A Molecular Basis for Gateway Drugs

The Gateway Drug hypothesis proposes that using a particular drug increases the likelihood that there will be a progressions to using other drugs of abuse.  The competing hypothesis is that there is a general predisposition to using more than one drug in people susceptible to addiction and that it does not depend on any sequence of exposures.  In this Shattuck Lecture in the New England Journal of Medicine, Eric and Denise Kandel examine the epidemiology and molecular biology of nicotine use and the development of addictions.  Most addiction treatment centers recognize the importance of nicotine cessation in improving abstinence rates from the primary drugs of choice.  Most of that depends on series of cases discharged from treatment centers.  The idea of nicotine also has importance because one of the approaches to nicotine cessation depends on nicotine substitution and it is important to know if that treatment intervention might lead to increased risk for ongoing substance use problems.  It also has implications for electronic cigarettes (e-cigarettes).  There is a general idea that any form of nicotine that does not involve exposure to combustible or chewed tobacco components is preferred because of all of the conditions associated with the physical and combustible products of tobacco.  If nicotine alone places one at risk for using another drug like cocaine, the risk/benefit decision will need to be reconsidered.

The authors briefly reviewed the epidemiology showing of all US adults who had ever used cocaine, the vast majority of them (87.9%) smoked cigarettes before using cocaine.  Only 3.5% used cocaine first.   The rate of cocaine dependence was highest (20.2%) among those who smoked cigarettes before using cocaine.  They proceed to use an animal model to examine the possible priming effects of nicotine and to possible elucidate the mechanism.  The animal models of addiction in mice included locomotor sensitization and  conditioned place preference.  In both of these models, micd primed with nicotine first and then treated with nicotine and cocaine showed the expected addicted response with heightened locomotor sensitization and place preference.  Mice primed with cocaine did not.

They proceed to look at the effect on synaptic plasticity and the model used was long term potentiation (LTP) in the nucleus accumbens (NAcc).   The  predominate neurons in the NAcc are medium spiny neurons (MSNs) and they are innervated by dopaminergic neurons projecting from the ventral tegmental area (VTA) and glutamatergic neurons from the prefrontal cortex and the amygdala.  Reducing excitatory (glutamatergic) input to the NAcc reduces inhibitory output to the VTA leading to more dopaminergic input to the NAcc or greater reward.  Repeated cocaine administration leads to reduced LTP in the excitatory synapses of the NAcc.  A single injection of cocaine in a mouse primed with 7 days of nicotine exposure leads to marked reduction in LTP.  Nicotine alone, or nicotine after cocaine had no effect on LTP.  Priming with nicotine causes a change in neuronal plasticity that increases cocaine associated reward.

The authors turned to known gene expression markers of addiction in the striatum specifically the expression of FosB.  They demonstrated that nicotine alone for seven days increased FosB expression and adding cocaine led to a further 25% expression.  The next step was to examine if nicotine alters the chromatin structure  at FosB promotor of the gene and they looked at the acetylation of histones H3 and H4 at the FosB promotor.  Nicotine alone increased the acetylation of both histones, cocaine alone increased the acetylation of H4 only.  They went on to demonstrate that the acetylation was widespread after nicotine exposure throughout the striatum.  Cocaine alone had no similar effect.  They went on to clarify that increase acetylation was due to inactivation of histone deacetylase activity (HDAC) and not activation of acetylases.  They carried out additional pharmacological studies to confirm that the hypoacetylated state (caused by nicotine) leads to depression of LTP associated with cocaine and that further it cannot be rapidly reversed.  The authors investigated if nicotine enhanced cocaine induced LTP in the amygdala and hippocampus and found that it did.

This fairly intensive research program and series of experiments allowed the authors to conclude that nicotine has a unidirectional priming effect and it works through an acetylation mechanism by affecting HDAC activity.  The mechanism explains what is seen in human populations at the epidemiological level and in mice at the experimental level.   That has obvious implications for treatment as well as drug development.  It  also points out that e-cigarettes are potentially as much of a potential gateway drug as combustible cigarettes.  In clinical practice it is also fairly common to see patients with addiction who are continuing to use nicotine substitutes (gum, lozenge, patch) long after they have stopped smoking.  If the mechanism elucidated by Kandel and Kandel is accurate it will be important to discuss the implications of continued nicotine exposure.

Kandel's work is always compelling because of his broad view of science and psychiatry.  He is as comfortable discussing psychoanalysis and Freud as he is talking about molecular biology.  In this case he combines views on epidemiology and molecular biology in a very compelling story and suggests it might be a broader model for how gateway drugs work.  As he is drawing his conclusions there is still room for the competing hypothesis and he makes this explicit.  His work is always a breath of fresh air compared to the current zeitgeist of political arguments about science and psychiatry often from people who know very little about either subject.  Go to the article at the link below and read this paper and compare it to his 1979 article Psychotherapy and the Single Synapse.  That covers at least 34 years of studying synaptic plasticity and it is a remarkable accomplishment.


George Dawson, MD, DFAPA


1: Kandel ER, Kandel DB. Shattuck Lecture. A molecular basis for nicotine as agateway drug. N Engl J Med. 2014 Sep 4;371(10):932-43. doi: 10.1056/NEJMsa1405092. PubMed PMID: 25184865. (free full text).

Supplementary 1:  Drawing depicts nicotine inhibiting HDAC leading to increased acetylation of histones per the above discussion.  CREB-1 = cyclic AMP response-element-binding protein; CBP = CREB-binding protein (acetylates histone H4);  PKA= protein kinase A; A=acetyl groups, P=phosphate groups; H2a, H2b, H3, H4 = histone proteins in chromatin; Pol II = RNA polymerase II (catalyzes synthesis of DNA to mRNA).

