Addictions Neuroclinical Assessment

I was quite excited when I heard about this paper in Biological Psychiatry a few days ago.  It was hyped as a way to forgo the usual DSM approach and others and make an addiction assessment based more on the neuroscience of addiction.  The basic dimensions for assessment are highlighted in the above diagram.  The authors make a compelling argument in terms of what is needed in addition to the clinical criteria "that has provided a reliable foundation for the practice of addiction medicine."  The clinical criteria that they are referring to are DSM criteria or basically problems and symptoms that are used to classify disorders from non-addictive use of the same substances.  Even the most biologically based of these symptoms - craving, tolerance, and withdrawal vary widely across all individuals in the same diagnostic group.  That variation is most likely due to biological complexity.  The authors contend that there should be a way to examine that heterogeneity among the larger clinical divisions to get at pathophysiologically based subtypes.  They suggest that the focus should be more on process than outcomes.  

They use cancer as an example of the importance of specific etiology in the diagnosis and treatment of disease.  In the case of the diagnosis and treatment of breast cancer, the BRCA1 gene is used to predict increased risk for breast cancer for a subpopulation of women with this diagnosis.  Detection of HER2 protein overexpression can predict response to a monoclonal antibody  (trastuzumab) that  interferes with the HER2/neu receptor.  All of this information is used within the existing clinical context and even then addition information about breast cancer would probably be useful.  The review several similar initiatives in psychiatry and addiction and compares the ANA (Addictions Neuroclinical Assessment).   The other examples include the Research Domain Criteria (RDoC), the Cognitive Neuroscience Treatment Research to Improve Cognition in Schizophrenia (CNTRICS), and the Impaired Response Inhibition and Salience Attribution (iRISA).  Clinicians will note that none of these initiatives has gained a foothold in routine clinical practice.  Only the CNTRICS has assessments across all 5 of the domains addressed by the ANA.

Looking at the major domain for assessment, the authors provide definitions and the rationale for their inclusion.  They define executive function as "processes related to organizing behavior toward future goals".  The reality is that executive function is really defined by convention, typically measures that are thought to reflect to reflect frontal lobe function like mental flexibility and set shifting.  Addiction significantly limits the repertoire of these frontal mechanisms to maintain rather than critically assess the addiction.  Impaired glutamatergic signalling to the stratum and extended amygdala and loss of top-down control are listed as the putative neuroscientific mechanisms.  Incentive salience is described as "psychological processes that transform the perception of stimuli, imbuing them with salience and making them attractive."  The underlying mechanism is given as "activation of mesocortical dopamine system".  Familiarity with the reward and motivational system that is focused on the ventral tegmental area and its dopaminergic projections to the nucleus accumbens is at the heart of this system but it alson includes projections to the frontal cortex.  During the initial phases of exposure to rewarding stimuli, the dopaminergic neurons will fire.  As that process continues, anticipation of reward causes them to fire.  That phasic dopaminergic activation leads to altered response to cue and noncue targets, craving, and heightened relapse risk.  Negative emotionality is defined dysphoria and negative emotional responses to stimuli associated with addictive states.  These states are often mistaken for an treated as depression.  The ANA has instruments to assess hypohedonia.  Brain stress and antistress systems are thought ot be involved with the latter contributing to negative emotionality.

When I look at the table of measures that comprise the ANA a couple of scenarios come to mind.  The first is the omnipresent Attention Deficit-Hyperactivity Disorder (ADHD) diagnosis encountered in psychiatric practice.  Most of these diagnoses are not made by psychiatrists.  In the people who I reassess because they may have an addiction, when I ask them about the diagnosis, I am likely to hear: "My primary care doctor sent me to a psychologist and I had two hours of paper and pencil and computer testing."  The problem is that there are no neuropsychological tests for ADHD, no matter how extensive.  Most of the test battery would be for executive function - right out of the ANA and those tests are not necessary for the diagnosis.  That led Barkley to come up with his own version of checklist symptoms that he thought matched the executive function deficits of the disorder better than the neuropsychological tests did.  The second diagnosis is Alzheimer's dementia.  Cortical dementias are based on higher cortical deficits, memory problems and the characteristic progression.  An extensive test battery for the disorder is not indicated.  I would argue that medical testing to rule out other causes is the single most important biomedical approach and that an extensive test battery would not add much.

In summary, there are several questions about the ANA.  The first is whether it can ever be widely implemented in its current form.  The total length of the test is 205 minutes on paper and three of the tests are based on neuroimaging.  The authors estimate that it would take about 10 hours to complete and cost anywhere from $3000 to $5000 per individual.  That alone restricts the ANA to urban areas where psychiatric clinics are well staffed and have access to neuroimaging and staff with the time and interest in complex diagnoses.  That runs counter to a 30 year trend to ration detox and addiction services and largely move them off of medical campuses.  It also runs counter to the collaborative care idea that suggests psychiatric staff can be marginally involved in primary care clinics that equate psychiatric diagnosis and treatment to a metric that can be completed in 5 minutes or less.  Following that logic, the ANA might fly in these settings if it was 5 to 10 minutes long and would reliably lead to a prescription.  A managed care organization (and they all are these days) will not be applying this kind of test to people with addictions.  It is hard to determine how many people with addictions are seen and assessed by these organizations.  The second question involves the cost-effectiveness argument applied to medicine.  I am certainly averse to this argument, but all of the bean-counters seeing this will ask: "If we do all of these tests will it change anything?  Current treatment of addiction is a crude proposition, but are there specific treatments based on the testing that will improve the process and outcomes of treatment?

