers. Suddenly the sharks appear and people start to die on a random basis. Whoever the sharks decide to kill. A random horrific process. That is my image.
It may explain the reaction of one of my attendings when I was a resident on a busy inpatient psychiatric unit. I was reading the description of one of our consultants to him and the consultant used the adjective "unfortunate" to describe all of the medical problems the patient had sustained. My attending glared at me and said: "Why is he unfortunate?" It seemed like an obvious descriptor to me. Anyone with all of these severe medical problems could be described as unfortunate, but I could not respond to him at the time. It seems to me if the sharks get you or there is a near miss, unfortunate in the bad luck sense may be a good description. He may have been thinking of another definition. But I think he was most likely giving me the message that it is best to not even recognize the random walk through life and the fact that the shark can eat you at any time. Without that element of denial, how can you function? How can you function as a physician?
After you have talked with thousands of people about their traumas and adversities, you realize that most people suffer. Personal biases make some people want to alleviate the suffering of some more than others. Nobody wants to see children suffer. There are some people who attract the ill wishes of others. They are generally unlikable or they have perpetrated some kind of shocking crime. There seems to be a likeability bias with compassion and that also makes it less useful for physicians. Physicians are obliged to perform competent medical care irrespective of how well the person is liked. There are often errors on the side of people who are very likeable. Sometimes physicians and medical staff get very attached to person based on their personality, physical characteristics, or demeanor. You may want to help that likeable person more, but that doesn't translate into whether you can or not.
If you are trained to render assistance, save lives when you can and alleviate suffering where does the compassion that you had before medical school go? Without invoking defense mechanisms it gets converted to other things that are adaptive in the profession. Empathy and technical skill are good examples. Empathy is probably a more accurate emotional appreciation of what is occurring in a person you are trying to help. It is focused on that person and their emotional state and if reflected back to that person they would agree with the observations. A better measure of burnout for physicians especially psychiatrists would be empathy fatigue rather than compassion fatigue. Seeing people as collections of symptoms and having no appreciation for the emotional side of their experience would be one example. Seeing patients as an endless stream of problems that you need to fix rather than unique individuals would be another. As the days get longer there are also the comparisons physicians make about how much time they spend taking care of others compared to how much time they spend with their families. As the family time gets shorter it may be harder to empathize with increasing numbers of patients.
Whether it is compassion fatigue or burnout, these seminars all seem to teach the same things. It is fashionable to refer to the skills as "tools". Mindfulness techniques, cognitive behavioral therapy. relaxation techniques, meditation, diet, sleep, and exercise are all parts of the "toolkit." Nobody ever seems to address the severely deteriorated work environment as a cause and ongoing factor. Productivity demands on physicians in terms of the number of patients seen, the amount of documentation that needs to be done and the other aspects of being a good corporate citizen are a recipe for burnout and that is probably the most common job scenario for physicians these days. Professional organizations seem to ignore that fact that if physicians are going to function the way they should and treat the whole person, a work environment without adequate time to talk with patients in one of the fast paths to burnout.
No amount of "tools" can reverse that.
George Dawson, MD, DFAPA
Supplementary 1: In talking with people over the years and trying to help them stay on the job, the most significant problem is unreasonable employers. People work in jobs where the job directly impacts their health. The best example is alternating shifts and never being able to establish a regular sleep routine. Hospitals are some of the worst offenders. They have adopted policies that allow them to tell nursing staff that they need to work "mandatory doubles" when there are shortages. The policies that have hospitalists working 7 days on and 7 days off are no better. I have interviewed hospitalists about their cognitive efficiency on day 6 and 7 and have been told that it generally plummets. They are taking twice as long to do the documentation and it is difficult to think. I was in a similar position one year when I was running a 20 bed inpatient service with assistance of a physician's assistant. I had to see everyone, everyday and managed both the medical and psychiatric diagnoses. When I decided to stop doing that, I was replaced by two full time psychiatrists and an internal medicine specialist to take care of all of the medical problems. Eventually those two psychiatrists felt it was too much work and a third psychiatrist was added to cover 4 of the 20 patients. The adverse effect of a business model on employee health that operates on personnel expenses cut to the bone can not be overemphasized. Hospitals and clinics will happily work medical staff to the point that it adversely impacts their health and lifestyle, adversely impacts their cognitive abilities at work, leads to burnout, and leaves them in a state where empathy is a thing of the past.
The only reason I quit running a 20 bed inpatient unit by myself was a colleague of mine who told me he did it for years - right up to the point he had his first heart attack.
Thursday, March 20, 2014
Public Sector Mental Health Continues to Be Squeezed Out Of Business
There was a story that shocked many in the local press earlier this week. A local mental health center serving about 3,000 people in five counties shut its doors, leaving nobody to fill that void. Although this appears to be scandalous news, it is really the logical progression of events that has been accurately described in E. Fuller Torrey's book. It is the logical result of federal and state governments selectively rationing mental health benefits and closing down both inpatient bed and outpatient treatment capacity.
People always ask me: "Well - what should an ideal community mental health center look like?" That is easy for me to answer because I was trained in community psychiatry, my first job out of residency was as the medical director of a community mental health center (CMHC) , and most of my career has been focused on helping patients who are largely in the public sector or certainly funded by those resources (Medicare/Medical Assistance). I know exactly what an ideal CMHC needs to run and provide services to a broad range of people who do not have access to metropolitan style mental health services. The vignettes provided in this article will also be addressed in the following points.
1. The backbone of any CMHC should be services that focus on people with disabling mental illnesses and helping them live independently. In the state where my original CMHC was located, statutes defined these conditions as schizophrenia, bipolar disorder, schizoaffective disorder, major depression, and borderline personality disorder. Adequate resources to treat those conditions generally means nursing and case management services that can meet with people in their homes and in the community. In the teams that I worked with over 20 years ago we also had a vocational rehabilitation component and we worked with a number of physicians and specialists to address medical problems. In any treatment setting where a CMHC is responsible for treating all public patients over a county wide catchment area, there is of necessity a legal component. That is typically focused on involuntary treatment like civil commitment, court ordered medications, guardianships, conservatorships and protective placement. Depending on the size of the county it can also involve competency assessments for ability to proceed to a court hearing based on concerns about mental illness.
2. A community trained psychiatrist with medical skills. The psychiatrist involved should enjoy working with people with people who have severe mental illnesses and medical comorbidity. The legal component of services means that this person also needs to be comfortable doing the necessary exams and court testimony. Medical and neurological illnesses need to be recognized and treated. In CMHC settings the psychiatrist generally has much more information available about the health of his or her patients and they know how to interview people to get it. When I was a medical director I also provided consultation to nursing homes, hospital consultations, and I would also travel to patient homes with case managers to provide consultation in that setting. A lot depends on geography and distances to the other facilities needing consultation.
3. Psychotherapists are critical to the functioning of a CMHC. It has been interesting to watch the government and managed care companies ration psychotherapy services as much as they ration access to psychiatrists. Correct me if I am wrong but as far as I know there are no HMOs or MCOs offering standard research based psychotherapies for psychiatric diagnoses. At the max, usually 2 or 3 "crisis counseling" sessions. In some cases a generic dialectical behavior therapy (DBT) group where many people with personality disorders end up because more specific therapy is unavailable. CMHCs could be leaders in the implementation of computer based therapies, and the argument against that would be the lack of information technology departments. The argument in support of this would be the fact that all counties across the state could share the same resource. With today's tech, it would be easily scalable to support anyone who needed it. It would be inexpensive, effective and a good way to not dilute the psychotherapy resources of the clinic. The other major change int he past two decades has been the focus on psychotherapy for people with severe mental illnesses. That should be a critical part of any CMHC function.