A Few Words About Sex

Sex remains a poorly studied and controversial topic.  It is a powerful interpersonal and cultural force.   Many ideas that originated with Freud are considered outmoded and yet when I have attended seminars that I thought might lead to ways to advance my knowledge in this area, they seemed like a dead end.  In fact, at the last seminar I attended I asked the speaker about experts in sexual consciousness he referred me to a psychoanalyst who I had corresponded with but who had since died.  The only real innovation in the area has been sexual compulsivity or sexual addiction.  Several authors write about this as though it is an actual disorder.  There have been the compulsory brain imaging studies showing activation of the reward center.  I have reservations about defining an addiction when so little is known about the baseline sexual consciousness of men and women.  It is against that backdrop that I watched two films by von Trier - both of them with the title Nymphomaniac.

After some deliberation let me say that I am not recommending that anyone watch these films.  At the very minimum they are highly controversial and they contain images that will be regarded as highly offensive or disturbing to many if not most people.  The point of this post is to illustrate how the basic storyline of these films brought me back to an issue that I have been pointing out for years, that psychiatry is no longer focused on this area of human experience even though we diagnose and treat these problems all of the time.  In many ways reading Kandel's book The Age of Insight highlights how there were more enlightened conversations about these issues in early 20th century Vienna, than I have seen anywhere during my professional career.   The public discourse is abysmal.

I was familiar with von Trier's work from an earlier film Antichrist, a film that I suppose in a very basic way was a psychotic repudiation of genital sex.  Like most things it popped up on my Netflix screen as I was getting ready to cycle.  Let me preface this post by saying that this is not a review of these films.  From what I can tell the film has been exhaustively reviewed.  The Netflix rating was a meager 2.9 stars.  Even informal reviews usually adhere to a thumbs up/thumbs down convention.  This is one of those films that is not conventional in that sense.  There are few people that would be very enthusiastic about this film based solely on content.   It is difficult to watch.  It is depressing, desolate, and in some cases violent.  It is a film that you would not necessarily recommend or even say that you had watched because it would invite inferences about your character or taste.  It may be an ideal backdrop for the trajectory of the main character and her sexual experiences in the  film.

The storyline is basic enough.  A middle aged man finds a woman who was apparently beaten up and left in an alleyway.  It is night time and lightly snowing at the time.  The alleyway is surrounded by brick walls and there is an impression that it is an impoverished part of the city.  The man offers to call for medical help but she declines.  She accepts his offer to go back to his apartment.  When she is more comfortable, she relates her history of compulsive sexual behavior in a series of eight vignettes with titles that seem interwoven with observations and stories from the man who appears to be helping her.  These stories are the main content of both films.

The stories all have the common elements of compulsive sexual behavior.  We start to learn that the chief protagonist Joe (Charlotte Gainsborough), made a conscious decision about this lifestyle at an early age.  We get to known her parents, her interactions with them and witness her father's death.  We see her embark on a vigorous program of engaging as many sexual partners per day as possible.  I think the number over much of the film that could have covered 15-20 years of her life was 8-10 men per day.  We witness some of the logistics when some of these men meet in her apartment and a scene where one of the men leaves his wife and his wife shows up at Joe's apartment with her children and is very agitated.  She angrily details the cost of  extramarital sex for the family.  Practically all of these scenes are difficult to watch.  We observe Joe over time as she becomes exhausted and eventually physically ill and debilitated, presumably from the excessive sexual behavior.  Whether or not she contracts sexually transmitted diseases is never made explicit, but we see rashes that do not heal and she describes bleeding from the genital area.  We also see her physically injured as a result of sadomasochistic behavior.  We watch her struggle emotionally.  The basic idea at the outset was not to develop any emotional attachments and to have as much sexual intercourse as possible.  Sex strictly for the sake of sex.  There are critical times during her life when that does not happen and attachments, jealousy, and envy happens and we see how she deals with these developments.  Near the end she is psychologically devastated, trapped and alone because of the sexual compulsion.  At the end, we have come full circle and realize how one of these emotional involvements has resulted in her being beaten and left in the alley.   There is additional drama at the end that I will not disclose.  If you can watch the entire sequence of these films, you deserve to discover that for yourself.

Films like Nymphomaniac are thought provoking and if you like your thoughts provoked that could lead you to give it a thumbs ups.  I have already listed my criteria for cinema as good entertainment and good acting and the film meets some of those standards.  As I thought about the content, my first thought had to do with the fact that this film was written by a man, so it is really a man's estimate of the sexual consciousness of a woman.  Strictly speaking, it is impossible for any one of us to understand the conscious state of another human being.  The thought experiment from consciousness researchers is typically, my experience of the color red is not your experience of the color red.  It is interesting to contemplate whether there might be a larger gap in understanding the sexual experience of the opposite sex.  People may argue that observations of dating and sexual behavior, anatomy and fairly crude mental and physiological data allow us to make reasonable estimates, but I would say this is more likely conjecture than the reconstruction of an actual conscious experience.  Since there is so little scientific evidence about this, the area is highly politicized.  Experts frequently talk about stereotypes of sexual behavior and the theories about why they occur.  Any attempts at discussion may break down to personal anecdotes supporting these political approaches that nobody wants to hear.   There are probably any number of reviews available online that will examine Joe's behavior from these perspectives.  Many of these arguments can come down to existential and moral dilemmas and what side of these arguments an observer happens to take.  And there is always the artistic argument that reality is relevant insofar as it may be part of the beholder's experience (see Kandel).

We get to know the man who seems to have saved Joe.  His name is Seligman (Stellan Skarsgård).  He is a self-described asexual man who gives the impression that he is an ascetic with far too much time on his hands.  His associations to some of Joe's stories often has a level of analysis that you could only get in a college classroom by a professor who is an acknowledged expert in his field. That level of sterile intellectual analysis seems consistent with his self described asceticism.   He seems to be different from the numbers of other men that Joe has encountered.  A key question is whether or not Seligman can interact with Joe in a non-sexual manner, although the obvious question is whether that can occur if a man is calmly listening to the sexual history of a self professed nymphomaniac for a number of hours.  That issue does not get resolved until the final moments of the film and I am sure that many film goers will find it controversial and suggestive of motivations on the part of the director and writer.

