Robust Doses of Extended-Release Mixed Amphetamine Salts To Treat Cocaine Use Disorder

JAMA Psychiatry. 2015 Jun 1;72(6):593-602

This article (2) caught my eye in JAMA Psychiatry.  Stimulant (methamphetamine, cocaine, prescription stimulants, and various synthetics) use disorders (previously called addictions) are difficult problems to treat.  That is especially true because of the epidemic of adult Attention Deficit~Hyperactivity Disorder diagnoses and the cross contamination from the cognitive enhancement movement as well as new indications for stimulant prescriptions.   Stimulant medications are widely available and generally work at some level for most people who take them leading to the common impression that:  "I took my cousin's Adderall and it worked!  Therefore I must have ADHD and need my own Adderall prescription."  By the time that has happened it is usually very difficult for any physician to explain to this patient why a positive response to a stimulant does not equate to an ADHD diagnosis, especially if the prospective patient has been functioning at a high level and is presenting for diagnosis and treatment after doing extremely well in college and their first few years of professional school.

A second problem with the ADHD stimulant use issue is the misconception that people with "true" ADHD are less susceptible to the positive reinforcing effects of stimulants than people without ADHD.  There are certainly subgroups of person with this diagnosis that do not like to take stimulants.  They find that stimulants decrease their appetite, given them increased anxiety and insomnia, and in many cases leave them feeling more restricted, affectively blunted and less spontaneous.  I find that these patients are generally selected out by the time they are adults.  They had true ADHD diagnoses in middle school, did not like the stimulants, or in many cases their parents did not like the effect they were seeing and they were taken off of them.  They may have developed significant coping strategies based on their dislike of stimulant effects.  Like many adult psychiatric disorders there is no one uniform phenotype, and the phenotype of the person who was diagnosed either as a child or an adult and who gets a euphorigenic effect from stimulants and escalates the dose clearly exists and is seen in treatment centers.  In many cases they have an iatrogenic diagnosis of bipolar disorder from a pattern of taking the month's prescription of stimulant in the first one or two weeks and then either going into withdrawal or using a depressant like alcohol, benzodiazepines, or opioids to treat the dysphoria and cravings associated with stimulant withdrawal.

There is also the situation where a person has been using high dose prescribed stimulants (taking more than prescribed) or using high doses of meth or cocaine off the street, where they develop a residual state that is identical to ADHD, but where the cause of the ADHD is the stimulant.  I think it is an error to treat that residual state with stimulants.  That residual state is generally associated with a profound level of impairment and lack of insight.  The patient is aware of significant cognitive problems, attributes them to ADHD and often insists on treatment with stimulants despite a clear addiction to stimulants.  They may insist that years or decades of stimulant use was their attempt to self diagnose and treat their own ADHD.  It is very common for patients with substance abuse problems to give a history of no formal diagnosis in childhood, no school or occupational impairment, but to offer the opinion that they think they may have ADHD.  All of these considerations lead to associated problems in providing care to people who have clear ADHD and stimulant use diagnoses.  

That leads me to this multisite study (2) on the effects of high doses of extended release mixed amphetamine (ER MA) salts on both ADHD and cocaine use in patients who have both of these diagnoses.  The doses used were 60 and 80 mg/day.  The most commonly used current prescription versions of these drugs typically recommend a maximum dose in adults of 30 mg/day (1), but interestingly there is a "titrate to tolerability" statement in the package insert of a drug where 20 - 60 mg/day were used in trials with the statement  "There was not adequate evidence that doses greater than 20 mg/day conferred additional benefit."  The authors describe their dosing selections as "robust" and suggest that there is evidence that higher doses are needed to treat cocaine use problems.

Looking at authors methodology, their screening for this trial is instructive of the problems encountered in clinical practice.  Of a total of 1614 patients screened, only 126 were ultimately randomized to placebo, 60 mg/day ER MA, or 80 mg/day ER MA.  Five hundred and sixty two were screened out due to medical or psychiatric exclusion criteria.  It is common in older populations of stimulant users to find significant cardiovascular morbidity in the form of cardiomyopathy, coronary artery disease, and arrhythmias and these were some of the exclusion criteria.  The other aspect of this study that I really liked and would suggest implemented in everyday practice is the authors approach to blood pressure and heart rate specifically:

"Participants with blood pressure higher than 140/90 mm Hg or heart rate higher than 100 beats/min for 2 weeks or with single readings of blood pressure higher than 160/110mmHg or heart rate higher than 110 beats/min were discontinued from study medication." 

It is always shocking to hear from a person who has been on stimulants for years that nobody has ever checked their blood pressure or pulse, especially when they are sitting in front of you and are hypertensive and tachycardic.  This basic procedure should be done on any person taking stimulants, antipsychotics, antidepressant and for that matter any CNS active drug.  If similar effects are noted with any of these medications they should be discontinued.

Another important aspect of this study is that although the patients were well screened, they were complex from a substance use standpoint with current alcohol (18.6 - 27.9%), cannabis (7 - 14%), and nicotine (45-65.1%) use disorders.  The high levels of nicotine use are not surprising considering the epidemiological correlations between smoking and cocaine use and recent evidence about the epigenetic effects of nicotine in substance use disorders.  The authors do not comment on whether there were different outcomes for the non-smokers in this study.

On the primary outcome measure for ADHD - a 30% reduction in the AISRS (Adult ADHD Investigator Symptom Rating Scale) 58.1% of the high strength group and 75% of the low strength group achieved that outcomes with odds ratios of 2.27 and 5.23 respectively (see text for confidence intervals).  In terms of cocaine use outcomes the 80 mg dose resulted in fewer cocaine positive weeks (by any positive toxicology or report) and abstinence in the last three weeks.  The numbers are given in the table below:

High dose MA ER resulted in both a significant reduction in cocaine positive weeks over the 14 weeks of the study.  The 60 and 80 mg doses were actually fairly equivalent form a statistical standpoint and both were superior to placebo in terms of ADHD and cocaine outcomes.  But the real question is whether this is a reasonable clinical approach to this problem?  This was an intent-to-treat analysis with significant drop out rates.  The drop out rates are illustrated in the rapid decline in denominators in each group in Table 2.

In my experience, a substantial number of patients with ADHD and either cocaine or amphetamine use disorder reach the end of the prescribing algorithm where they have failed or relapsed.  In many cases that failure does not lead to a prescription being stopped for many reasons, a lack of information to the prescribing physician being foremost among them.  In the real world there is no clinic that will follow patients three times a week with toxicology screens at most of those visits and offer them all cognitive behavioral therapy.  Models currently funded by managed care companies and governments consist of patients being seen every one to three months for 20 or 30 minutes.  Many of those  visits are done by clinicians with little to no addiction experience.  Within the medication maintenance literature, particularly with buprenorphine maintenance there are studies that suggest psychotherapy adds nothing to the outcomes.  But even without that data what business manager would consider those therapists "cost effective" beyond the stimulant prescription?

A key element that I never see in these studies is the patient's subjective response to the stimulant at increasing doses.    I have found that Koob's definition of addiction is generally predictive:

"Addiction is a chronic relapsing syndrome that moves from an impulse control disorder involving positive reinforcement to a compulsive disorder involving negative reinforcement."

