Bedless Psychiatry and A Recipe for Remaining Bedless

There is no better marker of the rickety psychiatric infrastructure in the USA than the lack of psychiatric beds.  A close second is how those beds are utilized to basically run patients in an out to maximize hospital profits. It seems like I have said it a thousand times on this blog but I will say it again - hospitals make money by getting psychiatric patients out in advance of the diagnosis related group (DRG) time limit.  These days that it is about 3-4 days. If management believes that the psychiatrist is not discharging people fast enough - they will turn up the heat on them to do so by using either a designated case manager or somebody who sits in team meetings and reports that psychiatrist to his or her superiors if the patients are not out by a maximum of about 6 days.

There are huge problems with that business approach to psychiatric care.  The first is patient complexity. Severe psychiatric disorders place people at risk for significant medical problems and often psychiatric care cannot proceed until those medical problems are stabilized.  During my career for example I had terminal cancer patients and patients with uncontrolled diabetes mellitus and hypertension admitted directly to my care because they had a major psychiatric disorder.  Substance  use disorders complicate at least half of the admissions and psychiatric care typically has to wait until a patient is detoxified from an intoxicant.  Very ill patients with schizophrenia and mood disorders who received outpatient treatment cannot be treated and stabilized in 4-6 days.  Specific problems like suicide risk and delirium often take many weeks of care.  Although brief stays can be useful in the case of event or intoxicant related crises the length of stay on psychiatric units is basically an arbitrary number of days determined by bean counters rather than doctors. They do no reflect clinical reality.

That brings me to the commentary by Sisti, Sinclair, and Sharfstein (1).  They lost me then they had me and then they lost me completely.  My first criticism is the title "Bedless Psychiatry-Rebuilding Behavioral Health Service Capacity."  Ironic that the authors use the managed care buzzword "behavioral health" to suggest that the bed crisis can be addressed by the same carpetbaggers that designed the current system.  I can appreciate a political turn of a phrase as well as the next rhetorician, but in the case it falls very flat.  The only way to address the bed crisis and the destruction of the mental health care infrastructure in this country is to get rid of managed care and all of their buzzwords.  There is no way that companies paid well for rationing care and kicking unstable people out of psychiatric hospitals are going to solve that problem.

From there the authors do an adequate job of describing the problem of a sharp drop in bed capacity in addition to the absurdly short lengths of stay.  They depend on data that may have another agenda.  In a recent post in this blog, I looked at the drop in state hospitals beds in Minnesota and the Medical Directors commentary on why that will never be reversed.  The same organization that authored the report used by the authors to describe the drop in beds (National Association of State Mental Health Program Directors (NASMHPD) is on record stating that "Building more inpatient bed capacity to meet demand is unsustainable".  State Mental Health Program Directors are all accountable to state politicians and generally run state mental health programs like managed care companies do.  They ration services and limit access to treatment. It is cost effective from their perspective to leave large blocks of people untreated. Better yet put them in jail and give them a baloney sandwich everyday instead of the à la carte fare that medical and surgical patients have come to expect in customer satisfaction based hospitals.  This conflict of interest and lack of interest in looking at whether bed capacities are too low is a bias that any reader of the report should be aware of.   They also consider OECD data and suggest that psychiatric bed capacity in the USA is 4th from the lowest bed capacity in the countries studied.

They go on to discuss the "types" of beds  and suggest that the notion that bed capacity may be too abstract.  They favor bed descriptions based on the function of the unit that they reside on - forensic, acute care, intermediate, and long term care.  They discuss beds in the grey zones between corrections and mental health.  For example in my discussion of the Minnesota situation, I did not include beds operated by the Minnesota Sex Offender Program (MSOP).  That program houses 726 clients at two large facilities or about three times the state bed capacity for all of the committed patients with mental illness in the state.  In a bizarre end run around psychiatry, sex offenders in the state are essentially granted mental illness status.  This occurs in order to allow the state to indefinitely commit them.  MSOP clients are essentially never discharged while committed patients back up and crowd local hospital psychiatric units and shut them to new admissions while they are waiting to be transferred into the state hospital system.  The argument about no new beds at the state level does not apply to sex offenders.