As as psychiatrist and a physician I naturally think about the implications of this movie.  Have I seen people with this problem?  Do I think this problem exists?  Have I been able to help people with all of the variations in between?  Are there implications for the training of psychiatrists and physicians?  As a first year medical student, I was exposed to a course that was described as cutting edge at the time.  It was devised and taught by a psychiatrist who had been brought  to my medical school expressly to teach this course.   It consisted of a surprisingly dry curriculum about the importance of taking a sexual history, videos of sexual behavior with group discussions, and lectures on how to address some very basic sexual problems.  It always struck me as the "birds and the bees" talk that your parents gave you at the end of elementary school but with better audiovisuals.  It seemed shockingly unsophisticated relative to some of the theories of the day.  The timing was also wrong.  Taking 30 minutes to do a detailed sexual history is not going to work when you start rotating through acute care medical and surgical settings.  Knowing enough medicine and psychiatry and practicing in an ambulatory care setting seem like better prerequisites.  A course like that is inadequate preparation for what occurs in those clinic settings.  The mechanics are irrelevant.  The focus is all intrapsychic and interpersonal, helping the person process that information and adapt.  A focus on the mechanics of sex,  either in the sexual history or sexual education in school really seems to miss the mark.  All of the discussion of mechanics even with the recent details of how the ventral striatum is activated during sexual behavior seems to marginalize the meaning of sexual behavior and how it influences the entire conscious state of a person.  Whether Joe's story is accurate or not, the common experience of sexual behavior organizing one's conscious state probably makes this story believable for most people.

The issue of whether of not nymphomaniacs exist is certainly another issue for psychiatry.  The diagnostic manual lists no similar term and no reference to the equivalent condition in the film - sexual addiction.  In some circles, sexual addiction is seen as a behavioral equivalent of substance use disorders.   The existing sexual dysfunctions available for diagnosis include problems with hypoactive sexual desire, arousal and orgasms.  Hypersexual disorder is not an option and Grant and Black explain:

"During DSM-5 deliberations, there was some controversy about the possibility of including hypersexual disorder, which is characterized by sexual behavior that is excessive or poorly controlled (commonly referred to as either "sex addiction" or "compulsive sexual behavior") and paraphilic coercive disorder, which consists of a sexual preference for coerced sexual activity (i.e. rape).  After considerable discussion and input from fellow APA members, the decision was made not to include these disorders in DSM-5." (p. 274)

A current Medline review shows that the research in this area is thin considering that there are experts out there who are treating sexual addiction or sexual compulsivity and there are several instruments that are designed to gather that data.   I also can't help but think that there are more cases that are under the epidemiological radar.  By that I mean the cases that present to psychoanalysts.  Some of the most fascinating areas that I studied as a resident were the different approaches to psychoanalysis, particularly the differences between Kohut and Kernberg.  Kohut's paper called "The Two Analyses of Mr Z." was particularly interesting because the presenting symptom was compulsive sexual behavior.  The symptom did not respond to traditional psychoanalysis but required Kohut to modify the technique and he used this as an example of his new self-psychology approach in psychoanalysis.  So a question for the analysts out there, I know that many analysts treat focal sexual symptomatology out there and eschew the DSM categorical approach to sexual behavior.  Are there psychoanalytical papers written about hypersexuality in general and is it a problem frequently seen in psychoanalytic practice?  The Psychodynamic Diagnostic Manual has the following commentary on the subject of the categorical (DSM) classification of sexual disorders:

"Sexual inclinations and experiences are sufficiently diverse among human beings that we urge caution in diagnosis.  In this area we are particularly uncomfortable with the categorical depiction of "disorders" in the DSM.  Especially in the area of paraphilias, it becomes easy to pathologize behavior that may simply be idiosyncratic.  In contrast to categorizing specific acts as inherently pathological irrespective of context and meaning, we recommend a thoughtful assessment of subjective factors, meanings, and contexts of variant sexualities...." (p. 126)

The diagnosis of Hypersexual Disorder was listed in the online proposed DSM-5 as a paraphilic disorder but it did not make the final cut.   There was a note posted that it would be included in "Section III" conditions for further study, but in the final version it was not listed there either.  It would appear that there is little guidance from either the DSM or PDM camp on this disorder.

I had originally planned to include a new graphic here summarizing the imaging results from studies of human behavior, but I am having some difficulty getting the original papers and images.  For anyone interested in that list of references you can find them here.  A recent paper in Science, raises some serious questions about what reward center activation really means (see Donoso, et al).  In this paper the authors demonstrate that reward center activation can occur with a purely cognitive task and seems to function in a way to continue to make correct choices.  That raises some questions about conventional approaches to reward center activation and what it means in the study of human sexual behavior but also addictions of all types.  How much reward center activation is purely due to making a "correct" choice and what does that mean in the case of an addiction or in the cases of normal function like eating, drinking, or sexual behavior?

In terms of clinical practice, I have treated hundreds of people with hypersexuality, socially inappropriate sexual behavior, and victims of sexual assault.  They were almost all due to mood disorders (mostly mania), neurocognitive disorders, chronic intoxication states associated with addictions, medication side effects (primarily medications used to treat Parkinson's Disease), or the effects of various forms of sexual violence.  I have fielded a lot of questions on the whole notion of sexual addiction, especially in chemical dependency treatment settings where compulsive behaviors are viewed as behavioral addictions.  I have never really encountered anyone describing a problem similar to what is portrayed in Nymphomaniac.   There is always a strong selection bias in clinical practice and for a long time, I assessed and treated people with severe mental illnesses and addictions.   The hypersexuality in these cases usually had causes that any psychiatrist could diagnose and hopefully treat.   My read of the psychoanalytic and family therapy literature suggests that there are cases that are independent of the etiologies that I have seen and many of them have intrapsychic/interpersonal and social etiologies.  Apart from individual case presentations by psychoanalysts and psychotherapists it is very difficult to see this as a widespread problem.  That seems to happen in other areas like Intermittent Explosive Disorder.  I have not seen a single case in 28 years and yet there it sits in the DSM-5.