A euphorigenic, hypomanic effect is usually the high risk positive reinforcer regardless of the substance taken.  One of the theories of abuse deterrent approaches is that the pharmacokinetics of the substance used prevents rapid availability in the brain and this decreases abuse potential.  Many abuse deterrent preparations fail because multiples of the dose can be taken and result in the positive reinforcing aspects of the addiction cycle.  I consider the authors' paper to be elegant in its experimental approach.  The graphic at the top of this page is first-rate as a source of information.  It also illustrates the problem of coming up with a clinical trial that can be translated into practice.  I would not consider implementing this strategy as a clinical approach until there was a long term study that looked thoroughly at all of the outcomes.  At this time, I don't think the modest results of this short term study warrant the widespread practice of using extended release mixed amphetamine salts for cocaine use disorders.  There are also legal issues with prescribing maintenance doses of controlled substances in order to "maintain an addiction" as some laws are currently written.  I would have liked to see an attempt to characterize the subjective responses to methamphetamine use measured along with an analysis of whether the non-smokers did better than the smokers.

George Dawson, MD, DFAPA



References:

1:  Drug Facts and Comparisons.  Wolters Kluwer Health.  St. Louis, MO, 2013.

2: Levin FR, Mariani JJ, Specker S, Mooney M, Mahony A, Brooks DJ, Babb D, Bai Y,Eberly LE, Nunes EV, Grabowski J. Extended-Release Mixed Amphetamine Salts vs Placebo for Comorbid Adult Attention-Deficit/Hyperactivity Disorder and Cocaine Use Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2015 Jun 1;72(6):593-602. doi: 10.1001/jamapsychiatry.2015.41. PubMed PMID: 25887096; PubMed Central PMCID: PMC4456227

Attribution:

1.  The figure at the top of this post is from reference 2 above and is used with permission from the American Medical Association, License Number 3660331303348.  Copyright © 2015 American Medical Association.  All rights reserved.

Johnny Cash On Doctors And Chronic Pain

Driving home on a Friday night, as usual I am listening to public radio.  This time I happened to catch an interview with the late Johnny Cash.  Many people are not familiar with how much pain he endured over the course of his life, especially toward the end.  His problems with drug addiction are better known and that combination of chronic pain and drug addiction is a dangerous one.   I found a photo of Cash on Flickr that was taken by a photographer who encountered him when he had significant pain and I am currently trying to get permission to post that photo at the top of this essay.  The years of pain and illness appear to have taken a toll in this portrait and he looks weary.  I heard him commenting in a radio interview on the PBS series Blank on Blank.  After and introduction that describes him as having severe constant pain in his left jaw and the statement that he cannot take pain medications, the interviewer Barney Hoskins suggests that he is brave and Cash replies (1):

Johnny Cash: "No. I’m not very brave because for five years I didn’t try to take the pain.  I fought it.  I had a total of 34 surgical procedures on my left jaw.  Every doctor I’ve been to knows what to do next, too.  To relieve me of pain, I don’t believe any of them.  I’m handling it.  It’s my pain.  I’m not being brave either.  I’m not brave at all after what I’ve been through, I just know how to handle it."

That is hard fought wisdom when it comes to dealing with chronic pain.  In the previous few lines Cash had explained why he could not take pain medications.  He described it being like an alcoholic not being able to drink alcohol.  His pain started when his jaw fractured during a dental procedure and never healed appropriately.  In Hilburn's biography (2), Merle Haggard is quoted as saying that Cash was at a chronic 8/10 level, using the typical 10 point pain scale for the last 8 years of his life.  It is difficult to imagine how hard it might be to try to sing with chronic jaw pain.

Managing chronic pain in a person with a significant addiction problem is one of the most challenging areas of medicine.   For the past 15 years, the USA has been in the midst of an epidemic of opioid painkiller use and accidental overdose deaths.  This has been largely due to the effects of the politicalization of pain and pain medications starting with initiatives to prescribe more opioid pain medications for chronic pain and for acute indications that previously may not have resulted in that kind of a prescription.  From what I can tell, the liberalization of opioid prescribing came about initially as the result of initiatives from the Joint Commission (JCAHO), the Veteran's Administration, and the American Pain Society.  The initiatives can be viewed on this timeline. 

The treatment of chronic pain is also viewed as a treatment that involves multiple modalities.  It can certainly involve the use of various forms of pain medication, but physical therapy and psychological therapies are also mainstays of treatment.  I have consulted in many situations where patients have had multiple surgical interventions for pain that have not been effective.  I have never seen a person with 34 surgical procedures for the same pain.   From a purely medical perspective, the treatment can involve opioid medications, but also gabapentin, pregabalin, and various antidepressants.  Chronic pain is frequently associated with insomnia, anxiety, and depression and additional medical or psychological interventions for these problems is useful.  Many people have strong biases about opioid medications and consider them to be the ultimate treatment for pain.  Double blind, placebo controlled studies show that for neuropathic pain, the relief is moderate and generally equivalent to non-opioids.  Unfortunately for many, that fact is not known until after the person has become addicted to the opioid.

The surgical approach to pain is gradually changing over time.  I did a lot of neurosurgery during medical school rotations and in those days, there was a definite prosurgical approach to back and neck pain.  Imaging studies were more primitive with a predominance of CT versus MRI imaging of the spine.  I observed a lot of laminectomies and posterolateral fusions, using bone graft from a rib or iliac crest.  I was also in the clinic and saw large numbers of patients coming back over time for chronic opioid prescriptions for continued pain that failed to clear up with the operative procedure.  Our standard prescription in those days was Darvocet N-100s,  a fairly low potency opioid analgesic that also contained acetaminophen.  It was voluntarily withdrawn from the market by the manufacturer in 2010 after this labeling revision by the FDA in 2009 highlighting the risk of overdose, cardiac conduction abnormalities and fatal arrhythmias.  In the course of psychiatric practice, I pay close attention to spinal problems.  Spinal injuries are surprisingly common.  Degenerative disease of the spine is also common and there is very little focus on spinal health and the prevention of these problems.  In the people I have seen over the years, good prognosis spinal surgery in terms of pain relief generally involves a well defined lesion and neurological deficit in addition to the acute pain.  Chronic unchanged pain is still an outcome after repeated surgery.  At that point the question becomes, is there any medication that will reduce the level of pain.   Some people will do well with chronic opioids, but the problem is that patients with addiction generally do worse and exposing more and more people to opioids is increasing the number of people with addictions.  SAMHSA suggests the algorithmic approach in Exhibit 3-1 (3) above.  The problem is that there is no good data for relapse, failure, or success rates after trying an opioid for chronic pain in a person with an addiction.  My experience suggests that relapse rates are very high and success rates are very low, but I am seeing a population with a very high rate of addictions
         

In the absence of any markers of opioid addiction liability or reliable interview approaches a conservative approach is required and an extremely cautious approach is required if the patient has a known addiction problem.  The comment on doctors by Johnny Cash is one that is best not forgotten.  One of the reasons that opioids are prescribed in the first place is that pain is chronic and refractory to usual treatments.  In some cases, years of trying multiple opioids and going through residential drug treatment centers has resulted in the perpetuation of chronic addiction and chronic pain.  The algorithm above suggests the appropriate course of action for patients with that problem.  They need to be tapered off the pain medication and typically maintain the medication is necessary.  In many cases there is a significant amount of pain relief and improved function by tapering and discontinuing the opioids.  In some cases, the ability to function improves because the addiction fades away even though the pain is no better.