From the pure egghead side of the equation, does the ANA go far enough in exploring the conscious state of the person with addiction?  I find that very few assessments examine the cycle of euphoria and positive reinforcement and dysphoria and negative reinforcement best described in a statement by one of the coauthors of this paper:

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

As far as I know there are no more accurate statements about addiction that capture course, clinical phenomenology, and implicit neuroscience in one sentence.  If that sentence was all that you knew about addiction, you could diagnose and treat most disorders by deriving your clinical interview from these first principles.  The problem in the DSM world is that the interview ends up being a collection of impersonal markers that may of may not uniquely apply to the person being assessed.  The ANA seems to take the encyclopedic approach to this problem.  The intense euphoric state of early addiction is rarely explored.  A lot of what constitutes a clinical evaluation is the tabulation of various adverse outcomes rather than the ongoing process.

Just adhering to the basic science of the situation are there easier and more straightforward approaches to executive function, negative emotionality, and incentive salience.  I think that there might be.  I am  familiar with most of the measures suggested by the authors but the proper analysis requires a much closer look at all of the suggested metrics and how well they will discriminate between thousands of people with the same clinical diagnosis.  Although I dislike using it in the same context, the PHQ-9 is a good example of a purported measure of depression that really does not discriminate and the authors include several similar measures in their list including the Beck Depression Inventory, the Beck Anxiety Inventory, the Fawcett-Clark Pleasure Scale, and the Toronto Alexithymia Scale.  Degrees of freedom are important in thinking about the total number of items available to characterize the population versus large binary discrimination.  A lot of these measures don't seem up to the task, but i am the first to admit that it would be useful to see research that focuses on that issue.

In the meantime, the take home message for any interested clinician is that the ANA is not ready for prime time - for a number of reasons - but stay tuned.   There also seems to be an opportunity to come up with new assessments of the systems in question that are more efficient and a better complement to clinical practice.

  

George Dawson, MD, DFAPA

References:

1: Kwako LE, Momenan R, Litten RZ, Koob GF, Goldman D. Addictions NeuroclinicalAssessment: A Neuroscience-Based Framework for Addictive Disorders. Biol Psychiatry. 2016 Aug 1;80(3):179-89. doi: 10.1016/j.biopsych.2015.10.024. Review. PubMed PMID: 26772405; PubMed Central PMCID: PMC4870153.

Managed Care Reform - The 4" x 6" Card

I got carried away in the last post and added this as supplementary information.  Sometimes I forget that this is a blog and not a research paper in Nature.  So here is the suggested 4" x 6" note card that is all that is required to reform an out-of-control managed care industry.  It is more out of control with regard to psychiatric and mental health services than any other health care services and some of the reasons were given in my previous post.  The additional data is contained in this blog and the obvious places to look have to do with jails being the largest providers of mental health services,  per capita psychiatric beds being at lower numbers than most OECD countries, overcrowded emergency departments due to the lack of available psychiatric beds and less intense psychiatric facilities, the lack of psychotherapy services. the lack of state-of-the-art psychiatric evaluation facilities, the lack of structured facilities for children with psychiatric problems, a lack of detox facilities, and a serious lack of treatment facilities for substance use disorders.

In one way or another - all of these services are casualties of managed care.

The 4" x 6" card is all that is needed to regain a focus on quality care and starting to develop adequate services again.  As we have recently seen - 300 page rewrites of health care law that are unreadable and contain a line for every business Congress wants to fund accomplish nothing.   Print off the card and spread the word.

Anything short of these basics is just special interest politics as usual.  In politics the excess usually means coming up short.


George Dawson, MD, DFAPA

Another Bad Editorial Decision and more.....

I am on record recently pointing out how top medical journals have evolved to the point that they are posting a continuous stream of opinion pieces of variable quality.  It is not uncommon to find that from week to week diametrically opposed views on topics are published.  The most alarming trend in the posting of business views; usually along the lines that there needs to be continuous business reform in health care.  These are basically opinion pieces looking for a political foothold.  The precedent of course is managed care.  After it gained a political foot hold in the Clinton administration it became a business worth hundreds of billions of dollars.

In the case of managed care it was sold as widespread "reform".  After 30 years of managed care rationing the per capita health care costs in the USA are quite unbelievable when compared with even the next most expensive system ($9,086 in USA versus $6,325 in Switzerland).  The other top ten nations are seriously outdistanced.  Rather than acknowledge managed care as just another political flop there are endless editorials on how it really slows the growth of health care.  There are editorials of how it is really a success despite these outrageous numbers and nearly complete hegemony by managed care and insurance companies.  It is difficult to see how responsible editors of medical journals can continue to publish this pro-business propaganda.  They are certainly more circumspect about making these pages a sounding board for the pharmaceutical industry.

The largest divergence when it comes to health care costs is a managed care propensity for a disproportionate focus on mental health and psychiatric services.  This is nothing new.  It has been well documented since the  Hay Group found that from 1988 to 1997 that a total value of health care benefits for over 1,000 large U.S. employers declined by 10%.  Of the decline general health care benefits declined by 7%, but behavioral health benefits declined by 54%.  Behavioral health is managed care speak for mental health and psychiatric services.  Those same services dropped from 6% to 3% as a total percentage of health care costs.  While general medical services increased by 27% outpatient mental health services dropped by 25%.  Mental health benefits from employer based health insurance dropped by 50% between 1988 and 1998.  The true costs of managed care rationing have never been seriously examined.  There is an obvious conflict of interest when the government basically invents and industry based on a flawed political theory and the system floats based on these invented special interests.  

I did not really think that these opinion pages could be any worse until I happened to open up JAMA Psychiatry the other to do some reading while I ate my Wheaties.  I ran across an article called "What to do when your managed care firm says no."

The answer from my experience is nothing - you are basically out of luck.  In my experience managed care companies don't care if you live or die.  They don't care if you have the world's worst eating disorder.  They don't care if you have tried to kill yourself while intoxicated and your psychiatrist is saying that you will absolutely use alcohol, heroin, methamphetamine, dextromethorphan or any number of drugs immediately if you are not sent to treatment after acute stabilization.  They don't care if you need a longer period of time in the hospital.  They don't care if you have been committed for a suicide or homicide attempt.  I am not saying all of this just because it is true.  I am saying it to point out something that is often overlooked.  Why would a managed care company or MCO care?  They have never met you and have no personal responsibility to you.  As a business, especially in the new era of business management - they basically have a responsibility to make money for their shareholders.  The caring aspect of MCOs is really a public relations stunt.  They involve your doctor and make it seem like their decision - is your doctor's decision.   They waste your doctors time in order to make it seem like their refusal to pay for your care is somehow a conjoint decision with your doctor.