4. Addiction treatment - many communities have more resources available outside of the CMHC for assessment and treatment or referral of addictions. The CMHC resources need to be more focused on the issue of co-occurring disorders and probably chronic pain and co-occurring disorders. This would be another opportunity for networking all of the CMHCs in a state to assure a standard of assessment, share treatment resources, consult on specific cases and assure that there is no deterioration in prescriber standards with regard to potentially addictive medications.
5. Crisis intervention services - 24/7 availability is necessary to provide acute evaluations but more importantly to resolve crises in patients who are well known to treatment teams. Ity reduces the likelihood of unnecessary hospitalizations when there are staff person available who know the person in crisis very well. It is much more efficient and patient centered than sending a person to an emergency department and asking them to start over there with professionals who do not know them.
In the CMHC I worked in we had a catchment area of about 100,000 people spread over a large rural county. We had a little over 100 patients in our community support programs for the severely disabled. We we staffed by 1 psychiatrist, 2 psychologists, 4 social workers, 1 occupational therapist, 4 psychotherapists, 1 RN, and 2 LPNs.
The progression noted in this article is very clear and it has been replicated thousands of times across the US. Shut down the large hospitals and tell people that treatment will be available in the communities near their homes. Then shut down community treatment. You will notice that officials make it seem like this is some kind of mystery.
“We’re so tight in [psychiatric] beds that any change in the delivery system impacts the whole system,” said Assistant Human Services Commissioner David Hartford. “The agencies need to reorganize to get people the care they need.”
People always ask me: "Well - what should an ideal community mental health center look like?" That is easy for me to answer because I was trained in community psychiatry, my first job out of residency was as the medical director of a community mental health center (CMHC) , and most of my career has been focused on helping patients who are largely in the public sector or certainly funded by those resources (Medicare/Medical Assistance). I know exactly what an ideal CMHC needs to run and provide services to a broad range of people who do not have access to metropolitan style mental health services. The vignettes provided in this article will also be addressed in the following points.
1. The backbone of any CMHC should be services that focus on people with disabling mental illnesses and helping them live independently. In the state where my original CMHC was located, statutes defined these conditions as schizophrenia, bipolar disorder, schizoaffective disorder, major depression, and borderline personality disorder. Adequate resources to treat those conditions generally means nursing and case management services that can meet with people in their homes and in the community. In the teams that I worked with over 20 years ago we also had a vocational rehabilitation component and we worked with a number of physicians and specialists to address medical problems. In any treatment setting where a CMHC is responsible for treating all public patients over a county wide catchment area, there is of necessity a legal component. That is typically focused on involuntary treatment like civil commitment, court ordered medications, guardianships, conservatorships and protective placement. Depending on the size of the county it can also involve competency assessments for ability to proceed to a court hearing based on concerns about mental illness.
2. A community trained psychiatrist with medical skills. The psychiatrist involved should enjoy working with people with people who have severe mental illnesses and medical comorbidity. The legal component of services means that this person also needs to be comfortable doing the necessary exams and court testimony. Medical and neurological illnesses need to be recognized and treated. In CMHC settings the psychiatrist generally has much more information available about the health of his or her patients and they know how to interview people to get it. When I was a medical director I also provided consultation to nursing homes, hospital consultations, and I would also travel to patient homes with case managers to provide consultation in that setting. A lot depends on geography and distances to the other facilities needing consultation.
3. Psychotherapists are critical to the functioning of a CMHC. It has been interesting to watch the government and managed care companies ration psychotherapy services as much as they ration access to psychiatrists. Correct me if I am wrong but as far as I know there are no HMOs or MCOs offering standard research based psychotherapies for psychiatric diagnoses. At the max, usually 2 or 3 "crisis counseling" sessions. In some cases a generic dialectical behavior therapy (DBT) group where many people with personality disorders end up because more specific therapy is unavailable. CMHCs could be leaders in the implementation of computer based therapies, and the argument against that would be the lack of information technology departments. The argument in support of this would be the fact that all counties across the state could share the same resource. With today's tech, it would be easily scalable to support anyone who needed it. It would be inexpensive, effective and a good way to not dilute the psychotherapy resources of the clinic. The other major change int he past two decades has been the focus on psychotherapy for people with severe mental illnesses. That should be a critical part of any CMHC function.
4. Addiction treatment - many communities have more resources available outside of the CMHC for assessment and treatment or referral of addictions. The CMHC resources need to be more focused on the issue of co-occurring disorders and probably chronic pain and co-occurring disorders. This would be another opportunity for networking all of the CMHCs in a state to assure a standard of assessment, share treatment resources, consult on specific cases and assure that there is no deterioration in prescriber standards with regard to potentially addictive medications.
5. Crisis intervention services - 24/7 availability is necessary to provide acute evaluations but more importantly to resolve crises in patients who are well known to treatment teams. Ity reduces the likelihood of unnecessary hospitalizations when there are staff person available who know the person in crisis very well. It is much more efficient and patient centered than sending a person to an emergency department and asking them to start over there with professionals who do not know them.
In the CMHC I worked in we had a catchment area of about 100,000 people spread over a large rural county. We had a little over 100 patients in our community support programs for the severely disabled. We we staffed by 1 psychiatrist, 2 psychologists, 4 social workers, 1 occupational therapist, 4 psychotherapists, 1 RN, and 2 LPNs.
The progression noted in this article is very clear and it has been replicated thousands of times across the US. Shut down the large hospitals and tell people that treatment will be available in the communities near their homes. Then shut down community treatment. You will notice that officials make it seem like this is some kind of mystery.
“We’re so tight in [psychiatric] beds that any change in the delivery system impacts the whole system,” said Assistant Human Services Commissioner David Hartford. “The agencies need to reorganize to get people the care they need.”
Sorry Commissioner but in case you didn't notice we are not talking about beds anymore. All of the people involved here were living at home in their own beds. Agency "reorganization" is not an option. There are no agencies anymore and one that was providing a valuable service was just shut down. The problem here is very clear, cost shifting by managed care and defunding by the state. Corporate welfare in the form of a carve-out for psychiatric services. Keep in mind that when the comprehensive and humanistic approach to community treatment is lost, the only alternative is going in to a large managed care clinic where the appointments are scheduled every 15-20 minutes, the focus is on a prescription, and the only thing the doctor knows about what is going on is exchanged in that visit and recorded in the electronic health record. That is frequently a symptom checklist.
I guess there is always the psychiatric hospital of last resort - the county jail. At least until the Sheriff's department goes broke.
George Dawson, MD, DFAPA
Christopher Snowbeck. Crisis mental health provider closes; 5 counties scrambling. TwinCities.com St. Paul Pioneer Press. March 18, 2014.
Chris Serres. Minn. mental health center shuts down, stranding thousands. Minneapolis StarTribune. March 17, 2014.
Supplementary 1: I e-mailed the author of the first article Mr. Serres to inquire about the recently released state report that he refers to in the article and got no response. As far as I can tell it may be the "Health Services in State Correctional Facilities Report" available at this site. The concerning highlights include the fact that there are units that provide intensive nursing and mental health services. About 33% (67,456) of all of the health services encounters with staff are for mental health purposes. That translates to 28% of the offenders receiving mental health services. At some point in their stay 32% are diagnosed with a "serious and persistent mental illness" as defined by state statute. The report provides an interesting overview of how mental health services are provided in Minnesota prisons and the special problems involved in treating mentally ill offenders.
Supplementary 2: According to Minnesota Statutes 2013, 245.462, subd. 20(c)(4)(i), states that a person has serious and persistent mental illness if he or she is an adult and “has a diagnosis of schizophrenia, bipolar disorder, major depression, schizoaffective disorder, or borderline personality disorder.”
George Dawson, MD, DFAPA
Christopher Snowbeck. Crisis mental health provider closes; 5 counties scrambling. TwinCities.com St. Paul Pioneer Press. March 18, 2014.
Chris Serres. Minn. mental health center shuts down, stranding thousands. Minneapolis StarTribune. March 17, 2014.