Johnny Cash got to the point where he could be tapered off the opioids and make it on his own.   That is a tough goal, but one that more people should strive for at least until there is a better solution to chronic pain and addiction.  He also reminds us of the role of physicians in this process.  My overall impression is that there are more physicians willing to draw the line and say: "I really don't think that another operation or medication is going to add much to what you have already tried." ..... but I don't think there is a lot of evidence to back up my opinion.      

George Dawson, MD, DFAPA

References:

1:  Barney Hoskins.  Johnny Cash on the Gospel.  Blank On Blank.  October 1996. 

2:  Robert Hilburn.  Johnny Cash - The Life.  Little, Brown, and Company.  New York. 2013. 

3:  Substance Abuse and Mental Health Services Administration.  Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders.  Treatment Improvement Protocol (TIP) Series 54.  HHS Publication No. (SMA) 12-4671.  Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011. (Figure 3-1 above is from page 34 of this manual).

Will Sitting Really Kill You?

This question should strike fear into the hearts of psychiatrists everywhere.  We do after all spend practically all day sitting.  I easily spend 8-10 hours, 5 days a week sitting in a chair and another 5 or 6 hours on the weekend.  Not all of that time is as comfortable as it sounds, but it certainly does not require a great deal of physical exertion.  This situation only got worse with the placement of computer terminals in every office.  When I first started working, I would walk down the hallway and randomly glance into office doors.  In order to look busy, the people in those offices would typically stare at a paper or papers on the desk or in their hands.  Now everyone is staring at the obligatory computer screen.  I won't digress into the massive problems associated with the computerized model but only point out how people have been immobilized by it.

Several years ago, I started to see stories about people who were exercising while they did their work.  I remember the first story showed an office where the person at the desk lost a significant amount of weight by walking on a 1 mph treadmill while he worked the phones and used his computer.  That was followed by the idea that it was healthier to stand all day than sit.  Suddenly there were people in my clinic standing at work instead of sitting.  And then I started to see the news stories suggesting that it was dangerous for person to sit at work.  Sitting at work could actually lead to a shorter life.  It could kill you.   They were the type of news stories that lead you to an immediate search of your memories to see if this could possibly be true.  Does it have face validity?  Has there been a hidden epidemic of deaths due to - (gasp) sitting.  I rapidly dismissed the idea as a combination of marketing and hysteria.  But the stories persisted.  There was an article from a reputable clinic that described how enzyme activation changed from the sitting to the standing position and that this had an effect on metabolism.  The usual concept for public consumption is that higher metabolic rates lead to more calories burned and weight loss.  It appeals to the American obsessions with calories, food, appearance, and weight loss.  Is there an easy way to trick the metabolism into burning off all of those calories I ate today?  Is there a hack?  Is it as easy as standing up at work all day?

I decided take a two pronged approach to look at this problem - review the whole idea of activity monitoring and examine the available literature.  The following graphic is the display of a Garmin vivofit2 activity tracker.  This tracker plots all activity in terms of steps.  If you are walking too slowly it does not count those steps.  During the setup phase it asks you to select a fitness level and it plots the number of steps per day based on the level you choose and your height and weight.  I chose the level at the 75% percentile or about 7500 steps per day.  So far it has not been much of a problem doing that especially because I work on a campus that requires a fair amount of walking.  The step plot only tells part of the story, because I also cycled 19 miles today, but that is not really indicated in the hour to hour plots - only steps.

Notice the red zones below the graphs.  The tracker emits a soft beeping sound and an extending red bar across the display if you have been "idle" for an hour.  You have to get up and expend about 200 steps to cancel the visual alarm.  The overriding question is whether a warning for inactivity is valid, especially in the case of a guy who just biked 19 miles the same day.  The graphic of that cycling is illustrated below.

It may not be readily apparent but during the time I was cycling, the activity monitor went into a mysterious mode of counting steps.  Not nearly enough to account for covering 19 miles, but it did put a green mark below the line indicating a high activity period.

I make a great example of the immobilized white collar worker who counters that problem with a lot of exercise away from work.  But I go into the endeavor with my eyes wide open.   I can see it now - the guy who thought he was going to live longer than anyone else.  I have already experienced this attitude.  One day I was walking down the hallway eating a granola bar and and one of my colleagues came up to me and said: "Do you think you are going to live longer than me?"  He was using the Socratic method to get at my unconscious motivations for eating a granola bar.  I tried to emphasize to him that sometimes a granola bar is just that and some people like me happen to like the way they taste.  But he wasn't buying that idea.

So if I do keel over, I apologize in advance to my widow and hope that my family will understand  that I present this data with the best of intentions.  I think that it is good data because it involves actual measurements rather than the usual epidemiological data that most of these studies provide.  I have been sitting behind a desk for at least 6 hours a day over the past 35 years.  In that time, I have had 4 exercise stress tests (one was a stress echocardiogram) and a CT scan of the heart.  All of them were negative.  On the CT scan of the heart my calcium score was 0.  For the first 20 years of that period, I was cycling about 200-250 miles per week between the months of May and October and either riding the equivalent time on an indoor trainer or speedskating the rest of the year.  The last ten years, the mileage figure has gone down to 100-150 miles per week with additional strength training.

What about the new sedentary science?  The early data is well summarized in a 2011 review by Proper, et al (2).  The authors reviewed the quality of the evidence and concluded that the evidence is strong for all-cause and cardiovascular mortality, moderate for diabetes mellitus Type 2, and poor for body weight/BMI, obesity, waist circumference, and endometrial cancer.  A very detailed epidemiological study (1) of five different categories of sitting time was very interesting because it showed a correlation of sitting time dose on mortality and it showed that effect persisted even if controlled for BMI, smoking status, and activity level when not sitting.  Suggested mechanisms included lipoprotein lipase activity and the effect of being sedentary on cardiac stroke volume and output.  The effect on lipoprotein lipase activity was not trivial with one study showing that activity restriction resulted in a 10 fold elevation decrease of lipoprotein lipase activity in red oxidative muscle fibers.   Subsequent studies show that breaking up sitting time has the expected positive effects on metabolic markers including triglycerides, waist circumference, and fasting blood glucose.  Some recent studies have looked at measures of endothelial function (3) and demonstrated that there is a measurable decline with 3 hours of sitting that can be countered by walking for 5 minutes at 2 mph every hour.  If replicated that has important implications for office workers who think they need to stand or walk on a treadmill continuously in order to prevent the problems associated with a sedentary work environment.  It also has implications for the kinds of exercise that we recommend to patients for prevention of metabolic syndrome and cardiovascular disease.  Although I am aware of no clear guidelines it may mean at some point that our sedentary patients may just need to get up and move around in a low intensity manner on an hourly basis and plan a more high intensity exercise at least once a day.  It also has implications for the patients we see who have not been moving much and have significantly abnormal lipids profiles like people who are admitted to hospitals and residential treatment centers who have been immobilized for weeks or months.  It may mean that medical therapy for dyslipidemia is not necessary until the patient is up and moving about for a while.  It may also have implications for the cognitive dysfunction noted with many psychiatric diagnoses.  In the past year I saw Roger S. McIntyre, MD present data on cognitive problems in bipolar disorder and major depression patients that were correlated with obesity and metabolic syndrome (5).  Impaired executive function persisted during periods of euthymia.  Interventions that impact those metabolic factors may have an effect in improving cognition.   A more recent review takes a look at the variables that may be important in the types of exercise used to break up prolonged sitting times (4).

