Billboard - Stigma or Not?

I don't know how I missed the controversy but the APA has vigorously criticized a billboard that sends a message about inadequate access to mental health services and inadequate gun control.  I found out about it only through the APA listserv yesterday.  The Psychiatric News alert can be viewed here.  The billboard can be seen on major news services like NBC here.   If anyone can spare a photo of this billboard please e-mail to me and I will post it in the body of this essay.  The message basically states "Over 40 million Americans with mental illness - some can access care - all can access guns."  It is signed by Kenneth Cole.  He has a history of activist billboards and Twitter posts and is no stranger to controversy.  He has also discussed raising his brand's profile through the social responsibility messages.  In this case some APA members were outraged at what they perceived to be a stigmatizing message.

My perspective is that the message on the billboard is accurate. There is nothing to be gained by suggesting that Mr. Cole is trying to state that most people with mental illness are dangerous.  But there is the issue of whether a professional organization should be commenting on what they perceive as a controversial billboard in the first place, especially when it may be used to promote a brand name.  In this era of social media and the current trend for public shaming, I would suggest that scoring points in that landscape is the last thing any professional organization should be doing.

The fact is that most acute care psychiatrists are making these kinds of assessments every day in the United States and multiple times a day.  The vast majority of people designated to have a mental illness on this billboard do not need to see psychiatrists.  Acknowledging the fact that psychiatrists are actively engaged in violence prevention and that a small but significant number of people with mental illness are violent and aggressive and that it is a treatable problem is a very important message.  The potential benefits include:

1. Less stigma for people who are violent and aggressive as a result of severe mental illness.  The current bias is to see this behavior was willful and punish them based on a moralistic approach to mental illness.  That is until the violent and aggressive person is a family member trying to harm other family members.  At that point, there is no myth of mental illness and all of the talk about how the mentally ill are not aggressive is meaningless.

2. Clearly define the problem and develop centers of excellence for treating this problem.  In every metro area in the U.S. there are a handful of acute care psychiatric units and even fewer who accept violent and aggressive patients.  All of the violent and aggressive patients are typically brought to one or two hospitals that are set up to address the problem.  Those hospitals have protocols in place to treat the problem and many of them do a lot of civil commitments.  There is no funding source that is adequate to provide the level of treatment for these patients who must be hospitalized until they are no longer dangerous.  They also require more intensive staffing patterns by staff who must have a much higher level of training than in less intensive situations.

3. A denial of the potential for violence and aggression is inconsistent with the recently released Practice Guidelines for the Psychiatric Evaluation of Adults, Third Edition.  That document has explicit commentary about the psychiatrist’s role in addressing aggression.  There are 41 references to aggression in the body of the paper including 13 bullet points on the Assessment of Risk For Aggressive Behavior (p 23).  There are thirteen references to firearms.

In my opinion, the assessment of violence and aggression that is typically done in crisis situations by psychiatrists is more extensive than what is captured in the guideline. As an example there is no discussion of transference or countertransference issues and how they affect the treatment team and their approach to the safe treatment of violent and aggressive patients.

4. A more clearly defined role among advocacy organizations is a better role for professionals. The political use of the term “stigma” is at times all encompassing and it obscures the real source of the problem. For example, stigma is not the reason why there are no services available for psychiatric care.  Managed care companies and the governments that subsidize them and sanctify their business tactics are the reason there are no services.  The APA has been talking about stigma for years and it has done absolutely nothing to increase services or stop the rationing.  The highly acclaimed parity legislation initiated by Senators Paul Wellstone and Pete Domenici has done nothing to break the chokehold on mental health by businesses and governments.  There is new legislation in the works to “enhance” the original parity legislation because it has no teeth and has not made a difference. Businesses do what they want with the blessing of state and federal governments.

5. In some cases advocacy organizations are at odds with clinical psychiatrists who are treating patients with severe mental illness and aggression.  One of the positions taken by at least one of these organizations is that psychiatrists could be easily replaced by “prescribers” in state hospitals where aggressive patients are sent.  The government in that case took the position that an administrator with no clinical experience could come into a state hospital setting and develop a program to treat patients with mental illness and violence and aggression.  That plan failed.

These are a few of the problems associated with denying the correlation between severe mental illness and violence and aggression in a subset of patients with severe mental illness. The reality is that there are thousands of psychiatrists that face these problems every day. Their goal is to keep people safe and prevent violence. Acknowledging what they do on a daily basis, supporting that work and the importance of that work to patients, families and the community is a step in the right direction.

Suggesting that it is too stigmatizing to discuss that issue is not a step in the right direction.




George Dawson, MD, DFAPA



Supplementary 1:    I contacted Kenneth Cole (the company) through the web site and asked them to send me an image of their billboard for use in this post.  I included a link to the post so the specifics could be read as well as the entire blog.  I was advised that although they appreciate my interest, the image was proprietary and therefore they could not send it to me.  I don't know if they are claiming that about every image or just the one I wanted them to send me.  It made me wonder if they are aware of how widespread the image is used on the Internet.

Supplementary 2:   I was graciously sent a photo of this billboard by a resident New Yorker.  I contacted Kenneth Cole again and was told again that I could not even use an independent photograph of their billboard for this post.  I really doubt that any place else displaying these billboard photos has gotten permission from them, but I am just a guy writing a blog and can't afford to get into it with them.  So there you have it.  Go to any one of the other hundreds of places on the Internet that have posted this picture to view it.

    

Happy Labor Day IV

This is my fourtth Labor Day writing this blog and it is my custom to summarize the work environment for physicians like I did in Happy Labor Day I, II, and III.  Things have not improved very much and there was a timely piece by an anonymous physician filed on another blog entitled Confessions of a Burnt Out Physician.  That post is full of anecdotes about physicians being managed like production workers and to the point of not even having an adequate work space to conduct work that requires focus and confidentiality.  Another key element of managing physicians is to make sure that their days and nights are filled with the modern equivalent of paperwork - e-mails and charting that is read by nobody except the occasional coding and billing staff.  If that is not demoralizing enough, there are always the suggestions that physicians are not doing enough, even though they are easily in the hospital for 4 or 5 hours after all of the business people are long gone.  This can all be handled masterfully.  As an example, the RVU productivity system was in many cases introduced to physicians as a system of "fairness".  That is - the idea that everyone has to pull their own weight.  That works very well in any environment of competitive physicians.  It was dovetailed in nicely with multimillion dollar lawsuits by the Department of Justice that were based on charting.  Now physicians could be fined or imprisoned if their documentation was not up to snuff.  And of course the Department of Justice wanted every physician in this country to know that any discussion of fees was a potential antitrust offense.  When all of that business rhetoric had settled out, the only things that really changed was how easily physicians could be manipulated and overworked while their professionalism was completely ignored.  Apparently none of us knew how to work or act before managed care came along.

There have been some additional business innovations in the last year to make physician's lives even more difficult.  I read another blog recently where the topic of physician managers affiliated with Big Pharma were desired to bring money into departments and how that and key opinion leaders (KOLs) from that field was a key corrupting influence in medicine and psychiatry.  That influence is trivial compared with the business influences on medicine and their adverse effects.  Excellent clinicians, teachers and researchers now need to get an MBA before they are considered as a department head.  A managerial class that is progressively less competent to manage may be an acceptable business standard but it seems like an extravagance in medicine and one that has cost us hundreds billions of dollars and untold unnecessary work for physicians.