The authors close by saying the concept of a psychiatric "bed" may need to be "jettisoned" in order to more accurately address the needs of patients and system capacity.  They end with the idea that "targeted payment reforms" are necessary to increase psychiatric bed capacity.  I think that they have it wrong on both accounts.  We have had 30 years of "incentives" that really are not incentives.  The DRG payment itself was allegedly a payment for what was the average amount of care for a particular diagnosis.  Instead, it became a way that managed care companies could game the system while they rationed care.  It may not be as easy to determine (another bean counter bias) - but looking at the flow though systems and where services are short is a better idea.  Classic examples are outpatient psychiatrists who are not able to refer one of their outpatients to an inpatient unit in the same system for purposes of detox, electroconvulsive therapy, or stabilization.  Whenever that happens it should be taken as a sign that health plan needs to improve their bed capacity.

Bed quality is as least as important as bed inventory.  Beds are worth less if there are problems with the physical structure or staffing problems.  Beds are worth less if a therapeutic environment cannot be maintained. Beds that can contain aggressive behavior are generally at a premium because fewer people can work in that setting. In every state there are only a few psychiatric units that will address aggression as a psychiatric problem.  Specialty units to treat depression, bipolar disorder, schizophrenia, substance use in addition to mental illnesses, or medically ill psychiatric patients are rare.  There appears to be no interest in either the quality or specialty side.  DRG payments create an incentive to get people out as soon as possible and provide the lowest level of quality.

A very basic comparison with any systems of high quality beds that address the medical problem with state of the art care is instructive. Any middle aged person in the US who presents to the emergency department with chest pain who has cardiac risk factors will be admitted to a telemetry unit, get the necessary blood testing, and (if all of those tests are negative) will probably get an echocardiogram and cardiac stress test before they leave the next day. That same person presenting to the emergency department with hallucinations or mania or severe depression or delusions will only be admitted unless they are determined to be "dangerous".  The standard definition of dangerousness being "imminent risk of harm to yourself or others."  Dangerousness is the managed care approach to psychiatric hospitalizations.  It contaminates emergency assessment and it contaminates what happens on the inpatient side.  When the overriding treatment dimension is dangerousness - inpatient units become holding tanks where nothing therapeutic occurs. Patients sit around and look at one another all day long waiting for someone to proclaim that they are no longer dangerous - so they can be discharged.  Beds that operate under this punitive model should probably not be counted. 

The authors' commentary seems to continue the same policy wonk approach that has contaminated practically all medical journals - basically a number of administrators sitting around and speculating.  Unfortunately we know that a lot of bad ideas get started this way. We also know that hypotheticals and incentives have have been the order of the day for a generation and that very process knocked out bed capacity and led to all of this low quality care.

To improve the bed capacity it will take a psychiatrist who is aware of the problems and how they can be addressed in each state.  Being on the ground as the inpatient beds and any quality they had were rationed away would be a plus.  Knowing how to build increased capacity and quality is the best possible approach. 


George Dawson, MD, DFAPA



References:

1:  Sisti DA, Sinclair EA, Sharfstein SS. Bedless Psychiatry—Rebuilding Behavioral Health Service Capacity. JAMA Psychiatry. Published online March 14, 2018. doi:10.1001/jamapsychiatry.2018.0219

Graphics Credit:

The above picture of an abandoned state hospital bed is downloaded from Shutterstock per their standard licensing agreement.

There Is No Joy In Medicine

At least not nearly as much as there used to be.

I read a comment by a medical student recently who said that he found nothing in medical school - none  of the clinical rotations to be enjoyable at all.  As I looked back on it, at the interpersonal level there is a lot of subjectivity.  Although it was never stated personalities could make or break a rotation.  There was none of the anonymity of sitting is a large lecture hall and passing three or four tests.  As a medical  student, most of the teams I was on consisted of me, an intern, a resident and occasionally a more senior resident and one or more attending physicians.  Just as in real life, it was common to find people who really did not want to be on those teams.  They were fulfilling some sort of obligation.  As in real life, it was fairly common to be on a team where someone did not like you and if they were personality disordered could make your life a living hell.  But that was relatively rare.  As a medical student, the job was to keep your head down, not make any waves and absorb as much information as possible.

And some of those rotations were a dream.  A perfect combination of senior staff who knew they were there to teach, did a great job of it, and went the extra mile to be as cordial as possible to everyone in the process.  I have written about the last team I was on in medical school as an example.  The Renal Medicine team of of Milwaukee County Medical Center and Froedert Hospital in Milwaukee.  In those days there were three senior attendings who were also Professors in the medical school.  They ran an inpatient unit, outpatient clinic, and hypertension clinic. They also covered all of the inpatient consults. There was an associated group that took care of transplant and dialysis patients and all of the complications.  As a medical student my job was to do the initial patient interviews on the consults and present it to the team and round with the team on all of the inpatients.