But back to the article.  Here we have a managed care insider giving advice to patients and physicians on how to deal with their denials.  I would consider this all tongue in cheek advice if it was not sitting right there in JAMA Psychiatry.  I will focus on a most familiar scenario denial of inpatient care.  This is a case of a hospitalization for schizophrenia where "the hospital tells the mother that it is time to discharge her son because the MBHO (Managed Behavioral Health Organization) says so and has an appointment for her son to be seen a month after discharge" (p. 1109).  The author suggests that in the case of this dispute the vendor will have a formal appeals process and that will include "a review by a psychiatrist not on the MBHO's payroll."  That has not been my experience.  The review is generally done by psychiatrists a long distance away.  They may not be licensed in the state where the patient is hospitalized.  The ones I have talked with are either openly hostile, pretending to be on your side, or clueless about the severity of inpatient problems.  Keep in mind that most psychiatrists do not practice in inpatient settings beyond their training years.  I have never seen a study that looked at whether these reviewers were actually treating very ill psychiatric inpatients - but from my conversations I think they were not.

The author goes on to say that the family can then apply to the employers benefits manager to apply leverage to the MBHO and have leverage in the case of inadequate care.  What is wrong with that picture?  For starters any sequence of events where clinical decisions are being made by business types is by definition - inadequate care.  Secondly, there is an inherent conflict of interest when your employer and an insurance company they are contracting with start negotiating your medical or psychiatric care.  Once again - neither of them has a responsibility to you for giving you the best possible medical advice.  They are giving you a business decision that saves them both money and calling it a medical decision.  The MBHO is protected against liability from that decision by federal law.  Your employer is protected by saying it was the decision of the MBHO and not them.  If you really think that your employer is interested in your personal health, go talk to the decision maker in person and note their level of interest.

The final vignette provided by the author is there to justify managed care.  It has been their war cry since day one and that is excessive utilization.  In this case we are lucky to have Big Brother watching in the case of psychotherapy delivered so inexpertly that the therapist states: "I am this patient's only friend so she needs to to keep seeing me."  This was after years of treatment.  I think that we can  all breathe a sigh of relief that an MBHO being paid millions plus incentives to ration psychiatric care can identify the worst therapist in the USA after years of therapy.  It is a miracle of modern management.

When you have editors who accept this level of an article it is a direct insult to anyone who has personally dealt with these companies and who knows what is going on.  It is a direct insult to the medical profession and physicians who have dedicated their lives to learning complex, highly technical profession to suggest that they should be clerical workers and work for free as employees of managed care companies.  It is an insult to desperate patients and their families who put up with all of paperwork, inefficient billing and arbitrary denials of care.

If the editors of medical journals are not bright enough to question the accuracy of a piece like this or they have not had the clinical experience of dealing with the constant harassment of managed care companies - they should defer the commentary section to somebody who knows what they are talking about.

Better yet - time for a moratorium on business and political commentary in medical journals.  When you try to complete with blogs - keep in mind that you are competing with a low standard.  That turns out to be no competition at all.  


George Dawson, MD, DFAPA

Reference:

1: Essock SM. What to Do When the Managed Care Firm Says No.  JAMA Psychiatry. 2016 Sep 28. doi: 10.1001/jamapsychiatry.2016.2409. [Epub ahead of print] PubMed PMID: 27680607.

Supplemental -  The 4 x 6 Card on Real Health Care Reform

No room for this in the original above.  The solutions to businesses and business managers making medical decisions about your health care is like most political quagmires in this country - very simple.  You can fit it on a 4 x 6 inch index card.

It goes like this:

1:   All managed care (MCO, MBHO) decisions are between the patient and the company.  The doctor is out of the loop.  The doctor advises the patient, the company says yes or no on the payment.  The doctor may have an alternative or the doctor may not.

2:  The doctor does no appeals , paperwork, reviews with the MCO.  Why would he/her?  The doctor does not work for the MCO and does not get paid for all of the time it takes to engage in what are business processes.  The doctor should not care what anything costs the MCO.  They have a tower of MBAs with nothing else to do but figure that out.

3:  The same process is true for PBMs (pharmacy benefit manager) - the pharmacy equivalent of MCOs.  The doctor does not work for the PBM and does not get paid for all of the extra time each day to essentially justify their decisions.  PBMs have another tower of MBAs with nothing else to do but price drugs to their advantage. 

4:  The MCO is liable for damages related to any of their financing decisions that result in harm to the patient.  No federal exceptions.

5:  Each state has an independent arbitration board comprised of physicians who are actively practicing in the discipline where the decision is being appealed.  The physicians are all actively screened for conflict of interest like the Medicare Peer Review Organizations that found there was no excessive use of mental health services or anything else in about 1998.  The arbitration board should contain only physicians - no insurance company insiders dedicated to shield the managed care industry.  Direct appeals by the public should be encouraged with the same amount of vigor that the public is actively solicited to complain against their physicians.   

Steps 1-5 above would assure physician recommendations in the best interest of you the patient rather than the financial interest of the managed care organization.  Unfortunately with Managed Care 3.0,  the rationing in many cases has been internalized.  Today physicians can be in a clinic or hospital setting that has internal case managers telling them what to do.  When managed care companies rationed some places out of business they were very successful in acquiring medical groups and facilities.  In other words; the doctors, the hospitals, the clinics and the pharmacies are all owned and run by the managed care company or a shell company.  They all get their marching orders from people in the management class pretending to be medical experts.

That should be a major problem - but in the manner of Orwell - if you use the term health care reform a thousand times - most people believe it happened.