Furthermore, we know what works in terms of physician management.  I worked in tens of departments where the department head was a physician who was in that position because of skills pertaining to clinical care, teaching and research.  That doesn't mean that they were necessarily easy to get along with, but in teaching institutions their skill set was on display every day.  That model transitioned to one where a physician and an administrator of some type both co-lead the department.  The physician leader was still affiliated with physicians in the field at that point and could feel their pain.  The next step was removing any physician with those alliances from an administrative position.  In many cases, this meant people who had no hesitation to manipulate physicians either by a "It's my way of the highway" attitude,  making the environment so hostile that they forced selected dissenting physicians to quit, or after pretending that the physicians had some input (usually through endless mind-numbing meetings about the business) simply telling them that no matter what their opinion was - this was what would be happening.  Throughout the process there was an endless stream of "Change is good", "Cost effectiveness", and "Managed care friendly" propaganda.  But it didn't stop there.  Managed care run institutions have an entire cadre of case managers whose primary job is to "manage" physicians and make sure they are discharging people according to the companies proprietary standards.  If there are any disagreements that low level administrator can easily go up the change of command to get decisions in their favor or identify physicians who are not in lock step with the company.  Everywhere within these organizations there are rules about identifying "disruptive physicians" and penalizing them.  I am not talking about doctors throwing scalpels across the operating room.  The threshold can be so low these days that a "disruptive physician" is anyone who gets into it with an administrator for any reason, including legitimate disagreements.

The effect on the psychological environment of physicians has been corrosive.  Within a generation we have gone from a training environment where medical students and residents could identify with senior physicians who embodied professionalism and an intellectual approach to medicine to managed care employees who use a business approach.  Instead of rounding on patients and learning the importance of medicine as a life-long intellectual pursuit, trainees are focused on the business manager's pursuit of getting patients out of the hospital so that corporate America can keep making money by easily beating the fixed reimbursement scheme set up by the government.   The business rationalization has always been "of course we need to make money to keep the doors open", but that never addresses the trade-offs.  In this case the trade-off is no relationship or plan to assist the patient.  In the case of patients with psychiatric disorders, there are inadequate inpatient and outpatient services, both due to business rationing to maintain profits in a rationed and cost-shifted world.  In many cases health care systems have carried these plans to their absurd conclusion - just close any inpatient beds, close the outpatient clinics, and hope that some taxpayer funded clinic or jail can pick up the slack.  The typical health care manager has an endless stream of bad ideas.

Are there any bright lights on the horizon?  I think that there are.  I would count the movements against the medical specialty boards and the proposed maintenance of certification (MOC) programs.  It is very positive that physicians are standing up and saying that they are unnecessary, not evidence based, and a tremendous waste of time, money, and resources.  More importantly all of that stress falls squarely on overworked physicians.  There is now at least one parallel certification organization that depends primarily on initial board certification and then continuing medical education courses - the historical standard.  It will take a significant commitment, especially from younger physicians to keep this movement alive because it is just a matter of time before credentialing committees for clinics and hospitals will be putting the squeeze on their physicians to use the labor intensive MOC programs.  There is also the question of medical boards.  Will they require MOC for maintenance of licensure (MOL)?  Only time will tell, but like all things American - the bet is on the oligarchs and that currently is everyone making a lot of money out of managing physicians.  At some level that includes professional organizations populated by members who are very friendly to the business world.  If anyone doubts the benefits to professional organizations, just visit the American Psychiatric Associations Learning Center and the MOC offerings.  If the monopoly can be broken, it suggests that physicians may have the ability to counter the business and government strategies that keep what is basically an anti-physician system afloat.  Business strategies have nothing to do with the practice of medicine.

Another bright light that I neglected to comment on initially is the young psychiatrists going into private practice.  At first I was reluctant to endorse this idea, primarily because it contrasts so starkly with my experience in community psychiatry, acute care psychiatry, and general hospital psychiatry.  I was concerned that there would not be enough psychiatric expertise to care for very ill people.  But in conversations with many young colleagues they are some of the brightest, happiest, and enthusiastic physicians that I have seen.  The reason I am given by these docs is that they decide who they are going to see and what their schedule is and not some administrator.  They decide what their clinic policies are and not some administrator.  Some of them have worked in managed care settings and had the courage to walk away after the standard "performance evaluation", especially when it had become an exercise in a loyalty oath to the company and trying to dredge up anonymous critical remarks from coworkers.  My opinion on this private practice trend is that it is a good one.  Any person consulting these folks is going to get recommendations based on quality psychiatric care and not proprietary managed care guidelines.  They will also be talking with a psychiatrist who has not seen ten other people before them and one who has the energy to focus on their problems and possible solutions.  Some of these private physicians also spend days in community mental health centers and on community support teams - treating patients with severe problems.      

So my fourth Labor Day message is slightly brighter than the last three, but not much.   I have to say that there are a few of us around yet who know exactly what happened and what is possible -  and I feel your pain.  If you feel up to it post your anonymous story here.


George Dawson, MD, DFAPA

Patentable Biomarkers of Suicide

From: Understanding and predicting suicidality using a combined genomic and clinical risk assessment approach (reference 1 with permission).

One of the most interesting aspects of biological psychiatry is the attempt to characterize complex biological systems.  It may not have been apparent but complex biological systems factored in a recent post about bronchitis.  Lungs are certainly complex with two different blood supplies and complicated immunology, but the lungs are not thinking organs.  They don't come up with any secondary concepts that need to be analyzed as possible derivatives of the biological substrate.  And even then, basic syndromes that we all learned about in medical school and in clinical rotations, defy more useful classifications.  I have previously posted on endophenotypes and their usefulness in the treatment of asthma and only recently noted that they have proliferated to include an obese endophenotype and how that affects response to therapy.  Diagnostic and treatment approaches to asthma and bronchitis are necessarily crude, largely because the biological complexity in these processes is not fully appreciated and addressed.

The brain is certainly the most complex organ in the body.  Cellular arrays in the brain produce a stream of consciousness, robust unconscious processing, unique conscious states, and all forms of emotional, social and intellectual constructs that can be observed, monitored, and changed.  That brings me to a paper from Molecular Psychiatry on possible biomarkers for suicide.  Not just any paper - at this point it is the most downloaded paper from the top-ranked psychiatry journal (1/140) in the world.  Molecular Psychiatry has an impact factor of 14.496 and that is the highest impact factor of all psychiatry journals.  In part that is probably driven by how absurdly expensive that similar journals like Biological Psychiatry are or other barriers to purchase like needing to be a member of the sponsoring society.  This is a public access journal that uses Creative Commons Licenses for their content.  The authors in this case have provided a 20 pages article and 124 pages in Supplemental Information.

The idea of a biomarker for suicide is very attractive to psychiatrists, because assessing suicide risk is a big part of what we do.  Current clinical guidelines suggest that we need to make that assessment at every patient visit.  The actual prediction of suicide is difficult due to the fact that mental states change over time and people may not be able to communicate their true level of risk.  I have had people tell me in retrospect that they lied about their degree of suicidal thinking and level of control when I asked them about it.  I have had acute care colleagues tell me that they were weary of having to guess about whether a person was going to try to kill themselves or not - many times a day.  The assessment is further complicated by a lack of acceptable acute care options that may further hinder complete self disclosure.  A biomarker would potentially be beneficial.  I qualify that by the fact that the dexamethasone suppression test was once considered a biomarker of suicide (1), but these days it is rarely done and certainly not as part of a suicide assessment.  A study by Coryell, et al (9) notes that the DST was not able to differentiate patients who died from suicide or cardiovascular disease when long term mortality was determined by the National Death Index.  Those authors suggest it may be useful as a predictor of suicide only in patients with depression.