It was an inspiring team to be a part of. One of the senior Internal Medicine residents was a guy who I had worked with before.  He was bright and had an incredible sense of humor. The most senior attending would give us all a hard time, but you could tell he was joking.  I never saw him lose his temper.  We were typically putting in 10-12 hour days with both patient care and didactics.  There was scheduled teaching time every day and plenty of teaching on the case presentations. Everyone was interested in the work and flexible. On my absolute last day of medical school the Internal Medicine resident told me they were swamped with admissions.  It was 6 PM and he knew I was graduating the next day.  He let me know that and then asked me if I could see 2 consults that needed to be staffed.  I did and felt good about it.  I lived about 1/2 mile away across the golf course sized county grounds and was ecstatic that night for completing medical school and that rotation.

Enjoyable rotations were not limited to medicine specialties.  I had plenty of contact with neurosurgeons in the same hospital.  The Neurosurgery residents had a grueling schedule starting as second year residents where they were basically on call every night.  They were in surgery in the morning and had to assess and treat acute emergencies in a very hectic emergency department.  The also ran a neurosurgery ICU.  On that service we rounded every morning and tried to get all of the work done on hospitalized patients by  11 AM.  The rest of the day was typically spent dealing with one emergency after another. The head of neurosurgery did not say much and appeared to be brusque, but he was an outstanding surgeon and teacher in the operating room.  We also had Radiology rounds every Saturday morning where he would review all of the imaging studies done on our patients in the previous week. That was a two month rotation for me and very enjoyable.

When I think of the common elements in those rotations that made them implicitly joyous - a few things stand out:

1.  They were intellectually rigorous:

There was no dispute that the teachers and professors knew the field inside and out and were interested in discussing it.  My only regret is that as a medical student - you really don't know enough to ask the best possible questions - at least I didn't.  My standard procedure was to study the problems that were being addressed in detail and in retrospect it might have been easier to ask a lot of questions.  Teaching occurred in detail and at length every day.  It was routine.

2.  They managed their own services:

These days practically all hospitalized patients are managed by hospitalists. Hospitalists will call in specialists as needed, but they basically assess the patient and leave a note in the chart.  People will say this is more efficient and have that same argument about primary care physicians not seeing their own patients in the hospital - but a lot is lost in the process.  Teaching is an obvious casualty. Are you going to learn more about a patient who is on your service 24/7 or one who you drop by and leave a note for the hospitalist team?  I have seen medical students following consultants around and they often look bewildered.  As a team, there is a sense of belonging and typically a place to hang your hat and discuss the work every day.

3.  There was no outside interference by the business world:  

The hospital landscape has become bizarre relative to the hospitals I trained in. Instead of morning rounds - you might see a team of physicians in a "huddle" in the morning.  That huddle may contain non-medical staff and administrators who have no role in patient care. There are really there to manage physicians. Some might tell physicians when to discharge patients.  Others are just there to report what physicians are doing to senior management.  Let me clarify that these are not multidisciplinary treatment teams. I had 20 years of those teams meetings that were clinically focused and then one day there was a case manager in that group and she was reporting what I was doing to a hostile medical director who threatened to override my decisions. At a team level there was an equally malignant administrator trying to undermine the relationship between medical and nursing staff.  It is clear from my medical school experience that none of the managers were necessary and they made the clinical situation much worse. Add utilization review and prior authorization done by companies with an obvious conflict of interest and the hospital landscape suddenly becomes a complete nightmare.  I found myself in the position of needing to go though 2 hours of prior authorization time in order to discharge patients on the same medications that they came in on. In other words the medications were already authorized but I had to do it again.

4: Physicians weren't treated like criminals:  

Physicians tend to not be very good with politics and have a short memory but I don't.  In the 1990s, a billing and coding system was introduced that was supposed to capture physician work and provide commensurate reimbursement.  Unfortunately the inventors of this system did not realize that it was totally subjective and far too detailed. In the only study ever done on the validity of the system, the chance that any two coders could agree on the same billing code was a coin toss. In the meantime, at some point during that decade my hospital colleagues and I were cloistered in a lecture hall and told that any mistakes on our documents were a crime and if a billing statement went out based on that crime - we could be prosecuted under federal racketeering charges. In the meantime, the FBI was raiding doctors offices and trying to make documentation errors into a federal crime.  Eventually the federal government must have seen this was a bit heavy handed and they turned enforcement over to compliance monitors in organizations.  I was awarded the "best documentation" one year by a compliance officer and the next year it was the worst. Over that year, I had made no changes to my documentation. Today there is a mountain of worthless documentation that takes each physician about 3-4 extra hours per day to produce that is the direct result of this initiative. If I was back on my neurosurgery rotation - the document would have been 3-4 handwritten lines.