This is probably another area in psychiatry that will require a lot of data and more research to resolve.  People often take offense to the idea of more research as a standard answer, but it should be clear that when it comes to sex, the approaches are largely anecdotal and it seems like an area that most people avoid thinking about in any scientific manner.



George Dawson, MD, DFAPA


Black DW, Grant JE.  DSM-5 Guidebook - The Essential Companion To The Diagnostic and Statistical Manual of Mental Disorders.  American Psychiatric Publishing, Washington, DC.  2014.  p.274.

Kafka MP.  Hypersexual Disorder: A Proposed Diagnosis for DSM-5.  Arch Sex Behav (2010) 39: 377–400.

"There are significant gaps in the current scientific knowledge base regarding the clinical course, developmental risk factors, family history, neurobiology, and neuropsychology of Hypersexual Disorder.  Empirically based knowledge of Hypersexual Disorder in females is lacking in particular."

Kandel ER.  The Age of Insight - The Quest to Understand the Unconscious in Art, Mind, and Brain.  Random House, New York, 2012. p. 394.

Kohut H. The two analyses of Mr. Z.  Int J Psychoanal. 1979;60(1):3-27. PubMed PMID: 457340.

PDM Task Force.  Psychodynamic Diagnostic Manual.  Alliance of Psychoanalytical Organizations.  Silver Spring, MD.  2006. p. 126

Donoso M, Collins AG, Koechlin E. Human cognition. Foundations of human reasoning in the prefrontal cortex. Science. 2014 Jun 27;344(6191):1481-6. doi: 10.1126/science.1252254. Epub 2014 May 29. PubMed PMID: 24876345.



Supplementary1:  This post may be modified as more data becomes available.  I just had to move on.

Supplementary 2:  Since there are apparently no conferences I had this idea for a conference based on this post to put sex back into psychiatry.  The conference would consist of the following elements:

1.  Update on the current epidemiology of sexual behavior.
2.  Review of the physiology and neuroendocrinology of sexual behavior.
3.  The neurobiology of the human sexual response.
4.  Brain imaging of the human sexual response.
5.  The sexual consciousness of men and women.
6.  An approach to useful clinical classifications across the DSM-PDM spectrum.
7.  Clinical approaches to identifying sexual problems and normal sexual function.
8.  Approaches to treatment across the DSM-PDM spectrum: disorders to focal problems.

Let me know if you can think of other topics, I am trying to get people interested in putting this conference together right now.

Happy Labor Day III

This is the third Labor Day of this blog.  I usually take the opportunity to mark the lack of progress in the physician work environment and this year is not much different.  All of the usual corporate and government buzzwords being promoted to suggest why physicians need to be managed by somebody who knows nothing about medicine.  All of the hype about computerization and how the grossly overpriced electronic health record will save us all, even as the printout from that record looks less and less coherent.  I just read a copy of The Institute from the IEEE on Big Data.  From that report:

"It's is estimated that the health care industry could save billions by using big-data health analytics to mine the treasure trove of information in electronic health records, insurance claims, prescription orders, clinical studies, government reports, and laboratory results.

Analytics could be used to systematically review clinical data so that treatment decisions could be based on the best available data instead of on physicians' judgment alone...."

The state of current electronic health records as the worst value in the information technology sector is is probably not too surprising given the above observations or the following:

"Instead of seeing only 20 patients a day, doctors are able to see 75 to 100 people and get ahead of the wave..."

I don't know what kind of doctor sees 75-100 patients a day or what the quality of these visits is, but I have never met a physician who wanted to see that many people in a day and wonder if it would not trip a billing fraud flag somewhere in the CMS data base.  I have talked with many physicians who were overwhelmed by coming into the office and having 200 tests to review and sign an additional 30-50 orders in addition to seeing 20 patients that day.  We are decades away from any machine intelligence being incorporated into the medical record.  The current EHR has destroyed the narrative, especially in psychiatry and converted the basis of care to a checklist.  Instead of higher order machine assisted decision making the electronic health record has not resulted in the expected savings or utilization of technology.  Paying tens of millions of dollars in licensing fees per year and larger IT departments with thousands of PCs running 24/7 to access the sever farm has not produced a nickel of savings and has added large recurring costs.

So I have not noticed any striking improvements in the practice environment.  At the same time, it is at such a low level that it is difficult for me to say that it has deteriorated any further.  The American Psychiatric Association (APA) the largest professional organization for psychiatrists still supports collaborative care - a managed care model of psychiatric care that in some cases eliminates any direct access to psychiatrists.  The American Medical Association also seems managed care friendly largely due to their support of the PPACA.  Both organizations support the onerous recertification process mandated by the American Board of Medical Specialties.

The only bright spot I can think of this year was being seated at the same table with 3 younger colleagues at at a Minnesota Psychiatric Society CME event.  They had all been practicing for 10 years or less.  They were all in private practice to one degree or another.  They were all women and although I haven't seen it studied I think that women may have a greater skill level (at least relative to men of my generation) in setting up and managing a private practice.  I was quite interested in their experiences and they listed all of the positives.  The overwhelming positive that I took away from that meeting was that their practice environment was very positive because they ran it and had eliminated all of the toxic administrators along the way who were supposed to manage them.  They did not have to tolerate the notion that just because they were an employee that they suddenly needed supervision from somebody who was not qualified to supervise them.  Near the end of our conversation they tried to talk me into going into private practice myself.  I have always been an employee, but my current vocational trajectory has been predicated on fleeing toxic administrators.  I gave the usual excuses about being one bad cold away from retirement and an old dog not being able to learn new tricks.

If I was starting out today - I would only be working for myself and I would try to design the practice to reflect my interests in neuropsychiatry and severe mental illnesses.   Any resident reading this should consider this career path.  The decision may be as easy as contemplating seeing 75-100 patients a day and meeting with an administrator who suggests that you could see more.