In this article the authors take a look at possible biomarkers in blood that could predict both suicide and some associated markers like risk of hospitalization.  There is a lot going on in this paper.  All the research participants were men.  They studied four different patient cohorts including 217 patients followed longitudinally.  This group was called the Discovery Cohort because markers were discovered based on 37 patients who had a switch from a no suicide state to a high suicide state defined as a score of 2 - 4 on the HAMD question about suicide.  26 deceased patients who committed suicide were used to validate the initial markers.  Two psychiatric cohorts of 108 and 157 to look at prediction of suicidal ideation and hospitalization with the chosen tests.  The flow of these experiments in depicted in the graphic at the top of this post from the original paper.  In the diagram, the designations AP (absent-present) and DE (differential expression) are techniques to capturing genes that are turning of and turning on and off and gradual  changes in gene expression.  The respective genes in this analysis are color-coded based on those properties.  The Convergent Functional Genomic (CFG) Approach is depicted in the box.  Candidate genes are ranked in the triangles according to CFG score.  The CFG score was the sum of various weighted factors including evidence of human brain expression, evidence of human peripheral presence, human genetic evidence and linkage with weighted scores in the CFG box.  Using their discovery and validation sequence the authors were able to pare down the total number of genes down from 412 to 208 to 143 and ultimately to 76 genes.  The supplementary information provides the validation of biomarkers and a table that looks at each gene and prior human genetic evidence, prior evidence of brain expression and prior human evidence of peripheral expression.

The authors discussion of the biological relevance of their findings was interesting.  They did pathway analysis looking at Ingenuity, KEGG, and GeneGO databases.  Of these only the Kyoto Encyclopedia of Genes and Genomes (KEGG) is publicly available without a subscription fee.  It is very useful to know about KEGG because of the relevance of pathway analysis in the psychiatric literature.  As an example, I have been teaching about the mTOR pathway discussed in this article in my neurobiology of addiction lectures for the past 4 years.    

This article is very interesting and can be read at  several levels.  It is premature to consider it definitive at this point and based on this paper and the work of the associated lab these authors are working on additional validation strategies.  If they are  correct,  suicidality may be captured in time as a polygenic event based on a combination of genes that are turned off and on and others that gradually change.  I titled this post as "patentable genes" because the only conflict of interest cited is the lead author is listed as an inventor on a patent application being filed by Indiana University.  For trainees and early career psychiatrists a familiarity with this technology and its potential uses and limitations would be one of the reading goals and including Molecular Psychiatry and its sister journal from the same group Translational Psychiatry (8) is probably a good idea.  Both are potentially good sources of neuroscientific information in psychiatry and if popularity is any indication - fill a niche in the field.  Some of the tools that they developed along the way are useful to think about from a clinical perspective (4, 5).  The thought that the CFI-S Scale was particularly interesting because it is a 22 point binary scale that looks at factors (excluding suicidal ideation) that they determined to be important.  The factors are also classified as to whether they represent increased reasons (IR) or decreased barriers (DB) to suicide.  The emphasis on suicide as a discrete syndrome independent of diagnosis is a research strategy that has been called for recently based on the need to come up with better ways to diagnose and treat the problem.  In a clinical setting I think that clinicians are still frequently surprised by suicide attempts and suicides being able to determine if a patient is in a high risk state based on a blood test independent of their clinical presentation and statements would be useful both in terms of the test but also the associated dialogue.

What I really like about this paper is that it is an attempt to deal with a common psychiatric problem at the appropriate level of complexity.  Clinical trials do exactly the opposite.  As an example, clinical trials in psychiatry will look at heterogeneous groups of patients pulled together under a vague diagnostic category.  There may be rating scales or global ratings just because the rating scales don't seem to have much discriminatory power.  In the end, the entire study is generally collapsed for a very simple statistical analysis.  Getting to those final variables and what has been ignored in the process is always the critical question.  I think it is trendy these days to commiserate about the fact that there are inconclusive, weak and non-reproducible results from the standard clinical trials technology.  I don't know why anyone would expect a different result.  If anything this paper illustrates that a lot of biological information can be considered and analyzed.  The popularity of this paper leaves me hopeful that this is a positive trend for the future.            


George Dawson, MD, DFAPA


References:

1:  Niculescu AB, Levey DF, Phalen PL, Le-Niculescu H, Dainton HD, Jain N,Belanger E, James A, George S, Weber H, Graham DL, Schweitzer R, Ladd TB, Learman R, Niculescu EM, Vanipenta NP, Khan FN, Mullen J, Shankar G, Cook S, Humbert C, Ballew A, Yard M, Gelbart T, Shekhar A, Schork NJ, Kurian SM, Sandusky GE, Salomon DR. Understanding and predicting suicidality using a combined genomic and clinical risk assessment approach. Mol Psychiatry. 2015 Aug 18. doi: 10.1038/mp.2015.112. [Epub ahead of print] PubMed PMID: 26283638.

2:   Lee BH, Kim YK. Potential peripheral biological predictors of suicidal behavior in major depressive disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2011 Jun 1;35(4):842-7. doi: 10.1016/j.pnpbp.2010.08.001. Epub 2010 Aug 11. Review. PubMed PMID: 20708058.

3:   Collection of references for biomarkers in suicide.

4:  Simplified Affective State Scale (SASS).

5:  Convergent Functional Information for Suicide (CFI-S) Scale.

6:  Laboratory of Neurophenomics Web Site.

7.  Niculescu AB Medline Collection on additional convergent functional genomics references.

8.  Translational Psychiatry Web Site.

9.  Coryell W, Young E, Carroll B.  Hyperactivity of thehypothalamic-pituitary-adrenal axis and mortality in major depressive disorder.  Psychiatry Res. 2006 May 30;142(1):99-104. Epub 2006 Apr 21. PubMed PMID: 16631257.

Attribution:

The figure at the top of the post is from the original article listed completely in reference 1 under a Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License.  To view the condition of that license view it here.

Supplementary:

1.  There is a Mayo Clinic Conference coming up this fall for anyone interested in translational approaches to psychiatric disorders and addictions.  Further information is available at this web site.

2.  There is also the 3rd Annual Update and Advances in Psychiatry conference at the US Madison and one of presentations is by Daniel Weinberger, MD on the neuroscience of schizophrenia and psychotic disorders.   Information on that conference and the conference brochure is available at this web site.

A Basic Question About Anxiety

For the past 5 years I have seen more anxiety than in the first 24 years of my career.  I just realized last night that is one of the consequences of being an acute care psychiatrist.  In that setting, I am sure that I have seen more people with schizophrenia, bipolar disorder, severe depression, catatonia, dementia, and delirium than most psychiatrists.  If the anxiety was present it was associated with a severe disruption caused by the major psychiatric diagnosis.  When that syndrome was treated, the associated anxiety and insomnia also resolved.  I think that inpatient docs also get a fairly skewed perspective of what kinds of problems the average person is looking for help with.  Now that I am no longer seeing an acute care population it seems pretty clear that most people present with a mixture of anxiety and depression.  They present with varying levels of sophistication to give the history of the problem.  It is common for me to hear: "I am not sure that I know the difference between anxiety and depression.  Can you explain it to me?"  It is also common to hear combinations of symptoms or descriptions that cross over from one category to another.  A good example would be getting a referral for the assessment of "hopelessness" and learning that happens only during a panic attack and in the complete absence of depression.