  
My preliminary take on all of this data is that sitting may be dangerous to your health, especially if your BMI is high and you have other risk factors.  In many of these studies the effect size of sitting seem relatively robust independent of other risk factors.  The measurements of rapidly deteriorating endothelial function over a period of hours raises a lot of questions.  For example, most people are going to be sleeping at least 7 hours per night.  Is there the equivalent amount of deterioration over that time period, or are there protective mechanisms during sleep that prevent that problem.  The 2001 review classifies sleep as a sedentary behavior that does not raise energy level substantially above rest.  And what about the idea that these periods need to be broken up by low level exercise every hour?   What are the optimal times and exercises for doing this?  The validation studies for these measures seem daunting.  And finally what about the technology.  It is obvious from what I have posted here that it is at a primitive stage.  Different manufacturers are marketing different features.  One manufacturer has a device that claims to wake you up in non-REM sleep in the morning.   I chose my device as the only one that has a one year battery life.   Practically every other equivalent fitness monitor battery lasted from 4-30 days.  I could use a monitor that tracks more than steps.  My guess is that my current device picks up some other accelerations based on the fact that it characterized my 20 mile bike ride as "high activity" but gave me a negligible number of steps.  It also needs to do a better job detecting sleep instead of using my specified sleep hours as a way to not count inactivity.  The best example of that is my attempts to catch up on sleep on Saturday and Sunday mornings being counted as inactivity.  And finally, if I am logging into a manufacturer's web site to log activity on all of the devices I have purchased,  that interface  should do a good job of integrating all of that data in a logical manner and showing the relevant scientific parameters.  A few references would not hurt.  I understand that a move to using software on your personal computer is a step away from the domination of internet cloud enamored device companies but I can't imagine there is not a market for that and the best possible display of data.

All things considered, it looks like there might be something here.  One of my colleagues stated her opinion that these devices might be useful for people who don't do much exercise.  But is there is a separate effect of being sedentary on your metabolism that prevents you from getting all of the effects of high intensity exercise?  There are reports of long time endurance athletes and high intensity athletes either sustaining heart attacks or having clear coronary artery disease at angiography.  A basic study that I could not find was the effect of interrupted sitting on lipid profiles and BMI.  That would be a difficult study to do because of the effort it would take in a community sample.

For now, I will add activity monitoring to my other exercise routines and see what I can learn from it.


George Dawson, MD, DFAPA


References:

1:  Katzmarzyk PT, Church TS, Craig CL, Bouchard C. Sitting time and mortality from all causes, cardiovascular disease, and cancer. Med Sci Sports Exerc. 2009 May;41(5):998-1005. doi: 10.1249/MSS.0b013e3181930355. PubMed PMID: 19346988.

2:  Proper KI, Singh AS, van Mechelen W, Chinapaw MJ. Sedentary behaviors and health outcomes among adults: a systematic review of prospective studies. Am J Prev Med. 2011 Feb;40(2):174-82. doi: 10.1016/j.amepre.2010.10.015. Review. PubMed PMID: 21238866.

3:  Thosar SS, Bielko SL, Mather KJ, Johnston JD, Wallace JP. Effect of prolonged sitting and breaks in sitting time on endothelial function. Med Sci Sports Exerc. 2015 Apr;47(4):843-9. doi: 10.1249/MSS.0000000000000479. PubMed PMID: 25137367.

4:  Benatti FB, Ried-Larsen M.  The effects of breaking up prolonged sitting time: a review of experimental studies.  Med Sci Sports Exerc. 2015 February 4, 2015, published ahead of print.

5:  Bengesser SA, Lackner N, Birner A, Fellendorf FT, Platzer M, Mitteregger A, Unterweger R, Reininghaus B, Mangge H, Wallner-Liebmann SJ, Zelzer S, Fuchs D, McIntyre RS, Kapfhammer HP, Reininghaus EZ. Peripheral markers of oxidative stress and antioxidative defense in euthymia of bipolar disorder-Gender and obesity effects. J Affect Disord. 2014 Oct 22;172C:367-374. doi: 10.1016/j.jad.2014.10.014. [Epub ahead of print] PubMed PMID: 25451439.

Attribution:

The chair photo at the top of this post is by Humanscale (shop.humanscale.com) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/)], via Wikimedia Commons.

Schizoaffective Disorder and Surfing Music

I will disclose my biases on schizoaffective disorder from the outset.  My decades of acute care experience suggests that it is a lot less common than suggested by medical records.  Reflecting on the unique experience of seeing people hospitalized many times over the course of 20 years, the most frequent pattern I observed was clear cut bipolar disorder turning into a diagnosis of schizoaffective disorder or in some cases "bipolar disorder and schizophrenia".  Since I worked at this hospital long enough and had the memories of my enthusiastic young psychiatrist self and my compulsive documentation to count on, I can say that the most frequent pattern was patients presenting with manic episodes turning to the less specific diagnosis.  Most of these people were in their 20s or 30s when they experienced a clear cut manic episode.  There was no doubt about it because of the rapid onset and mood congruent psychotic symptoms.  They responded well to treatment and I discharged them from the hospital.  They would be rehospitalized from time to time, either on my inpatient service or another.  I would eventually see them in more detail after another 5 - 20 hospitalizations, look at the chart and notice that for some time, the diagnosis had become schizoaffective disorder.  Some would ask me about the diagnosis and some recalled the original diagnosis.  If they asked my opinion, I would always tell them what I considered to be the best answer: "As far as I am concerned, your diagnosis is still bipolar disorder.  I am basing that answer on your first hospitalization and your response to treatment.  You don't have any residual symptoms.  Having episodes of bipolar disorder for various reasons does not change the diagnosis."

One of the biases that exists about this diagnosis is that it tends to be more chronic and difficult to treat than bipolar disorder.  The reality is that bipolar disorder can be associated with a significant number of losses in terms of social network, net worth, and in some cases functional capacity.   There are frequently problems with alcohol and use of other intoxicants. Primary psychiatric disorders are always made more complicated by addictions. Like schizophrenia and depression, psychiatric research has not done a good job of defining the cognitive problems associated with bipolar disorder or coming up with successful treatment approaches. Although some rehabilitative approaches are in place for people in Assertive Community Treatment (ACT) programs, successful treatment is usually based on getting the mood symptoms in remission and the prevention of rehospitalization and suicide.  I have treated people on an outpatient basis with chronic mood disturbance and a diagnosis of schizoaffective disorder - bipolar type who work and function at an excellent level.  If they ask me what the diagnosis is - I tell them that it is probably bipolar disorder, even if they have episodic hallucinations.  I tell them "probably" because I know how the diagnosis of schizoaffective disorder is made.  And also because they are functioning well and I don't think that there is a lot of good information on the prognosis of that disorder.  At some level I am also probably biased by the idea that bipolar disorder has a better diagnosis.