More Than 9 Questions About Sleep

I was just thinking about the PHQ-9 and it widespread use in managed care as a metric for depression.  The idea that 9 questions are all that is needed strike most psychiatrists as a gross oversimplification.  There has been plenty of debate over the years about the diagnostic criteria and waht should be included.  Kendler recently wrote an excellent paper on the fact that the diagnostic criteria as they stand in the DSM really indexes disorders rather than diagnosing them.  Some recent blog posts have looked at real patients and what is happening with them when they appear to have an elevated PHQ-9 score but are not depressed.  Past markers of psychiatric disorders like the dexamethasone suppression test had had to withstand more rigorous testing than the PHQ-9.  And lastly, the literature to support it seems to reflect the literature that justified managed care - a business concept with no basis in science or medicine.

And then I had the thought: "During an evaluation I ask more than 9 questions about sleep on the average."  By comparison the PHQ-9 has one question.  That question is:

3. Trouble falling or staying asleep, or sleeping too much?  
[Not at all] [Several Days] [More than half the days] [Nearly every day]


There are more complex sleep questionairres.  The Pittsburgh Sleep Quality Index (PSQI) and Functional Outcomes of Sleep (FOSQ, FOSQ-10) are good examples.  I thought I would tabulate my questions here.  Sleep disturbance can be a primary disorder independent of any psychiatric problem.  Sleep is also comorbid with many if not most psychiatric problems.  Most people do not recover from a priamry psychiatric disorder as long as their sleep is disturbed.  Sleep disorders can antedate the onset of mood and anxiety disorders by years and for that reason I think it is important to determine if the sleep disorder is primary rather than part of the mood or anxiety disorder.  That cannot be determined by a brief cross sectional look that considers all current symptoms as part of a mood disorder.  So during my standard evaluation I ask people the following questions about their sleep not necessarily in the following order:

When you were a kid in middle school or high school did you have trouble sleeping?
Did you have nightmares back then?
Did they occur early in the night or later in the early morning hours?
Did you sleepwalk?
Did anyone ever tell you that you had sleep terrors?
Did your sleep problems from childhood ever resolve - have you ever slept normally since then?


Do you work at night?
Do you do shift work where the work time changes?
Do you currently have sleep problems?
Do they occur when you try to fall asleep?
Tell me your experience of trying to fall asleep - what gets in the way?
Any idea how long it takes you to fall asleep?
Have you had sleepless night where you could not sleep at all?
Do you wake up off and on all night long?
Do you wake up early in the morning - like 4 or 5 AM and find that you can't fall asleep?
Is your sleep restorative - do you feel rested the next day?
Do you snore?
Have you ever had a sleep study?
Have you been diagnosed with a sleep disorder?
Do you take alcohol or any medication to help you fall asleep?
Do you take in many caffeinated beverages during the day as coffee, soda, tea, or energy drinks?

That is about 20 fairly basic questions about sleep.  It is a framework that requires elaboration.  Just the issue of sleep studies these days can lead to details about parasomnias, related surgeries, sleep disordered breathing diagnoses, restless leg syndrome, and all of the associated treatments.  For the pupose of this post that is about 18 questions or twice as many as the total on the PHQ-9. It should be apparent that severe sleep problems can lead to a score considered in the depressed range on the PHQ-9 by adding up the scores of questions 1, 3, 4, 7 and 8.  Critical distinctions need to be made between sleep problems, anxiety disorders, mood disorders, addictions, and also the excessive use of an adult attention deficit-hyperactivity disorder diagnosis.

This brief exploration should point out the problems with a screening versus a diagnostic evaluation.  If you are given a PHQ-9 or GAD-7 (for anxiety) in your primary care clinic that score alone is insufficient as a basis for a treatment plan for depression.  A person repeating the questions as confirmation does not constitute a diagnostic evaluation.  By itself it does not mean that an antidepressant prescription is indicated.

Ask that person how they know that you have depression and not a sleep disorder or something else.


George Dawson, MD, DFAPA

Waiting To Call An Ambulance Is Not Much Of Plan

I don't like to write about my own health problem - but it is a ready example and I already have another blog about it so here goes.  I also don't need to worry about violating my own confidentiality.  It involves a personal medical problem called paroxysmal atrial fibrillation.  I have consulted 5 different Cardiologists and the rhythm problem is not due to valvular or coronary artery disease.  It is probably due to excessive exercise - specifically exercise with sustained high heart rates.  After a period of frequent episodes, I started taking a generic brand of flecainide 4 1/2 years ago and have not had an episode since.  During that time I have had two episodes of influenza and 1 episode of acute bronchitis requiring prednisone therapy with no recurrence of atrial fibrillation.

Lately I have been seeing patients and about 40% of them have an upper respiratory virus and the various complications.  I knew it was just a matter of time.  Earlier this week I developed a cough, sneezing, facial burning, and a headache but no additional flu like symptoms.  It is not flu season here, but respiratory viruses abound.  Monday, Tuesday and Wednesday morning - I was awakened at 4 AM with an intense flurry of palpitations.  Taking the pulse showed a pattern of 4 or 5 regular beats followed by what seemed like a pause or dropped beat that I recognize as the early transition (I think) to atrial fibrillation.  In each case I drank a large glass of water, paced for a minute or two and I was back in sinus rhythm - the palpitations resolved.  Initial BP check was about 130/80 with a pulse of 88 rapidly back down to 110/70 with a pulse of 58.  The last readings are my typical baseline and I check them four times a day.  I know how much physical, mental, and emotional exertion affects those readings and I try to stay cool.