Happy Labor Day to any physician reading this whether you are in private practice or on the assembly line in a clinic or hospital somewhere.  And good luck to physicians everywhere in avoiding unnecessary administration.


George Dawson, MD, DFAPA

Kathy Pretz.  Better Health Care Through Data.  The Institute September 2014.  p 6 - 7.

Shut Down The Psychiatric Gulags - Don't Build More!

On my drive home from work yesterday, I heard an outrageous story about a judge ordering LA County jail to build 3,200 psychiatric beds to treat mentally ill inmates in that facility.  As is typical of MPR, I could not find the link today but I did find the link to this LA Weekly story , that basically brings people up to speed.  It is a typical journalistic approach with the human interest component.  In this case the human interest portion was interesting to me, because I have heard these stories hundreds of times from people I have treated who have been incarcerated with a few variations.  The most significant variations have to do with suffering acute alcohol or drug withdrawal and not being assessed or treated for that problem and not having access to maintenance medications that have proven effective for the specific mental illness.  The current plight of the mentally ill in the LA County jail system and increasing judicial pressure on the basis of rights violations for the lack of treatment led county supervisors to vote to build what was called the most expensive building project in county history.  From the article:

"That day, county supervisors ........ voted to spend nearly $2 billion on a long-sought jail to replace notorious Men's Central, a facility that federal investigators say is plagued by suicides, abusive conditions and violence. The funds will build a two-tower compound given the ungainly name "Consolidated Correctional Treatment Facility."

According to the article it will be a 4,860 bed facility,  3,260 (67%) beds of which will be dedicated to treating prisoners with mental illness.  My most recent post on the matter includes information that LA County jail has 19,386 inmates and that recent epidemiological surveys suggest that 30-45% of inmates have problems due to severe mental illness and impaired functional capacity.   That suggests that unless public policy changes, the most expensive building project in LA County could be overwhelmed by demand before it gets started.  The author in this case points out the folly of building this tower.  It is basically the folly of building any large psychiatric facility in the absence of any other infrastructure, but in this case compounded by the fact that this is in fact a jail and not a treatment facility.  There is really no evidence that the problematic aggressive or suicidal behavior will be any better in a new "two-tower compound" with the same jail atmosphere and mentality.

I have previously posted about the plight of the mentally ill being incarcerated in America and the fact that county jails are currently our largest mental institutions.  It is a basic collusion between governments at all levels and the business community to enrich corporations that have been set up to "manage" the American healthcare system.  As usual, the most vulnerable people are "cost shifted" out.  Cost shifting refers to cost center accounting that basically leads divisions within the same organization to try to save money on their budget by shifting the costs to somebody else.  In managed care systems it can lead to all kinds of distortions in care.  It also happens with outside agencies.  I was told about a situation where workers in one county actually dragged an  intoxicated patient over the county line and into another county so that patient would no longer be their  financial responsibility!  Cost shifting is the end result of these perverse incentives.

There is perhaps no better example than incarceration rather than hospitalization.  There are estimates as recent as from a few days ago that treatment and possible hospitalization may cost $20,000/year as opposed to incarceration costing $60,000/year.  In both cases the taxpayers pick up most of the tab.  The cost shifting has occurred from insurance companies and health care systems to the correctional system.  If an insurance company can dump a patient with a severe mental illness into jail, it doesn't cost them a thing.   If that same patient is hospitalized they may receive a one-time DRG (Diagnosis Related Group) payment of about $5,000 irrespective of how long the patient stays.  The hospital incentive is to get them out in 5 days whether they are stable or not to maximize profit.  When they are discharged, the patients are generally expected to go to appointments to discuss their medications.  Clinic profits on these visits are minimal but the main problem is that many of these appointments are missed - in some cases up to 50-60%.  Many of these patients lack stable housing and they frequently end up back in the emergency department and back in the hospital.  Hospitals now have bottlenecks in the emergency department and many people are discharged back to the street.  The cycle of ineffective care continues.

I can attempt a brief analysis of the problem as I watched it unfold during 23 years of inpatient practice.  I will demonstrate how things have changed to the detriment of patients with severe mental illness.  Consider the hypothetical case of Mr. A.  He has diagnoses of depression, schizophrenia and alcohol dependence.   He recently ran out of his usual medications and started drinking.  He became progressively depressed and stopped talking with his family members.  They went over to see him and noticed he has a loaded handgun on his table and was talking about shooting himself.   They called the police who came, confiscated his handgun, noted that he was acutely intoxicated and sent him to the local hospital emergency department.  How has the management of this scenario changed over the past 30 years and why?

In the early 1980s, Mr. A would have been assessed as a person who was high risk for ongoing suicidal behavior (depression, schizophrenia, alcoholism and acute intoxication) and admitted to a psychiatric unit.  The psychiatrist there would have done everything possible to stabilize all three conditions even if it meant civil commitment to a long term care institution.  The length of stay (LOS) would have been on the order of 20-30 days comparable to many current psychiatric LOS in the European Union.

By the late 1980s, a managed care company would have called the hospital or psychiatrist in charge.  They would initially demanded that the patient be discharged to a county detox facility.  They would claim that alcohol withdrawal detoxification was not a psychiatric problem, and therefore the patient does not meet their "medical necessity criteria" for inpatient hospitalization.  If that was ineffective they might say that he was no longer "acutely suicidal" or "imminently dangerous" two additional medical necessity criteria.  In the end they always win, because they just stop paying and the administrators force the clinicians to discharge the patient.  The length of stay is now down to less than 1 week and the patient may not be stable at all at the time of discharge.