Symptom severity and the perception of that severity turns out to be another problem.  Some people are fairly intolerant of the slightest bit of worry, especially if it leads to insomnia.  Others have a pattern of hyperarousal at night.  When their head hits the pillow, it is not a time to fall asleep.  It is a time to worry about what happened that day, the kids, the spouse, finances, and work.  Many of those folks are chronically sleep deprived but they are used to it and don't really complain about it.  A few will go to an even higher level of worry.  At that point their thoughts "race" (another cross-over symptom), but they seem more concerned about insomnia than anxiety.  In the people with severe early onset anxiety it is very common for that to morph into depression - a phenomenon written about by several researchers.  It is also common to see that happen on a week to week basis - with reports of anxiety dominating one week and depression the next.  After I define the symptoms for people I always try to ask a question about which syndrome is dominant this week and get the expected scatter of symptoms.  It is not surprising to me that these diagnoses have some of the lowest reliabilities of DSM-5 diagnoses in field  trials.  Critics of course point to problems with psychiatric diagnosis or the diagnostic manual.  Nobody seem to make the obvious point that this may reflect how people actually experience their problems.

I consider the developmental approach to psychiatric diagnosis the best one, especially when you have enough time to do that kind of work.  It requires constructing a timeline of symptoms across the lifetime of the patient.  It is necessarily biased by the imperfections of human memory including the reports of events that may not have really happened.  With anxiety and depressive disorders there are major landmarks that need to be discussed including sleep problems (insomnia and nightmares), school refusal or phobias, relationships with major attachments figures, losses of attachment figures, psychological trauma, and other forms of childhood adversity.  When I do that I notice that two patterns seem to emerge.  In one case, there are a number of people with what I would call an unremarkable developmental history in terms of events that might be associated with anxiety or depression.  At the other extreme are people with multiple events who have developed what I would call an anxious temperament.  Worry and some associated physiological symptoms are part of their personality.  They worry about everything.  They may know that they come from a long line of "worriers" and recognize these traits.  They have insight into the fact that they "overthink" everything and they are seen as being far too cautious about life.  They appear anxious, jittery and jumpy at times.  I am usually not the first physician seeing them and they have been treated with all manner of psychiatric medications with very few positive results.  They may be at risk for addiction, because some of them are looking for a medication that just "turns my mind off".   If they are prescribed a potentially addictive drug for that purpose, the dose required to turn off the mind is often very close to the euphorigenic dose and addiction results.  The people with anxious temperament do not have an episodic problem with anxiety, like some research articles describe.  It is with them all of the time.  I think it is also associated with other personality traits and disorders that makes treatment even more difficult.

In an effort to resolve this problem of episodic generalized anxiety versus anxious temperament I sent an e-mail to one of the top anxiety experts in the world.  He has hundreds of publications and is a co-author of what is considered on the the most authoritative texts on this subject.  I had that text sitting on my library shelf.  He agreed with my assessment of the problem but referred me back to a chapter in his text written by Kathleen Brady and colleagues on substance induced anxiety.  I read that but ended up on a section on the phenomenology of generalized anxiety disorder (GAD).  That section suggested a different phenomenology based on age.  The chapter by Taylor, et al had more detail on trait, temperaments and endophenotype models and I was able to take a closer look at endophenotypes in reference 5.  The Venn diagram below is based on the high points in this chapter.  It also confirmed by longstanding conviction that temperament are traits discussed about children and general and specific personality traits are discussed with adults.

Looking at the state of the art here it is apparent that a diagnosis of GAD does not provide anywhere near the level of information that is needed to treat it.   That is important because people are walking in to see psychiatrists with the expectation that there is a quick cure for the problem.  They will generally not get that if a checklist diagnosis is made based on GAD symptoms and they are given a prescription.  It is easy to see how some people will believe that blunting their levels of arousal with a non-specific sedating effect from a benzodiazepine is treating their anxiety.  Those same traits put people with high levels of trait anxiety at risk for alcohol and substance use problems.  More comprehensive formulations of anxiety need to be done that incorporate these factors in order to break the pattern of chronic anxiety and in some cases associated substance use.   Telling a person that they have generalized anxiety and treating them with medications alone, will probably not be enough to address the problem.  That is also the message that trainees might get when they consider research articles or read any modern text of psychopharmacology.  One text (6) provides stratified algorithms of decision-making for acute and chronic generalized anxiety, phobic disorders, PTSD, OCD, and panic disorder.  The authors do name specific psychotherapies in the algorithms and in some cases show that a trial of psychotherapy may be prudent before medications but all of the treatment is predicated on diagnoses rather than specific subtypes of the main conditions.  For example, there are a number of people with chronic anxiety who also have elevated heart rates (greater than 100 beats per minutes), marginal blood pressure and cardiac awareness in that they can sense their heart pounding in their chest when they are trying to sleep or they are in a quiet room.  These sensations are often a source of excessive worry and increased anxiety.  In the primary care setting there are many physicians who do not treat sinus tachycardia in the absence of a clear medical cause for it.  Is this a type of anxiety (endophenotype?) that should be treated with beta blockers? Does it require more than that for the cerebral component of anxiety or just the beta blocker?  Will physical exercise or psychotherapy treat the chronic tachycardia?  Are otherwise healthy patient with tachycardia excluded from clinical trials for anxiety on that basis?  And what constitutes an adequate medical evaluation for these patients?  Even today, I don't think that anyone has the answers to these questions and the same can be said for many other variants of generalized anxiety.

I have never seen a clinical trial of patients with anxiety and persistent tachycardia and doubt that I will.  If I had to guess, I would say that very few people are asked if they have cardiac awareness and whether that perception increases their anxiety.  I would also guess that (like hypertension) many of these patients do not have their vital signs followed very closely.  These are just a few of the ways to break down this very heterogenous syndrome and why further analysis is necessary.



George Dawson, MD, DFAPA


References:


1:  Dan J. Stein, MD, PhD; Eric Hollander, MD, and Barbara O. Rothbaum, PhD.  Textbook of Anxiety Disorders. Second Edition.  American Psychiatric Publishing, Inc.  Washington DC,  2010.

2:  Sudie E. Bach, Angela E. Waldrop, and Kathleen T. Brady.  Anxiety in the Context of Substance Abuse.   In Stein, et al, pp 665-679.

3:  Steven Taylor, Jonathan S. Abramowitz, Dean KcKay and Gordon JG Asmundson.  Anxious Traits and Temperaments.  In Stein, et al pp. 73-86.

4:  Lazlo A. Papp.  Phenomenology of Generalized Anxiety Disorder.  In Stein, et al pp.159-171.

5:  NLM Collection on Anxiety Endophenotypes

6:  Phillip G. Janicak, Stephen R. Marder, Mani Pavluri.  Principles and Practice of Psychopharmacotherapy, Fifth Edition.  Wolters Kluwer Lippincott Williams and Wilkins.  Philadelphia, 2011.

Attribution:

Attribution for the painting at the top of this post is is Edvard Munch [Public domain], via Wikimedia Commons.  This is a reproduction of an original work that is in the public domain based on US Copyright Law.