Supplementary 1: I e-mailed the author of the first article Mr. Serres to inquire about the recently released state report that he refers to in the article and got no response. As far as I can tell it may be the "Health Services in State Correctional Facilities Report" available at this site. The concerning highlights include the fact that there are units that provide intensive nursing and mental health services. About 33% (67,456) of all of the health services encounters with staff are for mental health purposes. That translates to 28% of the offenders receiving mental health services. At some point in their stay 32% are diagnosed with a "serious and persistent mental illness" as defined by state statute. The report provides an interesting overview of how mental health services are provided in Minnesota prisons and the special problems involved in treating mentally ill offenders.
Supplementary 2: According to Minnesota Statutes 2013, 245.462, subd. 20(c)(4)(i), states that a person has serious and persistent mental illness if he or she is an adult and “has a diagnosis of schizophrenia, bipolar disorder, major depression, schizoaffective disorder, or borderline personality disorder.”
Tuesday, March 18, 2014
Enduring Problems Of The Electronic Health Record
I think the national debate is coming back to the more reasonable position that the heavily hyped electronic health records (EHR) will not save up hundreds of billions of dollars due to "efficiency." But then again again any physicians not working as an administrator hyping the EHR could have told you this based on their experience over the past 10 years. If I had to think of a reason, I would imagine it is the companies trying to build a moat around their businesses. Software engineering can't possibly be this bad. Wall Street jargon considers moats or barriers to direct competition with a company to be a good thing. Let me illustrate with a real world example.
Let's suppose you are working in a clinic that is not online with the largest managed care (MCO) company in your area. The only way you can get electronic access is to pay a huge licensing fee, but in many cases the software company will not even accept that licensing fee. It will just conclude that that you are not big enough to do business with them. At any rate, you need electrocardiogram information on a patient from that MCO because you are looking at a new abnormal ECG on that patient. You need to know if the pattern on that ECG is new or it has always been there. You request the records from the MCO. They fax you 50 pages containing the lowest possible amount of information per page. There are two one line references in that 50 pages to an electrocardiogram. One says: "Prolonged QTc" and the other says "Normal". There is no graphic information (the tracing) and no numerical information (the intervals with the associated times in milliseconds, the machine read out). So after the work put in by you and your staff to request this data, you have just read through 50 pages and found absolutely nothing useful. A review of all of the pages shows scant information on each page. As an example, one entire page contains a chest x-ray report, when it could easily be printed on an area 1/20th that size. Some entire sheets contain 1 or 2 lab values of 3 to 5 digit numbers.
I am convinced that the multimillion dollar licensed legacy wide EHRs are designed this way. There is really no other explanation for providing such an abundance of low to no information records. Their intention is obvious. Make sure everyone is using their system and at some point make sure that the government is forcing people to use somebody's system. All physicians should be using electronic prescribing right? It is only a matter of time before politicians mandate access and an extremely expensive portal will be required.
There was a time when the medical record was coherent. Maybe I was spoiled by reading what sounded like fine literature by comparison. There was one Cardiologist in particular who wrote incredible notes for consults. Reading those notes gave you all of the medical information you needed and it also left the impression that you had just read something written by a highly intelligent person. Somebody you probably wanted to have a conversation with. Somebody you could learn from.
What has happened to the medical record leaves a bad taste in my mouth. It reminds me of when an EHR consultant was showing me their latest time saving way to create a choppy, incoherent progress note, and sign off on a billing document at the same time. She assured me that the "compliance people" would find it completely acceptable for billing purposes. When she asked me what of thought of their system she seemed taken aback by my response.
"I would be ashamed to sign my name on that note."
That was about ten years ago and the electronic health record has not changed much since. It will still kick out a phone book sized print out containing minimal to no useful information.
George Dawson, MD, DFAPA
Let's suppose you are working in a clinic that is not online with the largest managed care (MCO) company in your area. The only way you can get electronic access is to pay a huge licensing fee, but in many cases the software company will not even accept that licensing fee. It will just conclude that that you are not big enough to do business with them. At any rate, you need electrocardiogram information on a patient from that MCO because you are looking at a new abnormal ECG on that patient. You need to know if the pattern on that ECG is new or it has always been there. You request the records from the MCO. They fax you 50 pages containing the lowest possible amount of information per page. There are two one line references in that 50 pages to an electrocardiogram. One says: "Prolonged QTc" and the other says "Normal". There is no graphic information (the tracing) and no numerical information (the intervals with the associated times in milliseconds, the machine read out). So after the work put in by you and your staff to request this data, you have just read through 50 pages and found absolutely nothing useful. A review of all of the pages shows scant information on each page. As an example, one entire page contains a chest x-ray report, when it could easily be printed on an area 1/20th that size. Some entire sheets contain 1 or 2 lab values of 3 to 5 digit numbers.
I am convinced that the multimillion dollar licensed legacy wide EHRs are designed this way. There is really no other explanation for providing such an abundance of low to no information records. Their intention is obvious. Make sure everyone is using their system and at some point make sure that the government is forcing people to use somebody's system. All physicians should be using electronic prescribing right? It is only a matter of time before politicians mandate access and an extremely expensive portal will be required.
There was a time when the medical record was coherent. Maybe I was spoiled by reading what sounded like fine literature by comparison. There was one Cardiologist in particular who wrote incredible notes for consults. Reading those notes gave you all of the medical information you needed and it also left the impression that you had just read something written by a highly intelligent person. Somebody you probably wanted to have a conversation with. Somebody you could learn from.
What has happened to the medical record leaves a bad taste in my mouth. It reminds me of when an EHR consultant was showing me their latest time saving way to create a choppy, incoherent progress note, and sign off on a billing document at the same time. She assured me that the "compliance people" would find it completely acceptable for billing purposes. When she asked me what of thought of their system she seemed taken aback by my response.
"I would be ashamed to sign my name on that note."
That was about ten years ago and the electronic health record has not changed much since. It will still kick out a phone book sized print out containing minimal to no useful information.
George Dawson, MD, DFAPA
Monday, March 17, 2014
Turning the United States Into Radioactive Dust
I don't know if you noticed, but it appears that the post cold war era is over. The Putin appointed head of a Russian news agency Dmitry Kiselyov went on Russian television this morning and stated that Russia is "the only country in the world capable of turning the USA into radioactive dust." In case anyone wanted to dismiss that as being short of a threat, he went on to say the President Obama's hair was turning gray because he was worried about Russia's nuclear arsenal. We have not heard that kind of serious rhetoric since the actual Cold War. As a survivor of the Cold War, I went back and looked at what time period it ran for and although it is apparently controversial the dates 1947 to 1991 are commonly cited. I can remember writing a paper in middle school on the doctrine of mutually assured destruction as the driving force behind the Cold War. In the time I have thought about it since, some of the cool heads that prevented nuclear war were in the military and in many if not most cases Russian. We probably need to hope that they are still out there rather than an irresponsible broadcaster who may not realize that if the US is dust, irrespective of what happens to Russia as a result of weapons, the planet will be unlivable.
I am by nature a survivalist of sorts. And when I detect the Cold War heating up again I start to plan for the worst. The survivalist credo is that we are all 9 meals away from total chaos. So I start to think about how much food, water, and medicines I will have to stockpile. What king of power generation system will I need? What about heating, ventilation and air filtration? And what about access? There are currently condominiums being sold in old hardened missile silos, but what are the odds that you will be able to travel hundreds of miles after a nuclear attack? If you are close to the explosion there will be fallout and the EMP burst will probably knock out the ignition of your vehicle unless you have the foresight and resources to store it inside a Faraday cage every night. There is also the question of what happens to the psychology of your fellow survivors. In the post apocalyptic book The Road - a man and his son are surviving in the bleakest of circumstances on the road. We learn through a series of flashbacks that their wife and mother could not adapt to the survivalist atmosphere and ended her life. In one scene, they meet an old man on the road and the man gets into the following exchange with him after the old man says he knew the apocalyptic event was coming. It captures the paradox of being a survivalist (pp 168-169):
Man: "Did you try to get ready for it?"