My experience with the schizoaffective disorder diagnosis is a necessary backdrop for the following comments from the screenwriter Oren Moverman on whether composer Brian Wilson has a mental disorder:  "Yes, and it's public knowledge. It's called schizoaffective disorder, and it's really a combination of some schizophrenia symptoms, like hallucinations, and mood disorder, such as depression." (see transcript for reference 1).  Moverman is the screenwriter for the Brian Wilson biopic Love and Mercy.  For younger people reading this, Brian Wilson is the founder and composer for the rock and roll group The Beach Boys.  When I was in middle school in the 1960s, people of my generation started dancing to this group.  Their early genre was known as surfing music, based on that culture in southern California.  In these interviews Wilson talks about how he got started writing surfing music.   During the broadcast one of the early songs was Catch a Wave and that immediately brought me back to this time:





The Beach Boys were very successful in that type of music and made a significant comeback in the 1970s and 1980s with different types of music.  Behind all of that was Brian Wilson, a widely acknowledged musical genius who also performed live with the group in its early days.  Wilson is also known for his mental illness and substance use problems as well as his involvement with a highly controversial therapist.  The therapy methods included exerting total control over Wilson, by living with him 24/7 and having him under constant supervision by several case managers.  Wikipedia states that the cost of these services was about $20,000/month.  There was an initial 14 month episode of involvement followed by dismissal due to a dispute over fees and then another episode of involvement prior to permanent dismissal and placement of a restraining order.  Although that therapist seems to be credited in many ways with saving Wilson's life and getting him back to composing music, he was also reported to his California psychology licensing board for violations of professional conduct and according to Wikipedia resulted in a loss of license.  That same source points out that Wilson developed tardive dyskinesia and impaired functional capacity from prescriptions from this therapist's "staff".  I did not see any reference to prescribing psychiatrists or physicians.

This brings me to the inspiration for this post.  Once again it is Fresh Air's longtime interviewer for this program - Terry Gross.  In this series of interviews, Gross starts out with a story about the release of a new film about the life of Brian Wilson titled Love and Mercy.  She has two interviews that she conducted with Wilson from the past and a current interview with the screenwriter of the current film. One of the full length interviews is available on the Fresh Air web site from 2002, but I could not find the one from the 1990s.  There are also excerpts of earlier interviews played in the current interview.  The author starts out describing the focus on three discrete periods in Wilson's life and how that proved to be too much and how the focus had to be narrowed to two periods in the 1960s and 1980s.  Because of those time frames, Wilson is played by two different actors Paul Dano in the 1960s and John Cusack in the 1980s.  Moverman comments on the technical aspects of the film, like the reason for focusing on the musicians.  He also comments on the therapy controversy and states that Wilson was misdiagnosed and overmedicated.  At that point Terry Gross comments that the California Board of Medical Quality Assurance was investigating the therapist because medications were being prescribed and he was not licensed to prescribe them.

One of the most interesting aspects of Gross's work is the historical context.  She has commentary from Brian Wilson in an earlier interview commenting on the therapist controversy:

WILSON: "He's been performing a health operation on my head. He's done something that's impossible that nobody could do."

GROSS: "What do you think he's done that's really worked for you?"

WILSON: "Well, what he's done that worked for me was he's taken my body and transformed not only my physical shape, but he's transformed the chemistry within my blood, you know, from dirty to clean. And when you go through those transformation periods, you go through a little hell, you know what I mean? It's a little bit of hell to have to come through all that, all right?......."

Moverman thought that Wilson was referring to getting him off of intoxicants when he refers to blood chemistry.  Listen or read the complete transcript but in this section Wilson emphasizes the need for moving ahead rather than focusing on revenge for something that happened in the past.  I encourage anyone interested in this particular story or recovery from mental illness to listen to Brian Wilson's spoken words in these interviews with Terry Gross. 

Any acute care psychiatrist will probably be interested in this story.  For me it highlighted a number of issues.  Whenever I see a story like this, the usual way it is handled in the media is to get an expert and try to make diagnosis.  This is exactly the wrong thing to do at many levels.  One of the main concerns is the interplay between substance use and psychosis and mood symptoms.  In my experience, 95% of people seen in acute care and addiction settings are misdiagnosed with bipolar disorder, schizophrenia, depression, and even attention deficit hyperactivity disorder when they have a clear substance use problem that is responsible for those symptoms.  That does not mean that medical treatment is not necessary, but it probably means that it will be temporary.  I am not prepared to say that was an issue in this case, only that when you have seen that problem as often as I have that is one way to approach the issue.  The other dimension here is how difficult it is to effect changes and help people get back on path when they are clearly engaged in high risk and what is described in these transcripts as destructive behavior.  There are really very few options left for people with problems as severe as the ones that Brian Wilson was going through.  In most cases, it is a number of emergency department visits and brief admissions to psychiatric units.  I can say without a doubt that problems this severe are not reversible by those interventions or outpatient visits for twenty minutes to see a psychiatrist every one to three months or seeing a therapist every week for an hour.  Most people stop seeing the therapist after a visit or two.  They may have the thought that they are seeing the therapist because it is somebody else's idea.  

I certainly do not condone the therapy methods used Wilson's case, but fully acknowledge that our current systems of care are not likely to produce a positive result for persons with severe disabilities.  Above everything else this is a story of recovery.  Brian Wilson endured acute symptoms and significant disability and came out the other side.  He continues to write and produce music and that music inspires millions of people.  


George Dawson, MD, DFAPA


References:

1:  Fresh Air with Terry Gross.  'Love & Mercy' Brings The Life Of Brian Wilson To The Big Screen'.  June 18, 2015.

2:  Fresh Air with Terry Gross.  Producer And Arranger Brian Wilson, A Genius Of Rock.  August 27, 2002.

Supplementary:

I have not seen Love and Mercy yet but will probably add a few comments here when I have.

Attribution:

By Brocken Inaglory (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

The Mind and the Power of the Spoken Word

My usual drive home from work last night.  It was a late night and on these nights I get to listen to Terry Gross interviews on Fresh Air.  In two interviews, I heard two excerpts of speech that for both the content and the way they were delivered were just compelling.  Gross typically replays interviews of famous people that she has interviewed right after their deaths.  Her interviews are generally so comprehensive and have offered insights into the person that they serve as great memorials to that person and their work.  The first in an excerpt from an interview with Christopher Lee, the actor.  I have seen him in many roles, but remember him best for his work in Star Wars and Lord of the Rings.  He died last Sunday at the age of 93.  In these sentences, Gross asks him how he decided to play Dracula.  Only the words are listed below.   The interview occurred 25 years ago and he would have been 68.  Listen to the audio to capture how these sentences were delivered spontaneously:

LEE: "I never thought of him as - I never thought of him as a vampire, ever.  I mean, the blood is the life.  That's one thing you have to bear in mind.  And it is for all of us, isn't it?  Here's a man who is immortal.  Here is a man who, through being immortal, is a lost soul.  Here is a man who experiences the loneliness of evil, something he can't control, who wants to die but there is a force in him, a malefic force, which drives him to do these terrible things.  I said earlier the character is heroic, based on the real man - a war leader and a national hero, I may say, in Romania to this day - Vlad the Impaler....."