Supplementary 1:

I was sent a question about my comment in the above post about anxiety and morphing into depression and where that is referenced in the literature.  The earliest reference I have is in ES Paykel's text Handbook of Affective Disorders from 1982.  In the chapter by Roth and Mountjoy "The distinction between anxiety states and depressive disorders." the authors state:

"Clancey, et al (1978) reported that 49 of 112 (43.8%) anxiety neurotics developed secondary depression during a 4 - 9 year follow up period."

1: Clancy J, Tsuang MT, Norton B, Winokur G. The Iowa 500: a comprehensive study of mania, depression and schizophrenia. J Iowa Med Soc. 1974 Sep;64(9):394-6, 398. PubMed PMID: 4425518.

There are more of these articles and it may take me a while to find them due to the usual discussions about comorbidity and similar biological substrates:

2:   Martin C. [What is the outcome of childhood anxiety in adulthood?]. Encephale. 1998  May-Jun;24(3):242-6. Review. French. PubMed PMID: 9696917.

3:   Kessler RC, Keller MB, Wittchen HU. The epidemiology of generalized anxietydisorder. Psychiatr Clin North Am. 2001 Mar;24(1):19-39. Review. PubMed PMID: 11225507.

"The strong comorbidity between GAD and major depression, the fact that most people with this type of comorbidity report that the onset of GAD occurred before the onset of depression, and the fact that temporally primary GAD significantly predicts the subsequent onset of depression and other secondary disorders raise the question of whether early intervention and treatment of primary GAD would effectively prevent the subsequent first onset of secondary anxiety and depression."

4:   Kessler RC. The epidemiology of pure and comorbid generalized anxiety disorder: a review and evaluation of recent research. Acta Psychiatr Scand Suppl. 2000;(406):7-13. Review. PubMed PMID: 11131470.

"Results arguing that GAD is an independent disorder include the finding that GAD is usually temporally primary in cases of comorbidity with major depression, that primary GAD is a significant predictor of subsequent depression and that the course of GAD is independent of comorbidity."

5: Angst J, Vollrath M. The natural history of anxiety disorders. Acta Psychiatr Scand. 1991 Nov;84(5):446-52. Review. PubMed PMID: 1776498.

"The course is often characterized by a certain chronicity that manifests itself in residual symptoms and mild impairment in social roles even after many years and is frequently complicated with depression."

6:   Beesdo K, Knappe S, Pine DS. Anxiety and anxiety disorders in children andadolescents: developmental issues and implications for DSM-V. Psychiatr Clin North Am. 2009 Sep;32(3):483-524. doi: 10.1016/j.psc.2009.06.002. Review. PubMed PMID: 19716988; PubMed Central PMCID: PMC3018839.

"The development of secondary depression seems to be a particularly frequent and concerning heterotypic outcome of anxiety disorders. Is this a characteristic of anxiety in general rather than an issue of specific anxiety disorders or anxiety features (such as panic, avoidance, accumulation of risk factors)? Or is this related to an overarching anxiety or anxiety-depression liability, possibly through shared etiopathogenetic mechanisms (eg, neurobiology)?"

The authors of this study have a table summarizing the outcomes of childhood anxiety showing that in studies where is was mentioned 10/17 studies found depression as an outcome of anxiety.  This reference is available for free online.

Anger and Projection Are Not Political, Racial Or Gun Control Problems

Anger and projection are mental and public health problems.

The homicides of two young broadcast journalists yesterday continues to stimulate the same media response that it always does - mourning the victims, discussing the tragic aspects of the event, and doing a media profile of the perpetrator.  Anyone who has read this blog over the last three years knows my positions on this.  Lengthy posts and academic references don't seem to matter so I thought that I would keep this brief and reiterate the main points before it becomes the usual media circus about gun control and speculating about the perpetrator's mental state.   The most rational analysis considers the following points:

1.  This is first and foremost about the mental state of the perpetrator:

Without the perpetrator there is no tragedy.  Preliminary descriptions in his own words that he was a powder keg that was waiting to go off.  He had a pattern of angry conflicts with coworkers that severely complicated his life, led to job loss, and ongoing conflicts.  I heard a detailed analysis of an alleged pattern of behavior that results in this kind of homicide on the morning news today and it was too pat.   It sounded like the old "stages of grief" model that people used to adhere to.  I think there is a lot of confusion out there about what is normal anger and what kind of anger is pathological.  Anger is a socially and culturally difficult construct.  In many places like my home state of Minnesota it is generally unacceptable.  It is difficult to recognize when anger becomes a problem, if your reality excludes it as a possibility.

Anger is a problem when it is persistent and pervasive.  Normal anger is transient and does not persist for days, weeks or longer.  It is necessarily transient because it can activate physiological processes like hypertension that are not conducive to the health of the individual.  Persistent anger also gets in the way of normal social interactions that all people need in order to function properly.  Human beings are undeniably social animals and we do not function well if we are isolated or cut off from one another.  Anger tends to automatically focus people on an outside source for their problems and frustration while minimizing their own potential role in the process.  Persistent anger does not allow for the necessary productive interactions with family members, coworkers, or in many cases casual contacts in everyday life.

Projection is the attribution of a feeling state or problem to another person.  It is commonly experienced when observing a person blame other people or circumstances for problems they are having in life.  How rational that level of blame seems may be an indication of the severity of the problem.  In my years of treating people in inpatient psychiatric units, it was rare to encounter a person who did not see me as the root of their problem, even though I had barely met them, had nothing to do with why they were in the hospital, and was the person charged with helping them get out.  Some might think that was just a part of me representing an institution, but that goes out the window when the reasoning being given is that I am white or jewish or racist or I am physically attracted to the patient.  Those were typically the mildest accusations.  In many cases, this anger and projection was obvious to family members and coworkers for months or even years before the person was admitted to my unit.  Threats of physical violence or actual physical violence in these situations was common.

2.  This is a public health problem:

People with anger control problems and projection generally do not do well in life.  At the minimum these problems are significant obstacles to a successful career and social life.  One public mental health focus should be on optimizing the function of the population and preventing this social morbidity that is also associated with somatic morbidity and mortality.  In some cases, these mental states are also precursors to violence including suicide and homicide.  In some cases they have led to mass shootings.

There are very few people who talk about this kind of violence and the associated mental state as a preventable or treatable problem.  Part of the issue is that anger is socially unacceptable and it seems like a moral issue.  We should all learn how to control our tempers and keep ourselves in check.  If we don't, well that's on us and we should be punished for it.  Another part of the problem is that some people want to see it as a strictly mental health problem and turn it into a problem of prediction.  The argument then becomes the inability to predict who will "go off" and harm someone.  The additional issue that will heat up at some point is the gun control issue.  Any reasonable person will conclude that gun access in the US is too easy and the amount of firearm injuries and deaths are absurdly high for a sophisticated country.  That said, there appears to be no practical way to alter this problem within our current legislative system.  Even if all guns were removed, it would not stop the problem of people with anger control problems and projection from not doing well in life or harming innocent victims.

To address the problem, we need to take an approach that is similar to suicide prevention.  I am not talking about screening.  I am talking about identifying people at risk.  The best way to do that is to develop strategies to help them self-identify and request help or to help people in their lives assist them in getting help.  Typical ways this works in suicide prevention is public service announcements, volunteer hotlines, referrals through law enforcement and the court system, and referrals through the schools.  Suicide is also identified as a major public health issue and as such it is a focus of many organizations that do advocacy and intervention work in the area of mental health.  There are no similar resources for anger and violence prevention.