Old Man: "No. What would you do?"
Man: "I don't know"
Old Man: "People always getting ready for tomorrow. I didn't believe in that. Tomorrow wasn't getting ready for them. It didn't even know they were there."
Man: "I guess not."
Old Man: "Even if you knew what to do you wouldn't know what to do. You wouldn't know if you wanted to do it or not. Suppose your were the last one left? Suppose you did that to yourself?"
By my own informal polling there are very few people who want to unconditionally survive - either a man-made or natural disaster. Many have told me that they could not stand to be in their basement for more than a few hours, much less days or months or years.
For the purpose of this post, I want to hone in on the rhetoric or more specifically the threats. I have had previous posts on this blog that look at how this rhetoric flows from the history of warfare and dates back to a typical situation with primitive man. In those days, the goal of warfare was the annihilation of your neighbors. In many cases, the precipitants were trivial like the theft of a small number of livestock or liaisons between men and women of opposing tribes. In tribes of small numbers of people, even when there were survivors if enough were killed it could mean the extinction of a certain people. Primitive man seemed to think: "My adversaries are gone and the problem is solved."
Over time, the fighting was given to professional soldiers and it seemed more formalized. There were still millions of civilian casualties. I think at least part of the extreme rhetoric of Kielyov is rooted in that dynamic. Many will say that is is propaganda or statements being made for political advantage and in this case there are the possible factors of nationalism or just anger at the US for some primitive rhetoric of its own. But I do not think that a statement like this can be dismissed without merit. There were for example two incidents where Russian military officers exercised a degree of restraint that in all probability prevented a nuclear war. In one of those cases the officer was penalized for exercising restraint even though he probably avoided a full scale nuclear war. In both cases the officers looked into the abyss and realized that they did not want to be responsible for the end of civilization as we know it.
I don't think extreme rhetoric is limited to international politics. It certainly happens with every form of intolerance at one point or another if that intolerance is rooted in race, religions or sexual preference. That is especially true if there are physical threats and physical aggression. Intolerant rhetoric can also occur at a more symbolic level. We have seen extreme rhetoric on psychiatry blogs recently. Rather than the annihilation of the United States, the posters would prefer the annihilation of psychiatry. I would say it is a symbolic annihilation but it is clear that many of them want more than that. It still flows from the sense of loyalty to tribe, the need to annihilate the opponents, the necessary rigid intolerance and the resulting distortion of rational thought. Certainly self serving bias exists to some extent in everyone, and it may not be that apparent to the biased person. It took Ioannidis to open everyone's eyes to that fact in the more rational scientific world. It can serve a purpose in science where the active process often requires a vigorous dialogue and debate. Sometimes people mistake science for the truth when science is a process. In order for that dialogue and debate to occur in an academic field there has to be a basic level of scholarship in the area being debated. Without it there is a digression to tribal annihilation dynamics and complete intolerance. That is counterproductive and negates any legitimate points that the proponents might otherwise have.
In science, the risks are lower. At the minimum it adds nothing to the scientific debate. An irrational bias with no basis in reality is the most primitive level of analysis. In the 21st century, nobody needs to be annihilated in reality or at the symbolic level.
George Dawson, MD, DFAPA
Cormac McCarthy. The Road. Vintage Books. New York, 2006.
I am by nature a survivalist of sorts. And when I detect the Cold War heating up again I start to plan for the worst. The survivalist credo is that we are all 9 meals away from total chaos. So I start to think about how much food, water, and medicines I will have to stockpile. What king of power generation system will I need? What about heating, ventilation and air filtration? And what about access? There are currently condominiums being sold in old hardened missile silos, but what are the odds that you will be able to travel hundreds of miles after a nuclear attack? If you are close to the explosion there will be fallout and the EMP burst will probably knock out the ignition of your vehicle unless you have the foresight and resources to store it inside a Faraday cage every night. There is also the question of what happens to the psychology of your fellow survivors. In the post apocalyptic book The Road - a man and his son are surviving in the bleakest of circumstances on the road. We learn through a series of flashbacks that their wife and mother could not adapt to the survivalist atmosphere and ended her life. In one scene, they meet an old man on the road and the man gets into the following exchange with him after the old man says he knew the apocalyptic event was coming. It captures the paradox of being a survivalist (pp 168-169):
Man: "Did you try to get ready for it?"
Old Man: "No. What would you do?"
Man: "I don't know"
Old Man: "People always getting ready for tomorrow. I didn't believe in that. Tomorrow wasn't getting ready for them. It didn't even know they were there."
Man: "I guess not."
Old Man: "Even if you knew what to do you wouldn't know what to do. You wouldn't know if you wanted to do it or not. Suppose your were the last one left? Suppose you did that to yourself?"
By my own informal polling there are very few people who want to unconditionally survive - either a man-made or natural disaster. Many have told me that they could not stand to be in their basement for more than a few hours, much less days or months or years.
For the purpose of this post, I want to hone in on the rhetoric or more specifically the threats. I have had previous posts on this blog that look at how this rhetoric flows from the history of warfare and dates back to a typical situation with primitive man. In those days, the goal of warfare was the annihilation of your neighbors. In many cases, the precipitants were trivial like the theft of a small number of livestock or liaisons between men and women of opposing tribes. In tribes of small numbers of people, even when there were survivors if enough were killed it could mean the extinction of a certain people. Primitive man seemed to think: "My adversaries are gone and the problem is solved."
Over time, the fighting was given to professional soldiers and it seemed more formalized. There were still millions of civilian casualties. I think at least part of the extreme rhetoric of Kielyov is rooted in that dynamic. Many will say that is is propaganda or statements being made for political advantage and in this case there are the possible factors of nationalism or just anger at the US for some primitive rhetoric of its own. But I do not think that a statement like this can be dismissed without merit. There were for example two incidents where Russian military officers exercised a degree of restraint that in all probability prevented a nuclear war. In one of those cases the officer was penalized for exercising restraint even though he probably avoided a full scale nuclear war. In both cases the officers looked into the abyss and realized that they did not want to be responsible for the end of civilization as we know it.
I don't think extreme rhetoric is limited to international politics. It certainly happens with every form of intolerance at one point or another if that intolerance is rooted in race, religions or sexual preference. That is especially true if there are physical threats and physical aggression. Intolerant rhetoric can also occur at a more symbolic level. We have seen extreme rhetoric on psychiatry blogs recently. Rather than the annihilation of the United States, the posters would prefer the annihilation of psychiatry. I would say it is a symbolic annihilation but it is clear that many of them want more than that. It still flows from the sense of loyalty to tribe, the need to annihilate the opponents, the necessary rigid intolerance and the resulting distortion of rational thought. Certainly self serving bias exists to some extent in everyone, and it may not be that apparent to the biased person. It took Ioannidis to open everyone's eyes to that fact in the more rational scientific world. It can serve a purpose in science where the active process often requires a vigorous dialogue and debate. Sometimes people mistake science for the truth when science is a process. In order for that dialogue and debate to occur in an academic field there has to be a basic level of scholarship in the area being debated. Without it there is a digression to tribal annihilation dynamics and complete intolerance. That is counterproductive and negates any legitimate points that the proponents might otherwise have.
In science, the risks are lower. At the minimum it adds nothing to the scientific debate. An irrational bias with no basis in reality is the most primitive level of analysis. In the 21st century, nobody needs to be annihilated in reality or at the symbolic level.
George Dawson, MD, DFAPA
Cormac McCarthy. The Road. Vintage Books. New York, 2006.