5: Everybody was an expert - not pretending to be one:

Fake medical news is common across all social media.  Journalists commonly print the story that they want rather than reality.  A common story on this blog is is how physicians were bought off by (often trivial) gifts and this led to inappropriate prescribing and massive drug company profits. It was a good story while it lasted and some media is still trying to push it but when gifts to physicians were eliminated, the USA still has by far the most expensive pharmaceuticals in the world.  There are even more provocative headlines out there that don't pass the smell test.  It is in the best interest of click-bait journalists and business administrators to make it seem like knowledge in medicine is relative and anyone can possess it.

6:  Clinical care was cohesive and not fragmented: 

Business innovations in medicine leave a lot to be desired.  When the field is structured around the ideas of business managers and some of these problematic ideas are published as commentaries in prestigious medical journals - adequate care becomes an increasingly remote possibility.  On the services I mentioned patients were triaged to receive the state of the art care of the day.  They did not end up seeing a series of physicians or providers who had no clue about how to address the problem and hoping to see the appropriate specialist.  In fact one of the most embarrassing developments of managed care was the idea that they were going to put specialists out of business or install a gatekeeper to see who gets referred to a specialist.  There are ample examples on this blog of the importance of seeing the appropriate specialist without having to deal with any administrator erected obstruction.  The main fracture in medicine at this point has been the destruction of the psychiatric infrastructure and the incarceration of the mentally ill.

Just a few obvious reasons why my most joyous experience in medicine happened in medical school over 30 years ago.  I think it could all be distilled down to the basic truths of autonomy, professionalism, a singular patient focus, an intellectual approach to the field, and doing the right thing. That is when you have hard working physicians who enjoy the work and are not burned out.  Medicine is currently creaking under the weight of bad ideas from politicians and bureaucrats and all of the associated rationalizations.

It is no wonder that I often find myself thinking about my old renal medicine and neurosurgery teams and whether future physicians will ever be able to capture that joy again.

It is no wonder that when Grace Slick sings with conviction over my Bluetooth player that I am focused on those first 4 lines.......



George Dawson, MD, DFAPA




Graphics Credit:

Photo licensed directly from Gijsbert Hanekroot Fotografie. Title below:

Jefferson Airplane Perfornm Live At Kralingen Festival
ROTTERDAM, NETHERLANDS - JUNE 26: Grace Slick and Jorma Kaukonen from Jefferson Airplane perform live at Kralingen Festival in Rotterdam, Holland on June 26 1970 (Photo by Gijsbert Hanekroot/Redferns)


Lyrics:

From the song Somebody To Love performed by Jefferson Airplane.  Words and music by Darby Slick.


Supplementary:

Interested in Grace Slick photos from around the time of the release of this song. Contact me if interested.

The NEJM Depressed and Recovered Surgeon Commentary

In the March 1, 2018 edition of the New England Journal of Medicine is the story of a surgeon and told by that surgeon about lifelong depression and severe depression that required both involuntary treatment and electroconvulsive therapy.  The essay has been widely hailed on Twitter and elsewhere as a story that illustrates the problems in medicine as well as problems when physicians develop mental illnesses and need treatment.

The first few paragraphs are written in an interesting style reminiscent of one of my all time favorite books Zen and the Art or Motorcycle Maintenance (ZAMM) by Robert M. Pirsig.  In that book. Pirsig details a very personal and spiritual journey on a motorcycle trip across the northern USA from Minnesota to California.  He describes his journey through life at that point including his academic failures and accomplishments.  He talks about the relationships with the people on the trip including his son, another couple, and the friends they are scheduled to meet along the way.  He explores Eastern and Western philosophy and discusses personal difficulties that he has had along the way, including a psychiatric admission to a hospital and a series of electroconvulsive therapy (ECT) that left him delirious, confused, and obliterated a previous alter ego - Phaedrus. Much of his discussion focuses on threads he recalls about Phaedrus and the problems he encountered.