When it happened Wednesday, I decided to do the responsible thing and take the day off of work and see my primary care physician.  He did a physical exam, ordered labs and an ECG.  Everything was normal.  That is my ECG from that clinic visit at the top of this post.  It is normal sinus rhythm with a slight bradycardia (less than 60 bpm).  An interesting homage to artificial intelligence is that the ECG machine communicated with the electronic health record (EHR) and determined that there was no appreciable change between this ECG and one I had done 10 months ago.  The cardiologist is out of that loop.  The bottom line is that the tests were all negative and the plan was to see what happened and consider a Holter monitor if it persisted.  A Holter monitor in this clinic is a 48 hour recording of the ECG looking for discrete events that might suggest a cause of the rhythm disturbance.  It also allows the patient to mark any episodes of subjective disturbance on that record.

Yesterday morning I felt a little tachycardic at about 5 AM and got up and checked.  Heart rate was 66 and blood pressure was fine.   This AM, a flurry of palpitations wakes me up.  They are gone in two minutes after pacing and drinking water.  There was no chest pain or lightheadedness.  In fact when I had the initial episode about 10 years ago, I was speedskating and my heart monitor showed a rate of well over 200 bpm.  No chest pain or lightheadedness at that time and I drove to the hospital and told them I was in atrial fibrillation.

Today I respond to my primary care physician's note though the EHR and describe what happened.  I recall that he is not in, so I go back to the EHR,  agree that I can be billed if this is not a problem that I have been seen for in the last 7 days and attempt to cut and past my note to my primary care doctor into a separate email to his team.  The EHR cuts me off because it says that I can only use 255 characters.  It is the Twitter of EHRs.  I edit it down and send it - no response to my request for the Holter monitor.  I call the clinic and get on the phone with a triage nurse.  The conversation goes something like this (not a transcript):

Me: (Relating the history and Holter monitor request).
Triage RN:  "Well what is the emergency here?  It is Friday afternoon, there is no way that we are  going to get a Holter monitor today.  It will be Monday at the earliest. Your doctor can call it in then"
Me (a little steamed): "Maybe you could suggest criteria that I can use to call an ambulance."
Triage RN: "What?"
Me: "You know - when I wake up from a deep sleep with this arrhythmia at 4AM tomorrow morning, what criteria should I use to decide when to call an ambulance?"
Triage RN: "I did not know it was still happening."
Me: "It happened this morning.  That is why I e-mailed and called you.  That is why I stayed home from work."
Triage RN: "Well in that case I will run it by one of the attendings who is here and ask them about what should be done."

After another call back to get more of the usual information about cardiac symptoms, the Triage RN called again and connected me with the Holter Monitor tech.  I can apparently get in next Wednesday.  He told me the entire procedure would take 5 minutes so I would only have to miss a half day of work instead of a full day.  I did not pursue the obvious "Well why can't I just drive down there now and have it put on."  Everyone must be scheduled.  Schedules must be adhered to.

So that is where it stands tonight.  All of the bullshit that passes in the press for medical news does not apply.  There is no IBM Watson computer out there that knows more than I know about this condition or how to treat it.  There is no personalized medicine.  I have not encountered a single cardiologist interested in the genetics of atrial fibrillation or why I might have it.  Most  physicians assume I have neglected hypertension or have done something wrong with regard to my self care and therefore deserve it.  I still encounter physicians who doubt that I have never smoked a single cigarette in my life - even though it is true.  Hard to believe that somebody could bring this on by excessive exercise.  Isn't exercise supposed to be good for you?

I am probably being overly dramatic.  This is most likely a benign atrial arrhythmia.  On the other hand - why am I so certain if my physician wants another Holter?  I did a Holter and a longer event monitor 5 years ago.  I run a heart rate of 130 bpm during 4 hours of exercise per week and have tolerated a sustained heart rate of 140 bpm from a medication side effect - calmly pacing and taking incremental amounts of beta blockers to slow it down.  The final instructions from the triage nurse were to get to a hospital if a sustained heart rate of 120 bpm or greater and call an ambulance if chest pain.

Personalized medicine in the early 21st century is in many ways inferior to medicine the way it was practiced in the 20th century.  In those days, there may have been an interested physician who said: "Spend a night on telemetry and we will see if we can capture the beats and figure out what to do about it."  I saw those people being admitted when I was a medical student and an intern.  That was before you had to be dying to get into a hospital and the admission rules were dictated by case managers.  In those days personalized meant a long term personal relationship with a real physician who  could make things happen.

Now like me - those people are sitting at home waiting for something to happen and guessing about when they should call an ambulance.


George Dawson, MD, DFAPA




Disclaimer:

Don't try any of this at home.  This is not medical advice.  Only your personal physicians and consultants can give you that advice.

NEJM Three Part Series - Severe Medical Illness In the Context of Severe Mental Illness

Lisa Rosenbaum, MD has written a three part series in the New England Journal of Medicine that should be read by non-psychiatric physicians, family members, patients, and policy makers.  It is focused squarely on providing medical care to patients with severe mental illness and all that involves.  It is really impossible for psychiatrists to avoid the issue.  At some point in your career you find yourself in a situation with a patient who has a severe medical problems and refuses to address it because of the way that their decision making process has been impacted by mental illness.  If you are an inpatient or ACT team psychiatrist - it is usually up to you to come up with a plan to address that problem,  Several of the scenarios she describes across this series are directly from those settings.  Like any other specialty, psychiatrists will all migrate toward a certain niche.  For many reasons being that person who has to confront mentally ill patients about the fact that they are seriously ill or dying is not a position that is in great demand.  But mostly it is because inpatient and ACT team positions are rationed and none of the payers or administrators want those psychiatrists to do what they are capable of.

This series is part of an overall increase in psychiatric topics that are discussed in the NEJM.  So far this year there have been three Case Records of the Massachusetts General Hospital and a review of the basic science of addiction and a number of other articles on addiction and mental health policy.  Although I have not attempted to quantify it, there does seem to be a general increase in the coverage of psychiatric topics that include reviews of diagnostic groups, basic science mechanisms, clinical trials, and articles of general interest from the field.  The search function of the web site allows for grouping according to specialty and there are generally 20-30 psychiatry references per year over the past 5 years.  Lisa Rosenbaum is a cardiologist and is a national correspondent for the NEJM and in that field has probably seen a number of cases of people with severe mental illnesses and cardiac problems.