Sunday, March 16, 2014
Persecutory Delusions, Psychiatric Treatment, and Violence Prevention
For 23 years I ran an acute care inpatient service where the main focus was preventing violence and suicide. That is the default function of inpatient units these days and it has been decided by businesses and governments rather than organized psychiatry. Organized psychiatry used to take an interest in quality care in hospitals but it has largely been abandoned to the hospitals and organizations that run them. The regulatory bodies for inpatient care tend to focus on a number of parameters that are irrelevant to quality care. With such a fragmented regulatory and administrative approach, the focus on quality of care depends solely on the personnel on each unit and how well they work together as a team. The majority of patients are admitted these days because of concerns about aggressive behavior and suicide. In my experience, good inpatient teams are highly successful in assessing and treating those problems.
One of the key treatment interventions is determining the people with the highest risk potential for the most intensive treatment interventions. The treatment outcomes in terms of averting aggressive and suicidal behaviors are generally good. Given the relatively rare occurrence of aggression or suicide post discharge the actual power of the treatment intervention is unknown. The potential severity of outcomes precludes any placebo controlled clinical trials. No human subjects committee would authorize a placebo arm and since many patients are on involuntary status or court holds. No probate court judge would go along with it either.
The March 2014 edition of the American Journal of Psychiatry has some the most most extraordinary content I have ever noticed in that publication. Among the articles is a paper called "Association of Violence With Emergence of Persecutory Delusions in Untreated Schizophrenia". It adds significantly to the literature on psychosis and violence. The study focuses on the United Kingdom Prisoner Cohort Study and it looked at risk factors for future violence in prisoners who were incarcerated for a violent crime after they were released. It is a study that could be done on patients who were acutely hospitalized and released because of the naturalistic design and use of nonviolent participants as a comparison group. That authors were interested in looking at whether the presence of psychosis predicted future violence and if there was any specific pattern of symptoms. They were also interested in looking at the issue of whether or not treatment was helpful.
The sample consisted of 1,717 prisoner screened at baseline and 967 followed up (787 men and 180 women). Selection was based on incarceration for at least 2 years for a violent crime and release date within 12 months of the start of the study. All participants were given a number of structured research assessments to establish diagnosis. At follow up, the diagnoses of the patients in the study included 94 meeting diagnostic criteria for schizophrenia, 102 for drug induced psychosis, and 29 for delusional disorder. Only the subgroup with schizophrenia scored higher on psychopathy scores. Violent behavior at follow up was established by self-report and a national computer police database that classified violence against persons. According to that database 22.9% of participants were violent between release and follow up (mean 39.2 weeks).
In terms of the relevant results, the delusional disorder and drug induced psychosis subgroups were no more likely than the the participants without psychosis to be violent at follow up. Persons with untreated schizophrenia were more than three times as likely to be violent that the non-psychotic participants at follow up. In that group those with persecutory delusions were more likely to be violent than those with other symptoms of psychosis. The authors briefly review the indirect evidence supporting their findings including treatment non-adherence and risk of violence, risk of violence at first presentation of treatment rather than subsequent episodes, and psychosis as a risk factor for violence. They point out that to their knowledge this is the only study of violent recidivism in prisoners that looks at the issue of psychosis as a risk factor.
The actual treatment provided in this case was critical. In terms of violence prevention any treatment provided in prison only or in prison and on release was effective in preventing violence. They point out that identification of more people needing treatment by their study methodology may have led to more active treatment of study participants. They quote data on that fact that in prisons in the UK only about 1/4 of prisoners with severe mental illnesses are identified by mental health teams with that specific function and that of those identified only 13% are accepted into case management. Overall in the UK less than 1/4 of prisoners who screen positive for psychosis are given a mental health appointment at the time of discharge.
The accompanying editorial by Large is interesting in reviewing the issue of screening versus not screening populations for psychosis and whether that prevent violence. Several studies have concluded that "risk assessment is insufficiently sensitive to provide a basis for protection of the public." Without looking at all of the references (I would expect to find significant flaws) the issue is really not a screening issue. This study happens to appear like it is a screening, but the diagnostic approach is probably much more vigorous than most assessments in correctional settings. The issue is that you have a person sitting in front of you telling you that they have persecutory delusions and are at risk for continued violence secondary to those delusions. There is also a significant subgroup who are at personal risk for self harm related to these delusions that the authors either did not find or they did not comment on. The Large commentary also focuses on antipsychotic medication as the treatment for psychosis and in the UK psychotherapy is also a treatment modality. He makes the observation that treatment across the entire spectrum is important in that less treatment in the currently treat group will also result in more violence.
This study is useful in the US for several reasons. County jails have become the largest psychiatric hospitals in the United States largely as a result of government and business policy. Inpatient units may be useful for acute violence but there is an uneasy relationship with county jails. Hospital policy may result in suicidal and acutely aggressive psychotic patient being treated in jail settings and using methods that would be seen as completely inappropriate in a medical or psychiatric setting. Psychiatric follow up in jail settings is often fragmented and it is not uncommon to see medical treatment started and stopped based on the availability of medical staff or prescription medications. I would consider the UK to be much more enlightened with regard to mental health policy than the US and to have more medically based resources for anyone with a psychosis diagnosis. I can't imagine follow up numbers from American jails being any better than they are in the UK.
All of this creates a problem for the person with psychosis, persecutory delusions, and violent behavior. The focus of much of the literature seems to be protecting the public from them but when you are their treating psychiatrist the arguments you are making to them is to protect them from their delusional thoughts. That will not happen in a rationed, carved out environment that has shifted progressively more care for the severely mentally ill to correctional settings. The other interesting cultural phenomenon is that there is no coverage of this study or similar studies in the press. Their bias seems to be to look at the sensational results of psychosis associated violent crime, suggest that more treatment might be needed, attribute causation to being in the wrong place at the wrong time, and suggest that we all need to move on (lurch forward?) toward the next catastrophe.
This study provides a platform for a better approach to public policy and a more patient centric approach to violence prevention.
George Dawson, MD, DFAPA
1: Keers R, Ullrich S, Destavola BL, Coid JW. Association of violence with emergence of persecutory delusions in untreated schizophrenia. Am J Psychiatry. 2014 Mar 1;171(3):332-9. doi: 10.1176/appi.ajp.2013.13010134. PubMed PMID: 24220644.
One of the key treatment interventions is determining the people with the highest risk potential for the most intensive treatment interventions. The treatment outcomes in terms of averting aggressive and suicidal behaviors are generally good. Given the relatively rare occurrence of aggression or suicide post discharge the actual power of the treatment intervention is unknown. The potential severity of outcomes precludes any placebo controlled clinical trials. No human subjects committee would authorize a placebo arm and since many patients are on involuntary status or court holds. No probate court judge would go along with it either.
The March 2014 edition of the American Journal of Psychiatry has some the most most extraordinary content I have ever noticed in that publication. Among the articles is a paper called "Association of Violence With Emergence of Persecutory Delusions in Untreated Schizophrenia". It adds significantly to the literature on psychosis and violence. The study focuses on the United Kingdom Prisoner Cohort Study and it looked at risk factors for future violence in prisoners who were incarcerated for a violent crime after they were released. It is a study that could be done on patients who were acutely hospitalized and released because of the naturalistic design and use of nonviolent participants as a comparison group. That authors were interested in looking at whether the presence of psychosis predicted future violence and if there was any specific pattern of symptoms. They were also interested in looking at the issue of whether or not treatment was helpful.
The sample consisted of 1,717 prisoner screened at baseline and 967 followed up (787 men and 180 women). Selection was based on incarceration for at least 2 years for a violent crime and release date within 12 months of the start of the study. All participants were given a number of structured research assessments to establish diagnosis. At follow up, the diagnoses of the patients in the study included 94 meeting diagnostic criteria for schizophrenia, 102 for drug induced psychosis, and 29 for delusional disorder. Only the subgroup with schizophrenia scored higher on psychopathy scores. Violent behavior at follow up was established by self-report and a national computer police database that classified violence against persons. According to that database 22.9% of participants were violent between release and follow up (mean 39.2 weeks).