The second interview was with several people to commemorate the life of jazz great Ornette Colman who died this week at the age of 83.  He discusses how he innovated a type of jazz that was so controversial that it polarized people to the point that they would show up in clubs where he was playing and fights would break out over the music.  People would swear at him and try to strike him.  One of the musicians interviewed said that he witnessed Coleman being punched in the face over his music.  Here he tells Gross about his instructions to his fellow musicians about how to play his innovative style of music:

ORNETTE COLEMAN: "I had - originally, I had told them, I said, you know, the bass - the basics of music is first learning how to play music on the instrument that you choose to play.  Secondly, to eliminate the problems of having a style that get in the way that you think or feel.  And third is to not get so hung up in the technique of your instrument that you cannot play music anymore.  So - and I demonstrated those kind of things to them.  And since I first started, I was using just the trumpet, the bass and the drums, which was not lots of musicians at that time, so it was very simple for me to give them the information that I had figured out."

Equally interesting are the musicians interviewed and their descriptions of Coleman, his music, and the times.  They are Don Cherry, Denardo Coleman, and Charlie Haden who were all members of Ornette Coleman's quartet.  It seemed evident to me, that their performances were ground breaking.  They are all dedicated musicians at the top of their game, but more than that - they know how to work together.  At one point Gross asks Ornette Coleman a question about about working with his son Denardo.  He comments on the nature of the question and basically concludes that he likes to work with someone who knows what he is trying to achieve.  I strongly encourage listening to the recording of these men and their descriptions.

These interviews are very interesting to me from a number of perspectives.  The first is the experience of having your fantasies exploded.  If you watch a lot of films, there may be a time when you say: "I can do that." or "He/she acts the same way in every film".  That certainly might be true, but it also might be true that you are seeing a small fraction of the person in that particular role and it is difficult to have an appreciation for everything that went into it.  I have seen Robert DeNiro movies since his first critically acclaimed role in Bang the Drum Slowly.  I saw that in a dilapidated theatre in northern Wisconsin and it was apparent he brought a lot to the role.  But it wasn't until I saw him interviewed by James Lifton about 40 years later that I had an appreciation of the level of art he was exposed to in his childhood or how early he had started in acting.  

It is easier to appreciate the genius of musicians.  The only thing that is needed is an instrument and your own feeble attempts at trying to create music.  Even the most basic rock and roll requires more than casual effort.  I was trained to play cello and clarinet in grade school and high school and like most people let it slide after that.  Science and athletics seemed more important.  With the rudimentary training, I think that I can safely conclude that jazz, especially creating an entirely new and controversial style of jazz is a sign of real genius.  This excerpt from an interview with Charlie Haden, jazz musician and bass player for Coleman.     

CHARLIE HADEN:  "I was 19 years old, and we played all day long. And he had a room full of music strewn all over the floor, the walls, the ceiling; he was constantly writing music.  And he told me before we started to play, he said, Charlie, I've written these pieces now and here's the chord changes.  Now, these are the chord changes that I heard inside myself when I was writing the melody, but these are just a guide for you.  I want you to be inspired from them and create your own chord structure from the inspiration or from the feeling of what I've written.  And that way, constantly a new chord structure will be evolving and we will be constantly modulating, and we'll be listening to each other, and we will make some exciting music.  And that's exactly what happened."

I heard this and thought about the true genius of Coleman as a manager.  Imagine if you worked for a guy like Ornette Coleman doing any less complicated work.  A person who told you, well here is the basic structure of your job, but I really hope that you can innovate within these constraints and create new ways to do it.  It is difficult to find areas in life where somebody had that kind of vision in terms of people working together to create something but Ornette Coleman clearly did.

I talk to people for a living and have for 30 years - typically 60 to 90 minute initial interviews.  I don't like to impose too much structure, but I do have to cover at least 200-240 information points in varying degrees of detail.  Many of the people I talk with are like the above excerpt from Christopher Lee.  They are brilliant and have a command of the language.  Their vocabulary is excellent.  I gauge it by how many low frequency words they tend to use.  The words can't be jargon.  They have to be the same words that we all have access to in a dictionary.  I was taught at one point that there is a rough correlation between compound sentences and intelligence.  I usually comment on both the vocabulary and sentence structure in my dictations that record the results of the interview.  In some cases I comment on the emotional impact of a more objective observer - how someone standing in the room might be affected.  Psychiatrists are limited in the range of descriptors that they can use, largely because the field has limited itself to significant psychopathology.  That is fine for clear situations when those descriptors occur, but what about the majority of situations where they do not?  I like to push the envelope and explore those situations.  What if I am talking to a person who most people would see as being charismatic and that is the overwhelming aspect of the interview?  What if the person talks as if they are reading their answers out of a book containing compound sentences and low frequency words?  What if they are surprisingly different than what it says on the consult request?  Can I make those determinations?  I routinely do.

Another interesting aspect of these interviews is the time dimension.  In the course of clinical practice it is common to hear clinicians compare notes on how they conduct their clinical practice.  There are various external and internal rules applied to come up with the duration of interviews.  The entire duration of the interviews with Lee and Coleman were 15 minutes or less, but they were excerpted from longer interviews.  In psychiatry at some point, a decision by the psychiatrist is made about how much (if any) non-clinical discussion can occur.  The clinical discussion is driven by the billing and documentation guidelines determined by governments and insurance companies.  I have found that rarely accounts for all of the relevant treatment factors.  At the minimum, there is some source of stress at home or at work.  Some additional issue or question that requires a more detailed discussion.

In other interviews, I hear amazing stories like Charlies Haden's description of meeting Ornette Coleman.  One of a kind experiences from the full range of absolutely inspiring to absolutely traumatic - communicated to me with a full range of positive to negative emotions.  Not everyone is a genius, but everyone has a story to tell or history to give.  I have spent all of my life spinning that information down to see if there are any syndromes in that hinterland that is two standard deviations out past most human behavior.  I don't really know when it happened but at some point, I realized the importance was in all of the information.  I realized that when somebody says: "How much time do we have doc?" or "Do you want the short version or the long version?" that the correct answers are "All the time you need." and "The long version."  If the long version gives enough detail about the person's life, it allows me to say: "There is absolutely no way that you have that diagnosis from the history you just gave me."  It gives me more than enough to answer the more common question: "So doc - am I crazy?"

You never really know the whole story without all of that information communicated directly to you by the person who lived it.

George Dawson, MD, DFAPA

References:

Listen Back To A 1990 Interview With Actor Christopher Lee - June 12, 2015  Interview and Transcript.  NPR Fresh Air with Terry Gross.

Fresh Air Remembers Jazz Innovator Ornette Coleman - June 12, 2015  Interview and Transcript.  NPR Fresh Air with Terry Gross.


Attribution:

The photo of Ornette Coleman:  By Nomo michael hoefner http://www.zwo5.de (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons.