In the first article in the series she discusses the issues of informed consent and coercion in treating patients with severe mental illness.  It is well known that this population is undertreated from the perspective of primary treatment that is focused on the mental illness.  She uses an estimate of 9.8 million people with severe mental illness and only 60% of those people receiving treatment.  She cites the systemic problems of a lack of bed capacity 11.7/100,000 currently compared with 337 per 100,000 in 1955.  The contrast is more striking if per capita health expenditures for health and the number of psychiatric care beds per 100,000 population are compared.  For OECD data per capita expenditures for healthcare rank the USA at the very top by far and the per capita number of psychiatric care beds near the bottom compared with other countries.  The article discusses how deinstitutionalization was supposed to be linked to more community resources and not less.  The underfunded systems is portrayed as somewhat of a mysterious problem rather than system-wide rationing of psychiatric services.  The author in this case ties the underfunding to problems that it can't fix namely severely ill patients not seeking treatment  and antipsychotic drug side effects.  The high discontinuation rates in the CATIE trial are cited as proof of this problem.  I think that underfunding due to rationing is the problem.  With adequate resources comprehensive care is possible when the focus is comprehensive care more than medication.

The philosophy behind ignoring psychosis due to a psychiatric disorder compared with other physical illnesses is discussed.  The author points out that given the severe disability of these illnesses they cannot be ignored and that unlike other illnesses there are no major campaigns focused on prevention or treatment.  From there she transitions into the issue of intervention against the patient's wishes.  She discusses Stone's theory of paternalistic intervention if the affected person is likely to be grateful after they have been stabilized.  The flaw with that theory is that in many cases only a degree of psychiatric stabilization can be achieved.  In many cases it is likely that the person will have continued problems with insight and medical decision making and will continue to disagree with any suggested treatment.  She discusses the flaws with "dangerousness" as a component but does not take that discussion to its logical conclusion.  Dangerousness is of course not a psychiatric concept.  It is used by the courts as a basis for the initial stages of civil commitment and by managed care companies to decide if they will pay for psychiatric hospitalizations.  Any inpatient psychiatrist has found themselves talking with an insurance company reviewer - usually many states away who wants to know "where's the dangerousness?" and who is quick to deny payment for the treatment of a severely disabled person on that basis.  Dangerousness is probably the single word in the English language responsible for shutting down psychiatric care bed capacity and driving skilled psychiatrists away from the treatment of severe psychiatric disorders.

Rosenbaum makes the mistake of overemphasizing the importance of stigma.  She accepts as a given that stigma causes "countless harms" when the real harm is caused by systemic discrimination by the government and insurance companies.  The dangerousness concept as a justification for no treatment has done far more harm than the stigma of mental illness.  She also connects the attempt to counter stigma with illness minimization behaviors such as treating a person with a severe mental illness and impaired decision-making capacity as a competent decision maker.  Stigma is of course tied in with the recovery movement and policy that flows from the Substance Abuse and Mental Health Services Administration (SAMHSA).  Overmedicalization and disregard for civil liberties is cited as a need for this recovery based model.  That cannot be reconciled with the fact that for at least 40 years, all states have had civil commitment and guardianship/conservatorship laws in place that are in place to assure the civil liberties of anyone where there is a suggestion of coerced treatment.  When people "die with their rights on" they are generally dismissed by courts and end up dead as the result of untreated mental illness.  Only psychiatrists are generally bound by these laws and not other physicians and that part is left out.

The other significant group left out of course are the antipsychiatrists and their considerable allies whose raison d'etre is basically to bash psychiatrists and make them look bad.  That group frequently uses the term overmedicalization and pretends that there has not been decades of legislation to protect the civil rights of the mentally ill.  She is patronising in suggesting that "most psychiatrists" recognize "peer support, structured activities, psychotherapy, employment assistance, and case management" might be useful -  ignoring essentially a century of research by psychiatrists on these elements of treatment.  It also ignores the truth that every psychiatrist knows and that is - people recover and people with severe illnesses recover.  I don't need a recovery movement to tell me that.  I have people walking up to me on the street who I treated decades ago who tell me that they are married, they have children, and they are working.  Despite that severe shortcoming, I give her credit for pointing out how recovery proponents "twist data to advance their agenda".  There is currently a lot of twisted data out there.

She ends the first discussion with commentary on whether a living will for treatment of psychiatric disorders, innovations like a "one-time autonomy violation for forced treatment", or civil commitment as usual is the best approach to forced treatment of severe mental illness.  That assumes that some innovation is necessary and that it will be universally applied.  Both assumptions are incorrect.  It is possible these days to look at the editorial pages of any major medical journal and of course the non-medical media and read endless suggestions about how "the system" of medical care should be changed.  The reality is that there is a loose system of medical care and for psychiatric care the system is non existent except in the minds of antipsychiatrists.  As far as I can tell the only thing wrong with mental health law is that it is subjectively interpreted and that interpretation is clearly affected by the attitudes of attorneys and judges and the resources of the county that is financially responsible for treatment.  That skews undertreatment more severely to the counties with fewer resources.  There is nothing wrong with the law as it is written.  Civil rights are protected and the decision about rights is made by the legal system and not psychiatrists or physicians.

The second article in this series (2) is focused on the mortality gap between persons with mental illness and those without.  Unlike recent authors Rosenbaum points out that the problem was first identified by a psychiatrist in 1932, long before there were any effective treatments or treatments that allegedly cause medical complications.  She almost avoids the accusation of some recent extremists that psychiatrists and psychiatric treatment are responsible for this increased mortality rate but does bring that point up.  Nobody can argue that a lot of this mortality is based on pessimism in dealing with the mentally ill.  I can still recall the obsessing about the decision go to smoke-free inpatient psychiatric units.  One of the arguments is that it would lead to much more aggression among patients and toward staff.  The  other argument was that smoking was "all they had" and it should not be taken away from "them."  Both arguments were advanced by trained mental health staff and are extremely demeaning.  It is not surprising that patients with mental illness have lower rates of guideline recommended care or disease altering interventions.  I have contacted many primary care physicians who were surprised to hear that their patient was still alive.  I have also found myself in the position of treating people with sustained very high blood pressures or people who were actively bleeding because the patient was refusing treatment.  The only advice I got from consultants was to call them back when something bad happened and in some cases it did.