In terms of the relevant results, the delusional disorder and drug induced psychosis subgroups were no more likely than the the participants without psychosis to be violent at follow up. Persons with untreated schizophrenia were more than three times as likely to be violent that the non-psychotic participants at follow up. In that group those with persecutory delusions were more likely to be violent than those with other symptoms of psychosis. The authors briefly review the indirect evidence supporting their findings including treatment non-adherence and risk of violence, risk of violence at first presentation of treatment rather than subsequent episodes, and psychosis as a risk factor for violence. They point out that to their knowledge this is the only study of violent recidivism in prisoners that looks at the issue of psychosis as a risk factor.
The actual treatment provided in this case was critical. In terms of violence prevention any treatment provided in prison only or in prison and on release was effective in preventing violence. They point out that identification of more people needing treatment by their study methodology may have led to more active treatment of study participants. They quote data on that fact that in prisons in the UK only about 1/4 of prisoners with severe mental illnesses are identified by mental health teams with that specific function and that of those identified only 13% are accepted into case management. Overall in the UK less than 1/4 of prisoners who screen positive for psychosis are given a mental health appointment at the time of discharge.
The accompanying editorial by Large is interesting in reviewing the issue of screening versus not screening populations for psychosis and whether that prevent violence. Several studies have concluded that "risk assessment is insufficiently sensitive to provide a basis for protection of the public." Without looking at all of the references (I would expect to find significant flaws) the issue is really not a screening issue. This study happens to appear like it is a screening, but the diagnostic approach is probably much more vigorous than most assessments in correctional settings. The issue is that you have a person sitting in front of you telling you that they have persecutory delusions and are at risk for continued violence secondary to those delusions. There is also a significant subgroup who are at personal risk for self harm related to these delusions that the authors either did not find or they did not comment on. The Large commentary also focuses on antipsychotic medication as the treatment for psychosis and in the UK psychotherapy is also a treatment modality. He makes the observation that treatment across the entire spectrum is important in that less treatment in the currently treat group will also result in more violence.
This study is useful in the US for several reasons. County jails have become the largest psychiatric hospitals in the United States largely as a result of government and business policy. Inpatient units may be useful for acute violence but there is an uneasy relationship with county jails. Hospital policy may result in suicidal and acutely aggressive psychotic patient being treated in jail settings and using methods that would be seen as completely inappropriate in a medical or psychiatric setting. Psychiatric follow up in jail settings is often fragmented and it is not uncommon to see medical treatment started and stopped based on the availability of medical staff or prescription medications. I would consider the UK to be much more enlightened with regard to mental health policy than the US and to have more medically based resources for anyone with a psychosis diagnosis. I can't imagine follow up numbers from American jails being any better than they are in the UK.
All of this creates a problem for the person with psychosis, persecutory delusions, and violent behavior. The focus of much of the literature seems to be protecting the public from them but when you are their treating psychiatrist the arguments you are making to them is to protect them from their delusional thoughts. That will not happen in a rationed, carved out environment that has shifted progressively more care for the severely mentally ill to correctional settings. The other interesting cultural phenomenon is that there is no coverage of this study or similar studies in the press. Their bias seems to be to look at the sensational results of psychosis associated violent crime, suggest that more treatment might be needed, attribute causation to being in the wrong place at the wrong time, and suggest that we all need to move on (lurch forward?) toward the next catastrophe.
This study provides a platform for a better approach to public policy and a more patient centric approach to violence prevention.
George Dawson, MD, DFAPA
1: Keers R, Ullrich S, Destavola BL, Coid JW. Association of violence with emergence of persecutory delusions in untreated schizophrenia. Am J Psychiatry. 2014 Mar 1;171(3):332-9. doi: 10.1176/appi.ajp.2013.13010134. PubMed PMID: 24220644.
2: Large MM. Treatment of psychosis and risk assessment for violence. Am J
Psychiatry. 2014 Mar 1;171(3):256-8. doi: 10.1176/appi.ajp.2013.13111479. PubMed
PMID: 24585326.
Monday, March 10, 2014
Satanic Ritualistic Abuse - Revisited?
Mickey Nardo, MD on his 1 BoringOldMan blog has been writing a lot about the issue of satanic ritualistic abuse or SRA as it has been abbreviated. His key reference is an article in the Psychiatric Times by Richard Noll, PhD entitled When Psychiatry Battled the Devil. Dr. Nardo details the fact that the original paper by Noll has been pulled apparently out of concerns about litigation. I luckily printed it out and will add a different perspective to Dr. Noll's invitation to discuss the moral panic.
It was about 1989 and the era of satanic ritualistic abuse was born. I was in the middle of running a public health clinic on the northern fringe of the United States at the time and did not see any cases until I moved south to the Twin Cities (Minneapolis-St. Paul, MN). Showalter documents how the stories spread in the media until there was a fairly standard description of women "... forced to kill and eat babies at satanic ceremonies, about seeing children dismembered boiled an burned, about being drugged, tortured with cattle prods, branded with branding irons, raped with crucifixes and animal carcasses....." (p. 172). As the stories intensified prosecutions occurred in some areas based on these stories. After all, the alleged magnitude of these rituals would have left a significant amount of eye-witness and physical evidence. But it turned out that was never found. There were parallel phenomena of false prosecutions based on these accusations and ultimately malpractice cases against therapists making the diagnosis and proceeding with treatment on the basis of traumatic events that had never occurred and seemed to be introduced as a result of the therapy.
I started to see the initial traces of the multiple personality epidemic at my new job, and recall two distinct reactions from psychiatrists involved with these folks. But before I get into that, a little background about psychiatric interviewing is in order. In this era of rapid checklist diagnoses, it may be difficult to believe that psychiatrists are actually trained to interview people and question what they hear. The questions naturally come up for a number of reasons. The first has to do with how accurate the patient seems to be able to recall the history. That leads to associated questions about any inability to recall the history. The second has to do with common distortions that patients have in their perception of reality. Those distortions may occur at a neurotic or a psychotic level of consciousness. In the initial interview the focus is on understanding the patient's mental state to the point that if it was repeated back to the person they would agree with the interpretation. That interview process can be interrupted for any number of reasons along the way, ranging from cognitive disorganization to paranoid psychosis and aggressive behavior. It is important to keep in mind that the interview is a dynamic process that has elements far beyond a checklist or list of symptoms in DSM-5. Reading about confabulation is not the same thing as having assessed hundreds of patients with that problem. That assessment flows from the initial question in the mind of the psychiatrist: "Is this confabulation?' and noting all of the features in the interview situation to support or refute that question.
Of the psychiatrists I was affiliated with at the time, a few believed that there was such a diagnostic entity as dissociative identity disorder but the majority (as in >90%) did not. The psychiatric literature as early as 1988 doubted the existence of the disorder and suggested that it was iatrogenic. I can recall a journal club discussion we had about a British Journal of Psychiatry article that was not only skeptical of the diagnosis but suggested that it was iatrogenic. It seemed like a geographically based movement and in order to make the diagnoses and treat people you had to be trained by very specific people. Even though the diagnostic criteria were fairly straightforward it seemed like you needed the attend the appropriate seminars in order to make the diagnosis. You definitely did if you expected to proceed with treatment and even then it was unclear about how much additional training was necessary. I had the impression that most people affected had moderate to severe personality disorders and they could be approached using standard techniques. That approach was highly successful in stabilizing people in acute care and transitioning them to outpatient settings. The diagnosis could be reinforced by the time patients presented to a tertiary care center. Any hint of skepticism on the part of the attending physician could precipitate intense reactions if the patients thought they were not believed. That usually threatened any therapeutic relationship, created staff splitting, and great pressure on psychiatrists to accept the diagnosis and whatever the current treatment plan was at the time. There was also the novelty of the diagnosis that held a certain fascination for anyone who could not see that there was more heat than light.