By the 1990s, the patient might not even make it to the inpatient unit.  By now psychiatric departments are continuously burned by managed care companies, especially in the case of any patient who is acutely intoxicated at the time of admission.  Many have closed their doors.  Many departments have strongly suggested that the emergency departments send any intoxicated patients directly to county detox units if they are available.  The counties respond by refusing to take any patients on any intoxicants than than alcohol and even then the patient has to blow a number on a breathalyzer consistent with acute alcohol intoxication.   At any point in this process a decision can be made to just send the patient home.  There are various ways the patient can access more firearms at that point or even get the original firearm that was confiscated.  There are also various ways that the patient can end up incarcerated including going back home, drinking and getting arrested for disorderly conduct or public intoxication.  A more complicated situation occurs if the patient is intoxicated and wanders into a neighbor's home or place of business.  I have seen people end up in jail for months on trespassing charges in these situations.   And that brings us in to the 2000s where it is much more likely that a person with severe mental illness will be incarcerated than even make it to the emergency department.  In the 2000s the patient may end up stranded in the emergency department for days or sent home with a bottle of benzodiazepines to handle their own detox if they can deny that the are "suicidal" consistently enough.  There is also the mater of inpatient bed capacity.  Fewer beds are full constantly because bed capacity has been shut down due to managed care rationing and people are often released because there will be no open beds in the foreseeable future.  The LOS in many cases is now zero days, even for people with severe problems.

How did all of this happen?  How did the care of mental illness and addictions fall to such a miserable standard?  It is documented in many posts on this blog.  Professional guidelines were compromised and treatment infrastructure was destroyed by the managed care industry and the politicians who actively supported and continue to support it.  Professional organizations don't stand a chance against pro business state statutes,  commissions stacked with industry insiders, and federal legislation that protects these companies from lawsuits for interference with care.  Even a travesty as basic as prior authorization for generic drugs is unassailable.  I don't understand why these basic facts are so incomprehensible to people in the field.  Just a few hours ago, 1BOM posted a Hall of Shame of entities the original authors claim are failing people with severe mental illness.  This list completely misses the mark and is probably a good example of how deeply entrenched the mechanisms are to prevent treatment  and shift costs away from states and health care companies.

There are countless easy solutions to the problems, but the companies in power literally do not want to spend a dime.  The patient with severe mental illness can receive comprehensive community services and be maintained in their own housing at a cost of $10, 000 to $20, 000/year for clinical services.  That same patient costs corrections departments $60,000 per year.  That patient currently costs managed care companies nothing if they can transfer their care to a local state-funded Assertive Community Treatment (ACT) team.  Managed care companies incur the same cost if the patient is transferred to the correctional system.  If ACOs come to fruition and all of the chronically mentally ill are enrolled, it should be an easy matter to make the managed care companies responsible for both the costs and the patient.  A simple court order to pick up the patient from jail and stabilize them in the community could suffice.

Erecting more gulags won't work.  They are effective only for enriching health care companies that profit by denying care for those with severe mental illnesses and addictions.  They are also another hidden health care tax on the taxpayers who are already paying far too much in hidden health care taxes.




George Dawson, MD, DFAPA

Graphics Credit:  ConceptDraw Pro - this graphic was included as an example with this software.

YOUR PATIENT IS UNABLE TO START YOUR PRESCRIPTION

Just when I thought that prior authorization could not get any worse, I see a fax with that headline.  I guess the business geniuses who thought it was a good idea to send me that fax never stopped to consider what was wrong with that idea.  What could that possibly be?  Let me see, I have made several comprehensive assessments of a medical and psychiatric disorder that is extremely complicated, selected a medication that was seen as appropriate by medical consultants treating another major medical problem,  did all of the medical screening for this particular medication including a meticulous search for drug interactions across 3 different data bases, thoroughly assessed the patient for side effects and complications from this particular medication and stabilized the patient on that medication.  I also had a detailed informed consent discussion with the patient for this medication and not a general class of medications.

Remind me why my patient is unable to start the medication - - - Oh that's right:

YOUR PATIENT IS UNABLE TO START YOUR PRESCRIPTION BECAUSE WE WANT YOU TO PRESCRIBE THE CHEAPEST DRUG OR THE DRUG THAT WILL GET US THE BIGGEST KICKBACK FROM THE PHARMACY AND THAT IS WHY WE ARE IGNORING THE FACT THAT YOU HAVE PRESCRIBED A GENERIC DRUG AND WE THINK THAT ALL DRUGS IN ANY GENERAL CLASS OF MEDICATIONS CAN BE SUBSTITUTED FOR ONE ANOTHER AND OF COURSE WE DON'T REALLY CARE ABOUT THE TIME AND EFFORT EXPENDED IN THE EVALUATION AND TREATMENT OF THIS PATIENT AND THE FACT THAT IT WAS SPECIFIC TO THE DRUG YOU PRESCRIBED AND WE DON'T REALLY CARE ABOUT WHAT HAPPENS TO THIS PATIENT BECAUSE WE ARE IN THE BUSINESS OF MAKING MONEY AND WE HAVE NO PERSONAL RESPONSIBILITY TO THIS PERSON AND YES YOU WORK FOR US AND YOU WORK FOR FREE IN ORDER FOR US TO BE ABLE TO DO THIS.

That simple 8 word phrase says everything about how medical care in this country has been corrupted for the enrichment of companies that make money by denying or interfering with care that has been carefully prescribed for patients by the doctors who know them the best.

A serious rewrite is needed for their fax cover sheet.

George Dawson, MD, DFAPA

Psychiatrists Implicitly Asked To Fill In Large Gaps

I didn't realize this until relatively late in my career and it has been interesting to counsel several younger colleagues about not making the same mistakes.  Psychiatrists are continuously called upon to make up for significant deficiencies in the system.  Any one of these gaps can lead to a crisis situation that the psychiatrist has to address immediately or lapses in the quality of care.  In the extreme case they can render care impossible.  Many of these deficiencies also require a considerable time commitment by the psychiatrist.  That time is usually not compensated and often takes valuable time away from spouse and family.  The deficiencies are the direct result of rationing resources and not having enough resources available.  Another variation is that some of the staffing personnel available have no training or experience in how to assess and treat mental health problems or even discuss problems with psychiatric patients.  There are many people who are assigned to that role and I am convinced they make things worse rather than better.