The medical rather than psychiatric assessment of capacity to consent is discussed.  A study is presented that shows  that on a typical medical service 40% of patients lacked capacity to consent and the treatment team was aware of only 25% of those cases.  This implicit consent on medical and surgical services is widespread.  It is generally questioned only in the case of high risk procedures or if a patient illogically refuses routine care.  In hospitals with psychiatric consultation-liaison services - they are typically consulted with the question.   Rosenbaum suggests that in contested situations forced treatment results in brutal seclusion, restraint and forced medication.  That is an unlikely outcome in these situations.  Most people no matter how delusional agree to care if a judge orders it or they realize that just leaving is not an option.  The suggestion is made that more time and training for capacity to consent evaluations be considered.  That is not going to happen.  There is a reason that people avoid going into psychiatry.  Talking to patients and making these assessments is one of them.  And there is no way that hospitalists are ever going to have the time it takes to do this job in addition to their medical evaluations.  It is just another psychiatric resource rationed out of the system.

Rosenbaum concludes with a valentine to integrated care models.  She has access to some of the few internists who are adept are treating people with severe mental illness, including one internist who specializes in it.  The recent MGH Case Reports have discussed similar models.  The main model that was invented in 1974 by Len Stein, MD, Mary Anne Test, MSW and  others is never mentioned.  Since that time there are ACT teams that coordinate medical care for people with severe mental illnesses and help them stay healthy outside of hospitals.  As a psychiatrist trained in these community psychiatry interventions there was nothing about patient care in these three articles that was news to me.  There are plenty of psychiatrists trained in these interventions but very few settings to implement them.  That is because the rationed care approach has split psychiatric care off from managed care organizations and placed it under the purview of the state - usually as a way to justify shutting down state hospital bed capacity.   In states where the resource becomes state-run managed care poor outcomes can be expected to follow.  Since ACT treatment was originally focused on deinstitutionalization and quality of life it is easy to dismiss based on typical cost effectiveness arguments.  I can still remember Len Stein showing us the reason why ACT was invented.  It was a single slide showing a gymnasium sized room full of cots that were placed edge to edge.  The patients were all men wearing the same uniforms off to one side.  His question to the residents was whether it was better to help all of those men live independently or let them live in those state hospital conditions?  Unlike today - incarceration and homelessness were not acceptable options.      

The final article in the series suggests that inaction on the part of physicians in addressing the problem of medical illness in people with severe mental illness is a result of learned helplessness.  That refers to a well known animal model of depression where test animals are subjected to some insurmountable stressor and generally give up and stop trying.  That model alone provides an interesting disconnect between psychiatrists and the rest of medicine.  Since the days of German asylums, psychiatrists have wanted to talk to their severely ill patients - even before there were any effective treatments.  That drive is one of the most  compelling reasons for medical students to go into psychiatry in the first place.  I don't think that properly trained psychiatrists view these problems as hopeless situations, even though some of the inpatient units they work on are clearly repositories for problems that other physicians consider hopeless.

I have no problem at all talking with anyone who has a severe psychiatric problem, understanding them, and discussing treatment options for both their psychiatric and medical problems.  I have no problem understanding that the only reason I am the one offering help is a matter of genetics and good luck.

Any psychiatrist that I know can do that.      


George Dawson, MD, DFAPA



References:

1: Rosenbaum L. Liberty versus Need - Our Struggle to Care for People with Serious Mental Illness. N Engl J Med. 2016 Oct 13;375(15):1490-1495. PubMed PMID: 27732817.

2:  Rosenbaum L.  Closing the Mortality Gap - Mental Illness and Medical Care.  N Engl J Med. 2016 Oct 20; 375 (16): 1585- 1589.

3:  Rosenbaum L. Unlearning Our Helplessness - Coexisting Serious Mental and Medical Illness. N Engl J Med. 2016 Oct 27;375(17):1690-1694. PubMed PMID:27783917.

Stigma and Addiction

The basic position that I take on this blog is that stigma is an overblown concept.  Certainly no professional should ever be in the position of treating a person with a mental illness or addiction in any way that conforms to stereotypes.  I have been in many situations where that occurred during my training.  In those days a lot of alcoholics were admitted to medicine services because they needed detoxification by people who knew what they were doing .  They also needed close monitoring by nursing staff.  That did not mean that they were treated like all of the other medical patients.  There was usually a sense of hopelessness on the part of the house staff who could see several of these men admitted repeatedly during a 3 month rotation.  Men with hepatic encephalopathy, recurrent pancreatitis, alcoholic hepatitis, and upper GI bleeding from varices.  During one of the rotations, I encountered the term "incorrigible alcoholic" right there in the PGY3 note countersigning my intern note.  I had never seen a term in a medical chart like that before.  I had to look it up to make sure I knew what it meant and sure enough the first definition was bad beyond reform.

These reactions extended far beyond alcohol use problems.  Young addicts using various street and prescriptions drugs would present confused and aggressive.  At times paranoia and aggressive behavior were also prominent problems.  Nursing staff and house staff were frequently injured and in these emotionally charged encounters, the word "dirtball" was frequently uttered.  It was clear that at least some professionals viewed the confusion or aggressive behavior as volitional on the part of the patient and classified them as people who were intentionally trying to injure the staff.  The only way that you can make it in psychiatry is if you realize that aggressive behavior is a component of the illness.  It needs to be contained, but it does not need to be seen as a conscious "choice" of the patient involved.  Neither does their hygiene, cognitive problems, general lack of self care, inability to follow through with discharge instructions or stay away from drugs or alcohol.  That is not "excusing" them because you don't think they have a legitimate illness or can't prove that their behavior  is biologically based.  It is treating them like a human being and recognizing that you might be bringing too much emotion into the equation yourself.  There is nobody who needs a doctor with a cool head more than an addict or an alcoholic.