I started reading this book when I was in the Peace Corps in about 1976.  I say started because if you are like me and many other people - this book had a profound effect on you and you kept reading it.  I was reading it a decade before I finally became a psychiatrist.  I was discussing it with enthusiastic fellow Peace Corps volunteers - very energetic and bright people.  Like a lot of people, I look back on that as a very exciting part of my life.   I really don't have any regrets and don't miss those days.  I can still recall them with a great deal of excitement.  When people ask me what I got out of the Peace Corps - I always tell them that meeting and relating to the people I was with was the best part of the experience.  ZAAM  was part of that for me and it still is.

My first read through the book was chilling when I read the passage about ECT:

"He (Phaedrus) was dead. Destroyed by order of the court, enforced by transmission of high-voltage alternating current through the lobes of his brain. Approximately 800 mills of amperage at durations of 0.5 to 1.5 seconds had been applied on twenty-eight consecutive occasions in a process known technologically as "Annihilation ECS." A whole personality had been liquidated without a trace in a technologically faultless act that has defined our relationship ever since.  I have never met him. Never will."

Reading about it later confirmed that Pirsig had been hospitalized and treated with ECT.  He was misdiagnosed with schizophrenia and eventually diagnosed with depression.  He apparently had more than one course of ECT.  I thought about Pirsig's description of ECT in ZAAM.  The ECT would have happened about a decade before he wrote the book.  In many biographic pieces, Pirsig is described as having a genius IQ, high in that range.  He wrote a book that some reviewers equated to Moby Dick  - commonly seen as one of the greatest American novels.  After the book he moved from his job as a technical writer to an academic and was in the English department at the University of Minnesota for a number of years.

I thought about the description of ECT a lot as I learned it as a resident and referred many patients to our ECT consultants for treatment.  In one of the very first cases, I saw a patient depressed and completely immobilized in a coronary care unit by severe depression.  He was unable to eat and he was dying.  In those days we had few medications that we could safely give him and even they would not work fast enough.  When he consented to ECT, he got significantly better, started eating and within two weeks was back home.

Dr. Weinstein's article is a more matter-of-fact presentation. The Pirsig paragraph is a little dramatic and obsessive.  I can speculate on what happened during the ECT treatment and what happened to Phaedrus, but I won't.  Another element barely mentioned but easily overlooked in both pieces is that treatment was involuntary.  Both patients were ordered by a court to be in a hospital and accept the treatment offered.

Going into my career as a psychiatrist, it is common to have reservations about both ECT and involuntary treatment.  You don't have a lot of time to think about it because of the illness severity of the people you are treating.  In my career on inpatient settings it was common to be seeing people who had attempted suicide or homicide and barely missed completing the act.  I have treated many people who were admitted to hospitals because they had killed someone due to a severe mental illness.  I have also been called years after leaving a clinical setting to be informed about the suicide or homicides committed by patients that I had treated.  An even larger group of patients required treatment because they were unable to function and they were starving to death, not able to take care of their medical needs, or had judgment so poor that they were at high risk of accidental injury or death.  The only way any of these patients got better was with medical treatment by psychiatrists including antidepressants, antipsychotics, lithium, and electroconvulsive therapy.

To those people who are thankful that Dr. Weinstein published his experience in the NEJM, I agree with that opinion.  But to me as an inpatient psychiatrist who saw all of the people that are too ill to be included in clinical trials of antidepressants and in many cases too ill to consent to treatment there is a much bigger lesson here.  That lesson is that involuntary treatment, antidepressant medication, mood stabilizing medication, antipsychotic medication, and electroconvulsive therapy all work.  If you are a person with a severe disorder, see a psychiatrist who prefers treating severe problems. If you are a concerned family member, make sure that involuntary treatment is an option.  If it is not, find out why the county you live in is not protecting the most vulnerable people in our society.

But most of all don't let the the media circus about whether antidepressants work or all of the problems with psychiatric medications throw you off.  Psychiatrists know what they are doing and they are good at their job.  Health care corporations and governments do their best to restrict access to psychiatrists but this current paper is evidence why this access is critical and needs to greatly increase.

Nobody should be disabled by severe depression.  Nobody should die from it. The only acceptable outcome is complete recovery of a stable mood and ability to function.       


George Dawson, MD, DFAPA




References:

1: Weinstein MS. Out of the Straitjacket. N Engl J Med. 2018 Mar1;378(9):793-795. doi: 10.1056/NEJMp1715418. PubMed PMID: 29490178.

2:  Robert M. Pirsig.  Zen and the Art of Motorcycle Maintenance.  Bantam Books, New York.  Copyright 1974 by Robert M. Pirsig, p. 77.


Graphic Credit:

The photo at the top of this post is downloaded from Shutterstock and licensed per their standard agreement.