At the time I was dutifully reading volumes of the Annual Review of Psychiatry and completing the CME questions. Volume 10 had an entire section on Dissociative Disorders with some optimistic introductory lines (p 143):
"Dissociation is here to stay. The chapters that follow indicate there is a growing body of clinical observation and research documenting the prevalence, phenomenology, psychophysiology, and treatment of dissociation."
What happened instead was a flattening of publications as indicated by this Microsoft academic search and the end of a specialty journal (click to enlarge)
Despite the solid review that SRA probably did not exist, some bizarre reports began to surface. According to Elaine Showalter's book Hystories: hysterical epidemics and modern media:
"....almost half the patients.......were "reporting vividly detailed memories of cannibalistic revels and extensive experiences such as being used by cults during adolescence as serial baby breeders for ritual sacrifices."
My position on the subject has always been the position quoted by Elaine Showalter in her excellent book Hystories: hysterical epidemics and modern media. That position is all of these events never happened. But I took it one step further. Near the end of the decade, I contacted the author to see if she had any updated information. She did not and so I put in a Freedom of Information Act request for all of the information suggested in the book - specifically the results of of the investigations by Kenneth V. Lanning, then Special Agent of the FBI Behavioral Science Unit in Quantico, Virginia. I have previously listed problems with FOIA requests to the FBI and this was no exception. I was looking for the results of 300 case investigations that were all negative. After sending in the request through proper channels I was told that the information did not exist. In the 2000s, that report surfaced on the Internet, but it is still difficult to find a reliable copy.
I invite any reader to place themselves in the position of interviewing a person making claims, like the statements made in paragraph two of this post. Keep in mind that these patients are generally talking about local geography that everyone is aware of and the descriptions involve fairly massive abuse and homicide of large numbers of people. Even an untrained interviewer should have a degree of skepticism based on the fact that there have not been large numbers of missing persons and when these reports invariably get to local law enforcement, no hard evidence of a crime can be found. The reports did create considerable confusion among family members, prosecuting attorneys, inpatient staff and some psychiatrists but in the end even the psychiatrists who thought the SRA phenomenon was real realized that it was a distortion.
In answer to the idea that this era needs to be "reopened" I guess it depends on the intent. If the intent to illustrate once again that some or all psychiatrists are fools - there is more than enough propaganda out there already for the detractors of psychiatry to use. My perspective is that not only were the vast majority of psychiatrists not fooled by this phenomena there were articles at the time accurately describing the problem as a non-specific diagnosis and an iatrogenic problem and what to do about it. I would also question the applicability of the term moral panic. The phrase seems a bit too strong. It could apply in very small areas, but the majority of people in any community were generally unaware of the stories that were being told to psychiatrists in that era. If people were aware there would have been a larger buzz created by the media asking clinicians for examples and an analysis of the event. I suppose it would have been interesting to see what the local investigative news team found out if they were directed to a site where ritualistic abuse was alleged to have occurred. I would also not forget that in the majority of cases there were no attempted prosecutions. I think the moral panic was forgotten because for most people it was under their radar rather than a cataclysmic event like the Influenza Pandemic of 1918 where people were dropping dead in the streets. There were also psychiatrists at the time who investigated the issue of repression and false memory syndrome and became an asset to families affected by the hysteria. I would Showalter's book for a good discussion of the cultural determinants of the problem (there were many). If the suggestion is to reopen the issue with the appropriate perspective that it was a controversial and erroneous phenomenon that in some cases hurt individuals and families rather than a moral panic, that mistakes were made, and for the purpose of teaching appropriate evaluations and interviewing technique, then I am all for it. In addition to diagnostic issues, the area of dissociation and trauma in general also have treatment implications. Psychiatric residents need to know how to plan and conduct therapy on affected individuals, particularly since the main part of that treatment does not involve medications. They also need to know how to interview people without introducing artifacts as part of the interview process.
If the Psychiatric Times has pulled the original article, it probably makes sense to write a book or a review article for a journal less concerned about litigation. There are a number of public access online journals that I am sure would be willing to publish the article and probably consider a theme issue on the topic.
George Dawson, MD, DFAPA
Elaine Showalter. Hystories: hysterical epidemics and modern media. Columbia University Press. New York, 1997.
Merskey H. Multiple personality disorder and false memory syndrome. Br J Psychiatry. 1995 Mar;166(3):281-3. PubMed PMID: 7788115.
Piper A Jr. Multiple personality disorder. Br J Psychiatry. 1994 May;164(5):600-12. Review. PubMed PMID: 7921709.
It was about 1989 and the era of satanic ritualistic abuse was born. I was in the middle of running a public health clinic on the northern fringe of the United States at the time and did not see any cases until I moved south to the Twin Cities (Minneapolis-St. Paul, MN). Showalter documents how the stories spread in the media until there was a fairly standard description of women "... forced to kill and eat babies at satanic ceremonies, about seeing children dismembered boiled an burned, about being drugged, tortured with cattle prods, branded with branding irons, raped with crucifixes and animal carcasses....." (p. 172). As the stories intensified prosecutions occurred in some areas based on these stories. After all, the alleged magnitude of these rituals would have left a significant amount of eye-witness and physical evidence. But it turned out that was never found. There were parallel phenomena of false prosecutions based on these accusations and ultimately malpractice cases against therapists making the diagnosis and proceeding with treatment on the basis of traumatic events that had never occurred and seemed to be introduced as a result of the therapy.
I started to see the initial traces of the multiple personality epidemic at my new job, and recall two distinct reactions from psychiatrists involved with these folks. But before I get into that, a little background about psychiatric interviewing is in order. In this era of rapid checklist diagnoses, it may be difficult to believe that psychiatrists are actually trained to interview people and question what they hear. The questions naturally come up for a number of reasons. The first has to do with how accurate the patient seems to be able to recall the history. That leads to associated questions about any inability to recall the history. The second has to do with common distortions that patients have in their perception of reality. Those distortions may occur at a neurotic or a psychotic level of consciousness. In the initial interview the focus is on understanding the patient's mental state to the point that if it was repeated back to the person they would agree with the interpretation. That interview process can be interrupted for any number of reasons along the way, ranging from cognitive disorganization to paranoid psychosis and aggressive behavior. It is important to keep in mind that the interview is a dynamic process that has elements far beyond a checklist or list of symptoms in DSM-5. Reading about confabulation is not the same thing as having assessed hundreds of patients with that problem. That assessment flows from the initial question in the mind of the psychiatrist: "Is this confabulation?' and noting all of the features in the interview situation to support or refute that question.
Of the psychiatrists I was affiliated with at the time, a few believed that there was such a diagnostic entity as dissociative identity disorder but the majority (as in >90%) did not. The psychiatric literature as early as 1988 doubted the existence of the disorder and suggested that it was iatrogenic. I can recall a journal club discussion we had about a British Journal of Psychiatry article that was not only skeptical of the diagnosis but suggested that it was iatrogenic. It seemed like a geographically based movement and in order to make the diagnoses and treat people you had to be trained by very specific people. Even though the diagnostic criteria were fairly straightforward it seemed like you needed the attend the appropriate seminars in order to make the diagnosis. You definitely did if you expected to proceed with treatment and even then it was unclear about how much additional training was necessary. I had the impression that most people affected had moderate to severe personality disorders and they could be approached using standard techniques. That approach was highly successful in stabilizing people in acute care and transitioning them to outpatient settings. The diagnosis could be reinforced by the time patients presented to a tertiary care center. Any hint of skepticism on the part of the attending physician could precipitate intense reactions if the patients thought they were not believed. That usually threatened any therapeutic relationship, created staff splitting, and great pressure on psychiatrists to accept the diagnosis and whatever the current treatment plan was at the time. There was also the novelty of the diagnosis that held a certain fascination for anyone who could not see that there was more heat than light.