Community mental health centers are often places where the deficiencies exist.   They depend on government funding sources and the bureaucracy involved with some of these sources is only exceeded by the lack of adequate funding.  In many places, the managed care model is adapted and that means that nearly all patient concerns are translated into medication complaints of the form "I am having problems because I am not taking enough medication(s)."  Frequently the patients adapt to saying the same thing.  Any astute psychiatrist walking into this setting may see all of the usual markers including most drugs being prescribed at or above the manufacturers suggested maximum dose, far too many benzodiazepine and sedative hypnotic prescriptions, drugs being prescribed for questionable indications, medications being prescribed for a condition that should be treated first with psychotherapy (and the affected patients never received that therapy), and a lot of medications being prescribed to patients who clearly have a substance use problem.   There is generally a lackadaisical approach taken to the medical side of monitoring the patients including no monitoring or intervention for the metabolic side effects of medication, no attention to drug interactions, and no diagnosis and treatment of the neurological effects of medication.  Psychiatric practice is simplified to a contracted practitioner prescribing medications for a broad array of problems.  In many cases staff from the mental health center will call that practitioner when they are not on site and the request and/or response will be an increase in medication dose or a new prescription for medications.

Inpatient psychiatric units tend to attract psychiatrists with a lot of medical expertise and an interest in those matters.   The first problem is often a lack of medical services in terms of consultants or the necessary hardware.  Unless there are medical consultants and a clear delineation of responsibilities this may result in a significant additional time commitment to psychiatrists.  Thinking of admissions, the first step is who does the history and physical.  After a comprehensive psychiatric assessment it might only take an 20 minutes to do a medical review of systems and physical exam.  Depending of the medical complexity of the patients it may take an additional hour or two.  The second point is what is now called medication reconciliation.   That means that all of the medications the patient taking for medical and psychiatric purposes.  That is very easy in the case of one medication.  It is not so easy when a patient cannot accurately report their medications or they are taking up to 20 medications.  Those medication may include several apiece for chronic medical conditions like hypertension and diabetes mellitus.  There are also decisions that need to be made about which medications can be restarted and which medications need to be acutely discontinued.   That can lead to hours of time for an admission procedure that in a typical system of care is supposed to take an hour or less.  There is a strong incentive for administrators to have the same physician cover both the medical and psychiatric side of inpatient treatment.  It is far more cost effective for medical consultants to see patients elsewhere in the hospital.   Young psychiatrists wanting to do both jobs should be aware of the fact that most places would be more than willing to have you commit that kind of time.

Other residential settings can lead to problems similar to inpatient psychiatric units, but tend to be less intense on the admission side.  In many cases psychiatrists are consultants to a number of facilities like corrections, drug and alcohol treatment facilities, and nursing homes.  All of these settings present unique challenges to rational psychiatric care ranging from subtle to more obvious.  In many cases the obvious problems seem to escape notice by many of the people in charge today who have no clinical training.

An example of some of the most subtle but disruptive problems are the psychodynamics of treating groups of people in an environment with a significant number of treatment staff.  In that setting some of the characteristic psychodynamics of people with personality disorders occurs and leads to significant problems.  A  couple of good examples include staff splitting and projective identification and I will deal with these defense mechanisms extensively in a second post.  In this post I will give a hypothetical example of how disruptive these defenses can be in a staff and an administration that is poorly set up to deal with them.

Consider Dr. A. a seasoned inpatient psychiatrist with many years of experience.  Dr. A is highly regarded by the inpatient staff and her colleagues, but not so by administrators in her department.  With administrators, she is regarded as having a length of stay that is too long, because she refuses to discharge patients with inadequate evaluations or evidence that they will not be able to adequately function.  She has had several meetings with department administrators on this subject but stands her ground on what she sees as professional standards as opposed to managed care guidelines.   Nevertheless, she does feel the pressure from the administrators and does end up discharging a young man to a group home.  He has difficult to treat bipolar disorder and diabetes mellitus Type II and she made the difficult decision to treat him with an atypical antipsychotic despite the metabolic warnings for this class of medication.  He did not have all of the markers of adequate progress for discharge that she likes to see but he was sleeping well and no longer grandiose.  

The patient in question is discharged and returned in 3 weeks.  He is agitated and manic.  Dr. A notes that the patient saw a practitioner in the time he was out of the hospital and the dose of medication was cut in half.  That acute dose reduction was associated with the recurrence of manic symptoms.  Dr. A ordered the full dose of the medication and to contain the patient also ordered 1:1 staffing to redirect him from conflicts with other patients.  There was a hospital wide initiative to reduce the amount of 1:1 observation time.  On of the nursing staff suggests that the patient is getting special treatment because Dr. A has the "hots" for him.  The patient was regarded as attractive and referred to Dr. A as his "girlfriend".  None of the nursing staff notice that the staff person doing the 1:1 observation was verbally accused by the patient of stealing money from him during the previous hospital stay.  Part way through the shift the patient punches the staffer in the arm with a good amount of force.  The staff person is not injured, but an inquiry is held.

Dr. A walks into the inquiry and notices the administrators, some of them from the various disciplines on the unit.  The administration of disciplines in this hospital is in a silo manner like most hospitals with separate administration for physicians and nurses.  The question the group will consider is apparently the accusation by the nursing staff that Dr. A was prescribing an "inadequate" amount of antipsychotic drug even though the orders clearly show that the patient was given a dose that was beyond the maximum FDA recommended dose and the patient has diabetes - a reason for caution when using this class of drugs.  None of the staff in the room was aware of the previous confrontation that the patient had with the staff that was assaulted.  By making these points Dr. A seemed to be able to satisfy the requirements of the inquiry but suddenly out of left field, one of the nursing administrators suggested that Dr. A had a "communication problem" with the nurses and had in fact "ignored" one them.   The entire room of administrators seemed to be in agreement about this despite the fact that all of the nursing staff working that day had been interviewed an none of them had seen this pattern.

The final result was that the panel decided that Dr. A would meet with the inpatient director and the aggrieved nurse on a regular basis to focus on the "communication problem" that Dr. A allegedly had.