That is my basic message involving the most recent incident of preventable homicide in the United States.   I wanted to get this out after seeing just one broadcast on the issue and before I saw too many stories politicizing the incident.  I think that the factors that have resulted in lack of action in this area are obvious and several of them will be on display over the next few days.

As a psychiatrist who has worked in this area for nearly 30 years, I can say without a doubt that this unnecessary loss of life can be prevented and preventing it does not require psychiatric services, but it does require people who are willing and able to address the problem.

We just have to stop pretending that it can't be stopped.


George Dawson, MD, DFAPA



Supplementary:

1.  Previous violence prevention posts here.

2.  Previous homicide prevention posts here.





    

Evidence Based Urgent Care

I went in to urgent care today after battling an influenza-like illness that I got on a trip to Alaska, most likely in the flight home.  The symptoms are charted in the above graphic.  Without providing too much graphic detail on the symptoms, my concern was in whether or not I might have pneumonia and needed a chest x-ray.  Although I knew this was most likely not an influenza virus, the symptoms were fairly severe.  As an example, on last Saturday August 15, I had diffuse muscle pain that was so severe, I could barely move.  In the two days I took time off from work August 18 and 19, the muscle pain was restricted to chest wall muscles.  The cough had also become productive over the past 5 days.  I thought it was reasonable to get it checked out, especially against a backdrop of asthma and chronic asthma therapy.

I took my graphic along with me and showed it to the nurse and the physician.  I told her that I had bronchitis that was probably caused by a respiratory virus.  The nurse was overtly uninterested and at one point said that all she needed was a single symptom to write down and that symptom would be cough.  As she continued writing, she kept glancing at the graphic and taking additional notes.  I wanted to say: "Just scan it in and you can stop writing.  It contains almost all of the information that you need to know."  But I didn't.  I maintained standard medical office decorum.  As Seinfeld once said: "You go from the large waiting room to the smaller waiting room and wait again to see the doctor."  The nurse took all of my vitals including an oxygen saturation and stated matter-of-factly: "They're all normal."  My enthusiastic reply of "Good" was met with dead air.

The doctor walked in and I gave him a brief history.  He looked at my graphic and wrote down a few words.  He listened to all of my lung fields with a stethoscope and then listened to my heart sounds - both through my shirt.  The entire history and exam took about 5 - 10 minutes.  And then:

"You have bronchitis.  There is probably a lot of inflammation in there.  I am going to prescribe prednisone and an antibiotic.  Levaquin is a good one for this.."

At that point, I told him that I was already on two QTc interval prolonging drugs and that Levaquin might not be a good idea.

"OK then I will look up another antibiotic.  Doxycyline is one that should work.  Yes - there is no interaction between doxcycline and your medication.  Any other questions?"

I asked him about the issue of a chest x-ray.  I had three in the last two years and it seemed like the decision was a coin toss.

"I don't think so.  You have sounds all over your lungs and not in one place in particular.  If it doesn't get better I would do a chest x-ray.  Right now it is not going to change what I do."

I walked out with scripts for doxycycline 100 mg BID x 10 days and prednisone 40 mg QDAY x 5 days.  Entire length of the visit with the RN and MD about 15 minutes and I was the only patient in that clinic.

Of course all during this time, I was comparing the topology of this medical visit and medical care to the common uniformed criticisms of psychiatric care.  Just this morning and totally out of the blue somebody sent me a link to their letter in the British Medical Journal about the fact that 70% of clinical trials of paroxetine were unpublished.  He sent it in response to a post that I had made here some time ago, and apparently was unaware of the fact that I figured out that paroxetine was not a drug that I cared to prescribe by the time I had prescribed it to a second patient.  It should be obvious that unpublished clinical trials have been a significant problem in medicine for some time and that is nothing new in psychiatry.  Seems like the prevalent bias against psychiatry rearing its ugly head again.

How about the longstanding claim that psychiatric diagnoses are not valid because there is no "test" for them.  What was the "test" I got for bronchitis?  Of course there was none.  A diagnosis of bronchitis pretty much depends on the symptoms that I walked in with.  The same symptoms on the graphic that seemed to be shunned by the RN and casually interesting to the MD.  None of the measurements in the office had anything to do with bronchitis.  They were all essentially measures to look at whether or not I had any more significant disease - actually a more significant syndrome.  When I was an intern, we thought we had a more scientific way to analyze the problem.  We would obtain sputum samples and Gram stain the samples and culture them.  Once the integrity of the respiratory epithelium is disrupted there are all kinds of bacteria that colonize the area.  The sputum samples were not useful - either in terms of pathogenesis or guiding antibacterial therapy.  Thirty years later, antibacterial treatment of bronchitis is still empirical.  No specific pathogen is identified.  The thinking used to be that sputum indicated a bacterial infection, now we know it is just sloughed epithelium from the cytotoxic effect of viruses.  Empirical treatment of bronchitis is really no different than empirical treatment of any symptom defined mental illness.  Ignoring a couple hundred specific respiratory viruses is reminiscent of a hostile criticism of psychiatric nomenclature: "It is all one disease."  By comparison, acute bronchitis is also one disease.

Another interesting comparison is symptom severity.  I spend a lot of time discussing and documenting this with psychiatric disorders.  In the case of bronchitis, there was no particular interest in severity.  No questions about subjective experience, patterns of the cough, or sputum production.  You either have it or you don't.  Of course, I know that pattern recognition was in place and the physician was looking for signs of more significant illness like tachycardia, tachypnea, diaphoresis, and cyanosis.  But there were not any questions about functional capacity and how I was being affected (again more info in the graphic.)  Psychiatric diagnosis and treatment requires close attention to severity, impact on functional capacity and sleep, and whether the symptoms are in remission.

What about the "evidence basis" of the treatment?  A charitable interpretation of the e-mail about paroxetine would suggest that author was critical of the evidence basis for its use.  It is well known that over half of the drug studies from ClinicalTrials.gov are unpublished and that a significant number of the published trials omit details of interest (3) like side effects.  That same study looked at trials in 7 different medical specialties, none of them psychiatry.

It turns out that in clinical trials those adults with acute bronchitis treated with antibiotics are less likely to be rated as improved at follow up.  Some studies show a shorter duration of cough by 1/2 day but the trade off is a significant increase in antibiotic side effects with 19% of emergency department visits for adverse drug effects being due to antibiotics (1, 2).  A direct quote from UpToDate:

"Patients with known asthma may develop superimposed acute bronchitis.  It is common that such patients seek treatment and are inappropriately prescribed an antibiotic even though they usually have a viral illness."

The UpToDate review also looks at the associated issues of overprescription of antibiotics, the 20 year CDC initiative on antibiotic overprescribing that has essentially failed and the dire consequences of developing multiple antibiotic resistant bacterial strains.  My purpose here is not to imply anything about my treatment, but to illustrate that these practices are common and there is no equivalent amount of criticism similar to that targeted at psychiatric care.  In fact, if I wanted to take on the role of pseudopatient, I could walk in to any clinic or emergency department and walk out with the same prescriptions - even in the absence of acute bronchitis.  I could simply lie about the symptoms.  Nobody is going to ask me for a sputum sample, and 6/7 asthmatics have residual wheezing that can be picked up on a cursory exam.  Of course there would be public outcry.  I would be accused of lying to hard working physicians and wasting their time.  But that same poorly conceived idea is still cited as evidence against psychiatric diagnosis.