Delirium Reinvented

One of my colleagues posted an article from the The Atlantic on delirium to her Facebook feed a few days ago.  Most of my colleagues in that venue are hospital, consultation-liaison, addiction or geriatric psychiatrists and we diagnose a lot of delirium.  Entitled the Overlooked Danger of Delirium in Hospitals it makes it seem like this is some kind of new and strange diagnostic category.  The article talks about the prevalence, the association with critical illness and advanced age, and the diagnostic overlap of dementia and delirium.  We hear from an Internal Medicine specialist Sharon Inouye, MD about the need to correctly diagnose and prevent delirium.  She mentions that as opposed to a decade ago, physician and nurses are all taught about delirium.  There is mention of the CAM (Confusion Assessment Method) that Inouye developed.  Like all health care articles there are estimates of the massive cost of delirium as well some prevention techniques.  There is also political concern that Medicare will declare delirium a "never" event with penalties for any hospital with cases of delirium.  That would be unfortunate because it makes a mistake that also seems to be made in this article - that delirium is a manifestation of many illnesses, especially the kind of illnesses that patient's are hospitalized for.

The article seemed odd to me because it was written from the perspective that delirium is an iatrogenic preventable event!  Certainly that can be the case. Delirium is a primary feature of hundreds of different disorders and recognizing delirium and those etiologies is potentially life saving.  Delirium can mimic psychiatric conditions due to the presence of hallucinations and delusional thinking.  For example, it is entirely possible to see a patient in the emergency department with apparent paranoid delusions and miss the fact that they happen to be delirious.  Sometimes the only sign is that the patient is inattentive and when vital signs are checked they have an elevated temperature.  This can be a common presentation of viral encephalitis in younger patients or urinary tract infections in the elderly.  It is bad form to miss either of those diagnoses and attribute the symptoms to a psychiatric disorder.  Another common form of delirium that is missed is drug or alcohol intoxication or withdrawal states.  Some intoxicants will render the patient totally unable to care for themselves until they are detoxified.  Other deliriums from alcohol or sedative withdrawal are life threatening and can be associated with seizures and other life-threatening states.  An acute change in a person's mental state resulting in delirium needs to be recognized and assessed as a medical emergency.    

One of the first cases of delirium that I ran into after residency was a case of cerebral edema that I was consulted on because of "hysterical behavior".  After that, I worked in and eventually ran a Geriatric Psychiatry and Memory Disorders Clinic for about 8 years.  The majority of people coming to that clinic had dementia of some sort.  They would see me and a neurologist.  We started out with an internist who was also a geriatric specialist, but that turned out to be overkill in terms of the number of medical specialists seeing each person in an outpatient clinic.  We eventually opted for records from the patient's primary care physician.  One of the most valuable functions of that clinic was our ability to follow people with prolonged deliriums.  Once a delirium has been established by a disease state and that state has resolved the delirium can persist for months.  Some of the outliers in that clinic took up to 6 months to clear.  We found that in many cases, the patients were extensively tested for intellectual ability and functional capacity when they were in the delirious state and told that they had dementia.  It was always instructive for the patient and family to get the testing repeated when we were sure the delirium had resolved and find that they had been restored to baseline.  Many people know their full scale IQ score and were relieved to see that they were back to that level of functioning.

A valuable lesson from working in that clinic and in hospital settings was the use of the electroencephalogram (EEG) as a possible test for delirium.   EEGs are commonly viewed as diagnostic tools to determine if a person is having seizures, but they also contain a lot of information about brain metabolism.  EEGs can be difficult to interpret especially if the patient is on a number of medications that affects cerebral metabolism. There are two broad categories of EEG patterns for delirium: one with a predominance of slow frequencies (designated theta and delta) and one with faster frequencies (designated beta).  We found a number of people with very significant cognitive impairment that was thought to be either a psychiatric disorder or a dementia but with a profound degree of slowing more consistent with a delirium.    

Delirium is an augenblick diagnosis for most psychiatrists.  The patient could appear disinterested, apathetic, agitated, or overtly confused.  It occurs in situations where brain physiology is compromised such as post surgical/anaesthesia states, drug intoxication states, drug reaction states, or possible physical illness delirium should be high on the differential diagnosis.  The Atlantic article makes it seem like knowledge about delirium is something very recent, but psychiatrists have been focused on it for a long time.  In the first two iterations of the DSM, delirium was subsumed under the categories of acute and chronic brain syndromes (DSM-I 1952) and organic brain syndromes (DSM-II 1968).  The current diagnostic code and name has been with us since the DSM III in 1980.  One of the early experts in delirium was Zbigniew J. Lipowski, MD, FRCP(C) - a Professor of Psychiatry from the University of Toronto.  His first text on the condition was Delirium: Acute Brain Failure in Man published in 1980.  That was followed by his classic text,  Delirium: Acute Confusional States published in 1990.  A comparable text from a neurological standpoint was Arieff and Griggs Metabolic Brain Dysfunction in Systemic Disorders published in 1992.

Any psychiatrist trained in the past 30 years should be able to diagnose delirium and come up with a differential diagnosis and monitoring or treatment plan.  A significant number of people can be followed on an outpatient basis as long as they are in a safe environment with the appropriate level of assistance.  The main goal of treatment is to make sure that the primary medical illness that led to the problem has been treated.  There are no known medications that will accelerate the resolution of these symptoms and medical management usually involves getting rid of medications that can lead to cognitive problems.  That can include benzodiazepines, antidepressants and antipsychotics but also more common medications like antihistamines and anticholinergic medications that are used for various purposes.  Like most psychiatric interventions in our health care system, clinics with staff interested in doing this work are few and far between generally because they are rationed resources.

There is a current movement underway to train Family Physicians and Internists (like Dr. Inouye) to recognize and prevent delirium.  In the minority of hospitals where psychiatrists work they are also a clear resource.  A delirium in a previously healthy person should signal a fairly comprehensive evaluation to figure out what happened.

And whenever there is a question of whether a person has a delirium or a psychiatric disorder - call a psychiatrist.  Psychiatrists know a lot about delirium and have for decades.



George Dawson, MD, DFAPA



Reference:

Sandra G. Boodman.  Overlooked Danger of Delirium in Hospitals.  The Atlantic.  June 7, 2015.


Supplementary 1:  The graphic is a standard EEG.  I tried to post a slowed EEG seen in delirium, but the publisher wanted what I consider to be an exorbitant fee for a non-commercial blog.  If anyone has a slow anonymous EEG laying around, send me a copy and I will post it.

The Myth of Monolithic Psychiatry

One of the familiar strategies of the various antipsychiatry factions out there is the monolithic psychiatry tactic.  A monolith can be a monument that is often a large rectangular block of stone.  The most recognizable monolith in my time was the recurring black monolith in 2001 - A Space Odyssey.  A monolith can also refer to "a large and impersonal political, corporate, or social structure regarded as intractably indivisible and uniform."  In that sense, a monolith can just be a fact.  I could refer to just about every government agency and insurance company that I have to deal with as monolithic.  They couldn't care less about anything that I say to them or how infuriating it is that I have to deal with them.  Their only interest is in their corporation and doing the absolute minimum that might cost them something and they are very good at it.  In practical terms that means authorizing any treatment I am forced to ask them about.  But in a new twist many of these organizations also aggressively trying to make any physicians they are working with - look bad.  They must think there is some advantage in keeping physicians on the defensive.