The case of Dr. A is an excellent example of staff splitting the resulting very negative outcome for Dr. A.  The reality of the decision is that Dr. A had done nothing wrong.  She is very competent and used to making tough decisions in impossible situations like the one described above.  Her professional competence includes neutrality toward patients and she has never acted in an inappropriate manner with any patient.  In this case the process results in her being treated like a novice and punished for something that never occurred.  All of this is the result of treating a patient with difficult problems, and a lack of understanding on the part of the staff and the administrators about what was happening in terms of interpersonal dynamics.  Dr. A ends up being scapegoated and her confidence in decision making is temporarily affected until she can put the pieces together and figure out what happened.  Watching how the key staff interact in similar situations in the future is also helpful. 

What gap occurred in the scapegoating of Dr. A?  The best psychodynamic hospitals have group meetings for staff to examine the dynamics especially in the treatment of patients with complicated problems or complicated developmental histories.  Most acute care hospitals have no team meetings at all.  The basic premise is that the wards are short term holding tanks until the medications kick in and the patients can be discharged.  These days the medications don't even have to kick in as patients are discharged with a significant amount of symptomatology.  There is no analysis or discussion of defense mechanisms and projection that results in threatening behavior is generally handled as an acute psychotic symptom with medication.  I have really never seen any hospital administration recognize that this is a shocking deficiency and in many cases the splitting is worsened by administrative maneuvers.  Having an administrator with no clinical training  dictate how complicated patients with aggressive behavior are handled is a great example.

These large gaps also translate into a lack of quality in psychiatric care.   It is what happens when businesses and governments marginalize the role of physicians and exaggerate the importance of business administrators.  The practical implications are that psychiatrists should really avoid practice situations with these obvious gaps.

It would be great if the American Psychiatric Association would step up and comment on how these gaps should be closed but they appear to be disinterested in what is happening to the practice environment for psychiatry.

George Dawson, MD, DFAPA



 

Footnotes About Commenting On Mental Health Tragedies In the News

Recent events have led me to think about the issue of commenting about tragedies that affect celebrities and their families.  American culture and even the law suggests that anyone who leads a public life should expect public commentary even during a time when it would be considered poor form if applied to anyone else.   It is an interesting twist for people who are protectors of confidentiality their entire careers and who know some of the real reasons why that is important.  One of the most critical is the issue of self aggrandizement as in "I am a special person because I have access to information that nobody else has access to."  Introspection and self analysis are generally useful tools to examine this aspect of personal information and whether or not it can be handled neutrally.  As an added corollary whether that information comes from a celebrity can create an additional burden on the person who has received it.  Can the information be handled neutrally when the source is a celebrity who has millions of fans?  A few observations about the recent events:

1.  The event is a projective test - there are clearly individuals and groups who have specific points or observations that they would like to make about the person or event.  Those points may have very little to do with the reality of that person's life and more to do with the agenda of the observers.  In the worse case scenario there may be public remarks that are controversial or in some cases very negative about the person or the event they were involved in.  Nobody ever seems to bring up the obvious conflict of interest issues when these remarks are made, not the least of which is selling more media stories.

2.  In the case of a loss there is public but appropriate grieving.  Reminiscences about shared common events and critical events in the persons public life are good examples.  In this case, a psychiatrist generally has no more to offer specifically about that person than anyone else.  In the event that the psychiatrist was actually treating that person, ethical guidelines prohibit any disclosure about that treatment even after death.  That should include the identification of a person as a patient.

3.  Stereotyping can occur and I am thinking of the general sequence of events that "this person belonged to this subgroup and what happened to him/her happens to a lot of people in this particular subgroup."  Things are rarely that simple.

4.  Medical professionals are no different from anyone else and may make remarks that have more to do with their own interests than the deceased or the aggrieved family.  In some cases the medical professionals are paid to give their opinion in the media either as a regular commentator or as an interviewed guest.  I have heard some argue that their credentials allow them to make special interpretations of events to the public, but I have never really seen that play out.

5.  Commenting on these tragedies does very little to change the inertia in the system.  The problems with the care for addictions and mental illnesses are well documented on this blog.  The main problem is that our federal and state governments are oriented more toward enriching health care companies rather than providing practical and affordable health care insurance to the average person.  They do this by a number of state sanctioned rationing schemes and that rationing falls heaviest on the care for mental illnesses and addictions.  It is one thing to lament the tragedy of another fallen star, but the commentary is never followed up with any action to prevent further tragedies.

6.  A condensed life is one worth living.  A lot of media have canned obituaries that people have been working on for some time.  In the event of an untimely death, it seems that there is a lot of cutting and pasting going on.  It gives the appearance of a detailed analysis of the person's life.  The appearance of thoughtfulness.  People rarely think about why editors include some paragraphs rather than others.  The press generally gets far too much credit for objectivity and there is not enough focus on the ever present conflict of interest.  Articles are written after all to generate advertising dollars and in today's world that means clicks.  Controversy generates clicks and detailed objective analysis does not.

If it was up to me (and it clearly is not) - the whole process of the way celebrity tragedies are covered and reported would be revisited.  There is no evidence that I am aware of that the wisdom of professionals or public health officials regarding mental illness or addiction treatment is conveyed any better in this context than others.  The more specific problems of drug addiction and suicide are after all tough problems that generally do not respond well to basic education.  Attaching celebrity to those problems does nothing to heighten awareness or advance the public health message.  These tragedies are also common.  It is difficult to find a family that has not been personally impacted by similar events affecting the people that they personally know.  I take a very negative view of trying to "analyze" a persons problems based on media reports and other sketchy information and yet it is common to see experts in the media drawing all sorts of conclusions.  What I have personally found useful in the grieving process is a review of the person's positive accomplishments.  It is amazing what an "average" person can accomplish over the course of their lifetime.  Celebrity in all likelihood extends and intensifies that list.  It is also a prerequisite that people who actually know the person - that is people who have been in real relationships with that person - compile the list.

With that approach experts are left with offering their condolences to the survivors - like everybody else.


George Dawson, MD, DFAPA