Those experiences led me to pay close attention to an opinion piece in JAMA about stigma and addiction.  One of the authors was from the White House Office of National Dug Control Policy.  The other was from Harvard T.H. Chan School of Public Health.  I looked even closer when it became apparent that their arguments were focused on the stigma arguments that were used for mental illness.  The authors use mental illness and the early days of the HIV epidemic as examples of how the language used to describe these patients implied moral deficiencies and led to discrimination.  They go on to cite studies of how differences in words can affect how treatment decision made by professionals can be similarly biased depending  on how loaded the stigmatizing term is.  They describe how the fear of stigma keeps people out of treatment.  Finally they outline the government's approach to changing the language about addiction and how that will help.  The White House Office of National Drug Control Policy is releasing Changing the Language of Addiction for guidance on these issues.  Common examples include changing "substance abuser" or person with a drug "habit" to a "person with a substance use disorder."  Near the end of the essay they acknowledge language changes are not enough.

Their initiative will not have any impact for the same the same reason that the anti-stigma campaigns for mental illness don't have any impact and here is why:


1.  The real bias occurs at the level of the insurance industry -  Coverage for addictive disorders varies widely and the only unifying theme seems to be rationing of treatment resources.  That rationing has been going on for 30 years and has led to inadequate treatment capacity.  The best time to provide treatment is right at the point that the affected person needs help.  Setting them up for an appointment 2 - 4 weeks later does not make any sense and can be dangerous if they are using dangerous levels of addictive compounds.  It makes absolutely no sense at all to deny care to a person who is using dangerous levels of addictive drugs simply because they have not yet tried outpatient treatment.

2.  Clinicians don't resist evidence based treatment  - there is nobody around to deliver it -  It is well known that psychiatric and addiction services are understaffed and have been for decades and the situation will probably get worse.  The number of addiction psychiatrists and addictionologists is even lower on population based metrics.  Policy makers seem to have the idea that primary care physicians will start actively treating addiction because treatment is currently described as being contained in a medication.  A recent study showed the underutilization of buprenorphine by these physicians.  They expressed in that same survey that they wished that they had someone who they could refer their patient to.  It is very difficult to go from prescribing opioids for a pain diagnosis to diagnosing and treating addiction in the  same setting.  It is also very difficult to provide treatment without adequate cross coverage.  There need to be adequate numbers of clinicians in any primary care clinic who are interested and competent to treat addictions.  In the case of buprenorphine maintenance. they need to be licensed to prescribe it.  Even then they need referrals sources to physicians who specialize in treating addictions and have some access to more resources.

3.  Community factors are prominent -  Insurance companies still discriminate against anyone with a substance use disorder.  I had a recent conversation with a person who needed some form of treatment. but was concerned about what would happen once the medical records got out to a long term insurance carrier.  Previous experience suggests that company takes 5 years to reconsider any application from a person with an alcohol or drug use disorder.  He  declined any form of treatment that would become part of the medical record that could be accessed by the insurance carrier.

4.  The Mental Health Parity and Addiction Equity Act of 2008 is a bust - time to stop pretending that it means much -    This is the highly acclaimed parity act started by Senators Paul Wellstone and Pete Domenici.  Discrimination and unfair treatment are widespread and contrary to what was expected there has been no boom in treatment for addictions.  Addiction and mental illnesses are still subjected to the same rationing policies and lack of infrastructure as they were before this act.

5.  It all starts and ends with the government -  This essay has that familiar ring to it:  "We are from the government and we are here to help you."  Let's not forget who started the system of discrimination against people with mental illness and addiction in the first place - the government at all levels.  The government invented the managed care industry as its surrogate in the first place.  If they were really interested in solving the problem - they could use the same top down approach that they used to create it in the first place.  They could provide medical detoxification in hospitals and coordinate the development of those guidelines.  They could provide access to Addiction Psychiatrists and  Addiction medicine practitioners.  They could open up bed capacity for residential and sober house care.  They could fund clinics where medication assisted treatments for opioid use and alcohol use are conducted.  They could fund addiction centers of excellence.  They could fund research on treatment for court ordered offenders and whether it is effective.  This is all evidence-based care, but the article suggests that primary care physicians who are currently overworked by government mismanagement are going to suddenly see hundreds or thousands of new patients with addictions.  Suggesting that this is a language based problem put the blames directly on clinicians.  It is clear to me that there are no psychiatrists blaming people for mental illness or addiction.  Who are these people and how extensive is the problem?  The idea that everyone needs to be reformed or reeducated is a familiar tactic used by politicians and policy makers.  It was the rationale for managed care rationing in the first place.

6.  Prevention is a priority - The prevention of drug use is the surest way to prevent increasing number of people from experiencing morbidity and mortality due to drug and alcohol use.  Prevention of drug use at this point in time is historically difficult as the country swings into another era of permissive attitudes toward drug use.  Individuals not abusing their first opioids will have a much greater impact on the prevalence of addiction than all of treatments after an addiction has started.

All of these factors are what clinicians like me see as everyday interference with helping patients who have a substance use disorder.  Semantics may help some.  Training and recruiting physicians who know that it is only luck that separates them from people with addictions and mental illnesses will help more.  Ending insurance company dominance over clinicians will help the most.

In the end - words don't keep people with addictions from lifesaving treatment.

The government and health insurance companies do.             

  



George Dawson, MD, DFAPA


Reference:   

1: Botticelli MP, Koh HK. Changing the Language of Addiction. JAMA. 2016 Oct 4;316(13):1361-1362. doi: 10.1001/jama.2016.11874. PubMed PMID: 27701667. (free full text).