The beauty of monoliths is that no matter how hard you try there is no way to break in and get what you want.  No matter how many times I call the government bureaucracy in charge of dealing with managed care company complaints, I will get the same predictable runaround.  The first several lengthy calls will result in me talking to people who are not even sure that they should be talking with me.  They will send me to somebody in another building in an obscure department and eventually the calls will stop again.  I have wasted many hours of my life trying to crack into this monolithic state government bureaucracy without success.  I think it also illustrates some additional defining characteristics of monoliths - secrecy, anonymity, and a lack of accountability.  Eventually you end up talking with people so far removed from the problem, it is not clear how you ended up in touch with them in the first place.  Their names and positions are meaningless.  It is clear that they can't help you and if you wanted to complain about them it would not make any difference.  They are so far removed from your original problem it doesn't matter anymore.  You can rage against the monolith as much as you want and it doesn't make any difference.  There may be a conspiracy of monoliths if you are working with an employer who wants you to try to cooperate with them and makes that part of your contract.  Employers like that are often monoliths themselves, with various strategic firewalls around the organization to prevent employees from providing feedback on company policy.  Monoliths often trigger conspiracy theories because they are either intentional or unintentional conspiracies.

That brings me to the interesting phenomenon of monolithic psychiatry.  Assume for a moment that all psychiatrists in the country are in a monolithic structure like the one I described for the state bureaucracy.  It might make sense for someone to rage against the monolith by declaring psychiatry is heavily influenced by the pharmaceutical industry or psychiatry overprescribes medications or psychiatry isn't interested in psychotherapy or whatever anyone wants to apply to the monolith.  Since we are talking about a monolith, whatever applies to one psychiatrist applies to them all which logically makes the criticism one big absurdist editorial.

There are many things wrong with that picture.  Psychiatrists have the most diverse population of any medical specialty and it is the farthest to the left.  More psychiatrists are liberals and psychiatry is the only specialty group that is predominantly composed of Democrats.  The broad range of interests of psychiatrists are evident at any American Psychiatric Association (APA) meeting and various annual subspecialty meetings.  Courses are available on a broad range of medical, neuroscientific, and psychosocial topics.  Psychiatrists work in a number of specialty areas and it is very likely that certain practices are highly specialized and focus only on the diagnosis and treatment of specific conditions.  That is not the structure of a monolith.  The total number of psychiatrists varies on the source.  The American Medical Association (AMA) census in 2010 put the number at 42,885.  The Census put the number at 40,600 in 2009 and of those 26,200 were office based.     According to the Bureau of Labor Statistics there are only about 25,000 psychiatrists who are employees of organizations.  The remainder are in private practice.  The American Psychiatric Association sent me the following data on the membership for the past 15 years.

  

As a measure of monolithic behavior,  in one of the most critical APA election in recent years regarding maintenance of certification (MOC) only 6,943 members voted.  Action requires a vote of at least 40% of the membership.  Interestingly the MOC vote occurred in 2011, the year of the lowest number of members.  The total vote was not close to the 40% number, but it exceeded the vote for the President Elect and Secretary by about 1,300 votes each.  Presidents are typically elected by less than 20% of the members.  These facts illustrate that the majority of psychiatrists in this country at any one time are being directly influenced by employers and in the overwhelming number of cases those employers are managed care organizations whose policies are generally inimical to quality psychiatric care.  It is also apparent from the vote and the election patterns within the APA, that there is not a lot of political activism or interest for that matter.  Hardly the behavior of a monolith.

The real difference with monoliths is the anonymity and secrecy issue.  Every practicing psychiatrist is on record as being responsible to his or her patients.  That responsibility is documented in medical records and pharmacy records.  In any state, any physician can be reported to a medical board for practically any reason.  Psychiatrists are held to the same professional standards as all physicians and that is a high bar, but it illustrates again - no monolith.  I can beat my head against the wall all day trying to get a prescription authorized, but any complaint about me gets immediate attention and immediate scrutiny of my practice by the state medical board that I practice in, my employer, various committees or other state agencies, and in some cases my malpractice insurance carrier.

All of these factors combine to lead to more diverse interests and opinions that in any other field of medicine.  As far as critics of the field, some of the best criticism comes from within psychiatry than from anywhere else.  That does not prevent the various antipsychiatry factions from posting blanket criticisms of "psychiatry" (whatever that might be) and coupling it with any irrational or rhetorical criticism that they might like.  I criticized some of this in the past and avoided most of the expected endless argumentation in response to my replies to these points.  To me the rebuttals are factually no big deal, but critics of the monolith are so certain about themselves that they really don't do well with criticism directed back at them.   I thought I would illustrate my point about monolithic psychiatry with some direct quotes from Robert Whitaker's book Mad in America.  The page numbers are included for reference, but they are all from Chapter 7.

             

I thought about addressing all of these quotes point by point, but decided that would be the standard type of endless argument that passes for Internet discourse, but is really an exercise in futility. Instead, I will just point out what I mean by the monolith strategy.  In this case the author looks at a combination of quasi-experimentation, historical associations, rhetorical arguments, and actual problems that were researched and changed by psychiatrists themselves to indict monolithic psychiatry.  Monolithic psychiatry is frozen across time.  It can never change and it almost certainly does not self-correct without the valuable input of people who have never been trained as psychiatrists or practiced psychiatry.  There is no reason to expect that any of the worst case scenarios described were rare events or that they are less likely to occur today.   Monoliths don't change.  This is an interesting perspective of course because there is no organization or profession that could withstand this kind of criticism.  It is a unique form of criticism that is only applied to monolithic psychiatry.  It is also interesting because the real monoliths behind the current plight of the mentally ill in this country that I mentioned in the first few paragraphs are completely left out of the picture.

As recorded history would have it, things have changed and they continue to change.  Psychiatrists can treat mental illness successfully across a number of settings and with a number of methods.  It happens on a daily basis and it happens hundreds of thousands of times per day.  It doesn't happen because monolithic psychiatry has a monopoly on the treatment of mental illness or a diagnostic manual.  There are many more primary care physicians and non-psychiatric mental health providers (see supplementary 2).  It happens because the treatment is successful and psychiatrists generally provide patients with the treatment and information that they need.

That is hardly the behavior of a monolith.



George Dawson, MD, DFAPA



References:

Robert Whitaker.  Mad In America.  Basic Books, New York, 2002.  pp.  161-193.


Supplementary 1:  The graphic at the top is from Shutterstock. 

Supplementary 2:  Psychiatry is dwarfed by the number of other mental health providers including 88,000 Family Practice specialists, 162,400 Internists,  100,000 psychologists and 120,000  Social Workers.  I don't know the number of Psychiatric Nurse Practitioners or Physician Assistants whose primary role is to prescribe psychotropic drugs, but I will happy to add it if somebody has that information.  Although I am sure that some of the physicians in these primary care groups don't prescribe some psychotropics, I am sure that 80% of all psychotropic medications in the US and most western countries are not prescribed by psychiatrists.  So remind me again, what would Big Pharma get out of controlling monolithic psychiatry with pizza, donuts, and KOLs?