Unlike the unrealistic critics of psychiatry, my goal here is not to embarrass anyone, or illustrate that I am better than anyone.  But how is nonpublication of clinical trials of paroxetine (a drug that I have not prescribed in over 20 years) a problem with psychiatry?  Nonpublication of clinical trials is obviously a problem for everyone.  The poor quality of current clinical trials technology is a problem for everyone and unlike the Cochrane database, I don't see the point in the exhaustive documentation of predictable low quality results - at least not much of a point.

I am also not about to attribute the differences in practice and clinical trials to the art of medicine.  This is a problem of analyzing huge amounts of data in biological systems.  There are widespread problems with clinical trial design in every area of medicine because they cannot analyze that data.  Contrary to being a "gold standard" there needs to be better stratification of heterogenous diseases whether that is depression or bronchitis.  We can only have more specific treatments when we have better characterized molecular pathology and the treatments to target that pathology.  That includes markers that would suggest which patients would respond to drug treatment and which would not.  There is a promising biomarker for bronchitis that should be treated with antibiotics right now, but it is not widely studied or widely available.

The highlights of this post have really not changed since I began pointing out that psychiatry is singled out for criticism by various people with various motivations.  Looking at the facts in this post should leave little doubt that this is merely a continuation in this trend of unrealistic and unfair criticism consistent with the dynamic I outlined in the past.

Some things just don't change.


George Dawson, MD, DFAPA



References:

1:  Thomas M. File.  Acute bronchitis in adults. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on August 23, 2015.)

2:  Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2014 Mar 1;3:CD000245. doi: 10.1002/14651858.CD000245.pub3. Review. PubMed PMID: 24585130.

3: Riveros C, Dechartres A, Perrodeau E, Haneef R, Boutron I, Ravaud P. Timing and completeness of trial results posted at ClinicalTrials.gov and published in journals. PLoS Med. 2013 Dec;10(12):e1001566; discussion e1001566. doi: 10.1371/journal.pmed.1001566. Epub 2013 Dec 3. PubMed PMID: 24311990



Supplementary:

Graphic updated daily for the course of the illness:

This illness finally cleared at about Midnight on August 28, after 16 days.  The "common cold" typically lasts 2 - 3 weeks and is a significant cause of morbidity in this country.  I hope that I have also illustrated that it is also a problem in terms of treatment and a lack of real public health measures to reduce the spread of these viruses.

What Have I Learned So Far?

I started writing this blog over three years ago.  I decided to start writing it for a number of reasons.  First and foremost was the constant stream of inappropriate criticism aimed at psychiatry that contrasted with my real life experience working in the field and working with very competent colleagues in the field.  The second reason was to strike back at managed care and its various forms that I would include today as pharmacy benefit managers, government bureaucracies and even politicians.  All of the individuals and organizations continue to promote and institutionalize rationing strategies that are supposed to be "cost effective" but basically route hundreds of billions of dollars away from patient care to unnecessary business managers.  The third reason is the disproportionate impact that the first two have on patient care.  The care of patients with psychiatric problems has been decimated by this mindset that is both hypercritical but ignorant of psychiatric care and at the same time rationing the resources to the point that incarcerations are commonplace.  Even if a person with a serious problem gains entry into a system of care, there is no guarantee that they will receive any - as administrators with no expertise at all make critical decisions about whether they are hospitalized, whether they get detoxification services, what medication they take, how intensively they are seen in clinics, and whether they get the additional supportive services that they need.  A related fourth issue is that even though systems of care define "dangerousness" as essentially the only reason people need to be hospitalized these days, they do a very poor job of assessing and treating it.  It needs to be addressed at a public health level as well and aggressive and homicidal behavior associated with mental illness needs to be systematically addressed rather than being swept under the rug as "stigmatizing".  Teaching is something that I am good at and I take an informational rather than process based approach.  What I post here is more likely to be high in information content and unique rather than entertaining.  In that area, I have wide interests in the field and how they apply to patient care and theory.  I post some scientific articles and clinical strategies that I hope will be clinically useful by my colleagues and in many cases they have already been vetted by some of my fellow psychiatrists.  Human consciousness is a related issue that I think has essentially been ignored by modern psychiatry and some of what I post here are examples of consciousness and how it works - both my own and other peoples.  That is the basic matrix that I am working from.  Other points that I have observed and what might be useful information for other potential psychiatric bloggers follows:

1.  Nobody really cares about your blog:  Blogs are a dime a dozen and everyone writes one these days.  My initial goal was getting my viewpoint out if people are interested or not.  An additional corollary in psychiatry is that in order to maximize the readership, the odds are better if you are criticizing the field or provocative rather than debunking a lot of the unrealistic criticism.  I hope it is clear that I am writing no matter what and will keep doing that as long as I care about what happens to psychiatrists, physicians, and their patients and and I continue to know exactly what the problems are.  As far as I can tell - there is very little of that perspective available in the blogosphere, the press, or even the editorial section of professional specialty journals.

2.  Thirty years of practicing medicine saps your creativity:  Most physicians realize this, but I have not heard many actually come out and say it.  I was a fairly skilled writer at one point, at least according to my undergrad professors.  Tens of thousands of pages of medical documentation later, much of it meaningless bullet points added for administrative purposes that mind numbing exercise has taken its toll.  Most physicians consider writing to be a burden for that reason.  My prose has become obsessive at times and (thanks to the electronic health record) grammatically incorrect.  I have been fortunate to have a regular reader here send me corrections and ideas on how to improve and greatly appreciate that advice.  Medical schools select bright and creative people to become physicians.  When those same medical schools are unconcerned about a deterioration in the practice environment that stifles creativity and dumbs down medical practice they are doing a disservice to medical students who they select for those qualities.

3.  Ignoring the haters:  This has never been a really big problem of mine.  Once you discover that a substantial number of people dislike psychiatrists and their reasons are irrational, they are easy to ignore,  My only initial mistake here was allowing several of these posts onto my blog when I should have just rejected them all.  I have seen what happens to threads and blogs where this irrational corrosive opinion is allowed to persist under the guise of "freedom of speech" or "freedom to criticize".  Any collegial atmosphere that I have ever trained in allowed rational criticism delivered in a manner that was acceptable to everyone.  Any post sent in my direction that I don't think would fly in a meeting of physicians, will not see the light of day here.  A good example would be attempting to post that I am a "drug company whore."  That is inappropriate first and also wildly inaccurate.  Some of the most notorious critics clearly do not know what psychiatrists do and have glaring deficits in scholarship on the subject.  For those who are inclined to ethical arguments, I would argue that it is unethical to allow a serious discussion by trained medical experts to be disrupted by people who are basically there to be disruptive and have nothing else to offer.

4.  Ignoring the numbers:  It is always difficult to figure out what the Blogger statistics mean.  They vary by a factor of 10 on a day to day basis.  In some cases, I have gotten 900 page views in less than one minute and doubt those represent anything real.  In many cases, the referring URLs are clearly spam sites or originate in countries where the youth are encouraged to become hackers and steal money from foreigners.  There are the occasional referrals from sites that seem to be legitimate, like valid educational sites.  I don't get too excited about the statistics - aggregate or parsed.  Anybody reading this and having a sense of solidarity with my statements and goals whether they say so or not is good enough for me.