At the time I was dutifully reading volumes of the Annual Review of Psychiatry and completing the CME questions. Volume 10 had an entire section on Dissociative Disorders with some optimistic introductory lines (p 143):
"Dissociation is here to stay. The chapters that follow indicate there is a growing body of clinical observation and research documenting the prevalence, phenomenology, psychophysiology, and treatment of dissociation."
What happened instead was a flattening of publications as indicated by this Microsoft academic search and the end of a specialty journal (click to enlarge)
Despite the solid review that SRA probably did not exist, some bizarre reports began to surface. According to Elaine Showalter's book Hystories: hysterical epidemics and modern media:
"....almost half the patients.......were "reporting vividly detailed memories of cannibalistic revels and extensive experiences such as being used by cults during adolescence as serial baby breeders for ritual sacrifices."
My position on the subject has always been the position quoted by Elaine Showalter in her excellent book Hystories: hysterical epidemics and modern media. That position is all of these events never happened. But I took it one step further. Near the end of the decade, I contacted the author to see if she had any updated information. She did not and so I put in a Freedom of Information Act request for all of the information suggested in the book - specifically the results of of the investigations by Kenneth V. Lanning, then Special Agent of the FBI Behavioral Science Unit in Quantico, Virginia. I have previously listed problems with FOIA requests to the FBI and this was no exception. I was looking for the results of 300 case investigations that were all negative. After sending in the request through proper channels I was told that the information did not exist. In the 2000s, that report surfaced on the Internet, but it is still difficult to find a reliable copy.
I invite any reader to place themselves in the position of interviewing a person making claims, like the statements made in paragraph two of this post. Keep in mind that these patients are generally talking about local geography that everyone is aware of and the descriptions involve fairly massive abuse and homicide of large numbers of people. Even an untrained interviewer should have a degree of skepticism based on the fact that there have not been large numbers of missing persons and when these reports invariably get to local law enforcement, no hard evidence of a crime can be found. The reports did create considerable confusion among family members, prosecuting attorneys, inpatient staff and some psychiatrists but in the end even the psychiatrists who thought the SRA phenomenon was real realized that it was a distortion.
In answer to the idea that this era needs to be "reopened" I guess it depends on the intent. If the intent to illustrate once again that some or all psychiatrists are fools - there is more than enough propaganda out there already for the detractors of psychiatry to use. My perspective is that not only were the vast majority of psychiatrists not fooled by this phenomena there were articles at the time accurately describing the problem as a non-specific diagnosis and an iatrogenic problem and what to do about it. I would also question the applicability of the term moral panic. The phrase seems a bit too strong. It could apply in very small areas, but the majority of people in any community were generally unaware of the stories that were being told to psychiatrists in that era. If people were aware there would have been a larger buzz created by the media asking clinicians for examples and an analysis of the event. I suppose it would have been interesting to see what the local investigative news team found out if they were directed to a site where ritualistic abuse was alleged to have occurred. I would also not forget that in the majority of cases there were no attempted prosecutions. I think the moral panic was forgotten because for most people it was under their radar rather than a cataclysmic event like the Influenza Pandemic of 1918 where people were dropping dead in the streets. There were also psychiatrists at the time who investigated the issue of repression and false memory syndrome and became an asset to families affected by the hysteria. I would Showalter's book for a good discussion of the cultural determinants of the problem (there were many). If the suggestion is to reopen the issue with the appropriate perspective that it was a controversial and erroneous phenomenon that in some cases hurt individuals and families rather than a moral panic, that mistakes were made, and for the purpose of teaching appropriate evaluations and interviewing technique, then I am all for it. In addition to diagnostic issues, the area of dissociation and trauma in general also have treatment implications. Psychiatric residents need to know how to plan and conduct therapy on affected individuals, particularly since the main part of that treatment does not involve medications. They also need to know how to interview people without introducing artifacts as part of the interview process.
If the Psychiatric Times has pulled the original article, it probably makes sense to write a book or a review article for a journal less concerned about litigation. There are a number of public access online journals that I am sure would be willing to publish the article and probably consider a theme issue on the topic.
George Dawson, MD, DFAPA
Elaine Showalter. Hystories: hysterical epidemics and modern media. Columbia University Press. New York, 1997.
Merskey H. Multiple personality disorder and false memory syndrome. Br J Psychiatry. 1995 Mar;166(3):281-3. PubMed PMID: 7788115.
Piper A Jr. Multiple personality disorder. Br J Psychiatry. 1994 May;164(5):600-12. Review. PubMed PMID: 7921709.
Supplementary 1:
From Merskey 20 years ago:
"It has been all right to treat patients on the basis of dynamic notions of repression so long as the concept was only one which was exchanged between therapist and patient and merely served to revise, in a positive fashion, the patient's view of himself or herself in the world. Using repression as an idea which works to the detriment of other people, disrupts families, wipes out the life savings of parents, abolishes their contact with children and grandchildren, and embroils some in painful legal battles, is another matter altogether and not compatible with the old principle "first do no harm"."
From Piper 20 years ago:
"However, there is a profound difference between standard psychiatric interview procedures -where practitioners take great care not to bias patients' reports-and the techniques and treatment espoused by the leading contributors in the MPD field. It is absurd to maintain that those techniques are not vehicles of grossly overt suggestion to patients. It is equally absurd to believe that in any other branch of psychiatry, one would see a clinician prodding a schizophrenic patient to produce more voices, or taking part in a 4 hour interview with a patient who might possibly be bulimic to suggest more frequent binging."
Supplementary 2: To this day I have not been able to locate a copy on any FBI report describing the investigation of 300 case reports of alleged SRA activity. My FOIA experience with the FBI is very negative and it is clear to me that if they don't want to give you information you will not get it. If anyone has this report consider sending me a copy.
Supplementary 3: The Psychiatric Times decided to publish an edited version of Nolls original article today. That is certainly the preferable course. Their rationale:
"Editorial Note: In light of the responses we have received regarding this article by Richard Noll, PhD, that was posted on our website on December 6, 2013, the article has been reposted with a modification. Additionally, we are posting responses from certain of the individuals mentioned in the article and from Dr. Noll in order to leave analysis of the article up to our readers"
From Merskey 20 years ago:
"It has been all right to treat patients on the basis of dynamic notions of repression so long as the concept was only one which was exchanged between therapist and patient and merely served to revise, in a positive fashion, the patient's view of himself or herself in the world. Using repression as an idea which works to the detriment of other people, disrupts families, wipes out the life savings of parents, abolishes their contact with children and grandchildren, and embroils some in painful legal battles, is another matter altogether and not compatible with the old principle "first do no harm"."
From Piper 20 years ago:
"However, there is a profound difference between standard psychiatric interview procedures -where practitioners take great care not to bias patients' reports-and the techniques and treatment espoused by the leading contributors in the MPD field. It is absurd to maintain that those techniques are not vehicles of grossly overt suggestion to patients. It is equally absurd to believe that in any other branch of psychiatry, one would see a clinician prodding a schizophrenic patient to produce more voices, or taking part in a 4 hour interview with a patient who might possibly be bulimic to suggest more frequent binging."
Supplementary 2: To this day I have not been able to locate a copy on any FBI report describing the investigation of 300 case reports of alleged SRA activity. My FOIA experience with the FBI is very negative and it is clear to me that if they don't want to give you information you will not get it. If anyone has this report consider sending me a copy.
Supplementary 3: The Psychiatric Times decided to publish an edited version of Nolls original article today. That is certainly the preferable course. Their rationale:
"Editorial Note: In light of the responses we have received regarding this article by Richard Noll, PhD, that was posted on our website on December 6, 2013, the article has been reposted with a modification. Additionally, we are posting responses from certain of the individuals mentioned in the article and from Dr. Noll in order to leave analysis of the article up to our readers"
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