5.  Analyze the rhetoric:  One of the most consistent dynamics that can be observed is how the most criticized branch of medicine is handled with a total lack of accountability on the part of the critics.  They of course can say whatever they want to and often loudly proclaim this as their right.  There is an inevitable group of hero worshipers that back them up like they have some new insights.  In fact, they have a collection of vague and inaccurate observations that they cling to like they know something about medicine or science.  Some real experts uncritically lend credence to some of these off-the-wall ideas.  One of the leading authors in this area had his book endorsed by an editor who was herself very critical of psychiatry.  It doesn't seem much different than coalescing around the concepts of Intelligent Design.  No science or even rational analysis.  Only an understanding of rhetoric prevents one from falling into this trap.

6.  You can only save yourself and maybe your patient:  Much of the heat when it comes to psychiatric criticism flows from business and ethical problems with pharmaceutical companies and associated physician conflict of interest.  There are entire blogs where this seems to be the only topic of interest.  One of those blogs claimed that they were "keeping psychiatry honest."  The implied claim in these sites is that complete transparency of all drug trials and no contact between physicians and the industry will lead to a new idyllic state, where we will only have completely safe and effective drugs.  Maybe we will also be able to stop studying neuroscience and hearken back to the psychotherapies and psychosocial interventions of the 1970s.  Those ideas are so naive that I could barely stand to type them out.  That line of thinking completely ignores the corrupt elephant in the room (Congress) and the fact that the FDA is clearly politically influenced to the point that they can ignore the recommendations of their own scientific committees and put any drug on the market that they want.  It ignores that fact that American governments are pro-business to the detriment of the individual and that corporations readily accept the model of paying civil penalties as a reasonable risk for pushing the business envelope.  It also greatly ignores that fact that psychiatrists are really minor players in the pharmaceutical and medical device industry, but nobody in the press seems too worried about that.

7.  There appears to be little solidarity among physicians:  Physicians have been divided for decades now by splitting and political factors both between specialties but also within the same specialty.  I think that is part of what fuels the cultural norm of criticizing colleagues even though the vast majority do good work and have no apparent or appearance of ethical problems.  See my post on monolithic psychiatry rhetoric.  I think that the critical component of scholarship is also frequently ignored when some adopt the posture that any criticism is the equivalent of criticism from within the field.  To me that is a falsely modest position when you have been rounding with physicians who are clearly well read and have the associated clinical experience.  Medicine is not something that you can learn from reading snippets on the Internet.  I don't know if there is widespread knowledge that physicians are actively managed to maintain them in a fractioned state.  When productivity units were first introduced,  managers everywhere suggested it was because there was tremendous variation in productivity and some physicians were not pulling their weight.  After everyone was being measured and pilloried about their "production" every month, it was apparent that was a lie.  But what better way to foster an "every man/woman for themselves" attitude and destroy any semblance of professional solidarity?  Let me say this here for future reference, the "management" of physicians is really psychological warfare against physicians and the motivation for those strategies is varied but certainly not benign.

8.  An ethical climate is well ..... an ethical climate:  Part of the business of manufacturing news and headlines includes constructing an ethical climate and applying it to the people being criticized.  There are generally set-ups for provocative articles that seem scandalous.  In fact, most of the ethics is debatable and the debates are typically one-sided.  That is the best way to both win an argument and successfully smear an opponent.  There are many an ethical environments and straw men set up against psychiatrists.  If it is clear that a physician has broken the law or the medical practice rules in their own state that constitutes proof of wrongdoing.  I have lost count of the times I have referred people to the Medical Board when they were complaining about a physician.  That generally marks the end of the discussion.  Most seem to have the expectation that publicly shaming a physician through ridicule means something.  It doesn't mean anything to me.

9.  Physician professional organizations are weak and ineffective:  I am a 30 year member of the APA and AMA.  That does not prevent me from criticizing these organizations or recognizing their shortcomings.  Psychiatry organizations are no different than the AMA or other physician organizations.  They have been very ineffective in the area of mental health policy especially countering managed care tactics to ration and restrict care.  They no longer advocate for state of the art care.  As I recently critiqued their guideline, it was not clear that you had to be a trained psychiatrist to use it.  That said, they have supported a few good initiatives like banning the participation of psychiatrists in torture and the resumption of Clinical Guidelines.  I am committed to speak out against APA positions that I think are problematic like their support of the American Board of Psychiatry and Neurology (ABPN) position on recertification, collaborative care, the use of rating scales to establish quality of care parameters, and their participation with managed care entities to establish guidelines or quality parameters.  The APA has to do far more in establishing criteria for inpatient care of psychiatric and addiction problems and be actively critical of proprietary guidelines that facilitate the rationing of care.  But the commonest distortion is that the APA or the AMA have some kind of power to influence the politicians and businesses that run medicine in this country.  Nothing is farther from the truth.

10.  Developments in the field are important:  The psychiatric literature is better than it has been at any point in my lifetime.  There is a lot more to it than clinical trials and the current state of clinical trials seems like a dead end to me due primarily to a lack of sophistication.  Certain buzzwords like evidence-based medicine, controlled clinical trials, and collaborative care have been coopted by non-physicians to the point that they are often meaningless.   I critiqued a massive Medicare guideline that included a 40 page description of the evidence necessary for basic documentation.  In addition to the literature, there are excellent educational conferences widely available across the country.  People often lose sight of the fact that life is not a clinical trial, the clinical method is faster and probably safer, and that clinical trials both real and proposed are not necessarily the best use to time and energy.

11.  Trying to be creative:  Creative commentary and creative writing is possible and it is part of the tradition of psychiatry.  I have added a few things along the way that illustrate important concepts in a non-technical way and I am trying to add more graphics.  Some of these pieces are also there to illustrate stream-of-consciousness concepts - either mine or somebody else's.

12.  Supporting other bloggers:  I am quite happy to support other psychiatrists who are bloggers and any bloggers who I consider to be useful sources of information.  The blogosphere is immense and I am sure I have missed some people.  I try to include them in the list of blogs I follow and consult that list regularly.  If you are a psychiatrist, I encourage you to start your own blog, find your voice and add it.   I am very familiar with the work of hundreds of psychiatrists in the Midwest and know that my opinion reflects the opinion of many of them.  If your experience is my experience, you know that psychiatrists deal with impossible problems with minimal resources, put up with some of the most obnoxious administrators and managed care bureaucrats and we still get good results for our patients. Add your voice to the realistic information about psychiatry on the Internet and I doubt that you will regret it.

13.  Staying non-commercial:  Bloggers are encouraged to add on commercials and in some cases make money by blogging.  That seems like a potential conflict-of-interest to me, especially if you are marketing additional products like books, CDs, and speaker fees that espouse your personal viewpoints.  That is good because it may allow an appreciation of what it is like to attract paying customers including what needs to be said and the manner in which it is said.  It can also be a laboratory for the forces similar to the corrupting influences in the business world that can affect the delivery of health care.  Either way that is an influence on a blog's content.  Many posters seem to view blogs as their own method of advertising and attempt to design posts that bring readers to their own sources of advertising.  I think it makes sense to avoid avoid that advertising like you can avoid talking with pharmaceutical company sales staff and carefully consider what you are reading on a blog that is trying to sell you other products.


Paying attention to all of these things and more will hopefully keep me on track and keep me posting what is really going on in psychiatry as well as information that is useful to psychiatrists, other physicians, trainees, and anyone really interested in some of these topics.  I am not enough of a megalomaniac to believe that I can change the trends I am attending to, but I will not let them slip by without some realistic commentary.

That's about all I can say.


George Dawson, MD, DFAPA