Drinking Your Way To Your 90s.

The headlines recently have been unmistakable:

Drinking alcohol key to living past 90, study says

Drinking Tied To Long Life In New Study

Drinking alcohol increases longevity more than exercise, according to study

Alcohol more important than exercise for living past 90, study claims


Could these headlines be true?  After all, wasn't there a recent headline that said drinking alcohol was the largest single modifiable risk factor for dementia (1)?  Buried in some of those headlines are also secondary stories about political decisions that did not go well for the producers of some alcoholic beverages.  France's Health Minister Agnès Buzyn - a physician stated recently that alcohol is alcohol.  She went on to say that contrary to what French citizens are taught to believe about the health effects of wine it is no  different than drinking beer or distilled spirits and it is bad for health.  I think that we have been in the midst of a tremendous  amount of hype about alcohol, the specific types of alcohol, secondary natural products, the purported metabolic effects and the effect of alcohol on longevity.  The current headlines were the only ones I can recall where the positive effects of drinking alcohol was estimated to be on par with exercise.

I come at the problem from the perspective of an acute care and addiction psychiatrist. For 22 years, I worked at a tertiary care center that was also a Level 1 Trauma Center and it contained a burn unit.  At one point our medical director surveyed our admissions and determined that at least 50% across the entire hospital were there because of drugs or alcohol.  We saw every type of injury and chronic illness due to intoxicants and the patients with those insults often had markedly shorter life spans than expected.  How could alcohol use extend life?  Why was it seen as a common finding? Most importantly - why were all of these headlines surfacing right now?

Some of the articles named Claudia Kawas, MD and her work in the 90+ Study and Leisure World Cohort Study as the source for the headlines (2-4).  The Leisure World Cohort Study (LWCS) followed a group of 8,371 women and 4,828 men from a media baseline age of 74 for a period of 28 years or until death.  The group was located in a retirement community and were described as predominately white, middle class and well educated.  They were sampled at intervals with questionnaires that asked about their dietary habit including beverage intake in terms of alcohol and caffeine containing beverages and other types,  a number of activity levels, and total amount of exercise.  A large number of papers resulted from this study and are still being written as the continuation study of the members that survived into their 90s.  Dr. Kawas gave a presentation at a recent American Association for the Advancement of Science (AAAS) meeting on some of her findings and that appears to be what the headlines based on.

 From the LWCS group, there were several notable findings.  In terms of activity level (2), any activity of 1/2 hour per day or more reduced mortality risk 15-30%.  A broad range of exercise of various levels of intensity and whether they were done inside or outside.  Level of activity at age 40 was a predictor of activity in old age.  Relative Risks (RR) for all cause mortality were calculated for the activities and their duration. as well as the time spent.  After 3/4 of an hour per day the RR effect tapered off.  Sedentary activities like watching television had no significant impact on the RR.  The greatest observed risk occurred when activity levels were reduced due to injury or illness.  They found no survival advantage for a high activity level (1+ hours per day) compared to a moderate level of 1/2 to 3/4 hours per day.

The same group looked at the issue of alcohol intake in the LWCS group.  In their introduction they note that 4% of the annual mortality in the world is caused by alcohol.  They review some of the previous literature and the purported J - or - U shaped mortality curves for alcohol consumption - meaning higher mortality rates for abstainers, lower mortality rates for moderate drinkers (1-2 standard drinks per day), and higher mortality rates for higher levels of drinking. The response choices on the survey were for 1, 2, 3, and 4 or more drinks per day.  They also broke the sample down based on their responses drinking surveys in 1992 and 1998 to to stable non-drinkers, stable drinkers, starters, and quitters based on comparing their survey answers.  Three quarter of the sample drank.  Two drinks a day conferred a 14-16%  in decreased mortality irrespective of the type of alcohol.  At follow up there were more non drinkers than at baseline (36% versus 26%).  The quitters and starters acquired the expected mortality risks in each group.  They conclude that there was a small beneficial risk of alcohol on mortality of about 15% but qualify the result based on the study limitations.

The final dimension in this sample of the LWCS paper was a look at non-alcoholic beverages and caffeine content.  They looked a coffee, decaffeinated coffee, black or green tea, cola drinks (sugar or artificially sweetened), other soft drinks and sweetener combinations, and the amount of chocolate eaten (daily versus a few times per month.)  They found that there was a U-shaped mortality curve for caffeine consumption with peak protection at about the 100-399 mg/day.  They also found that consuming as little as one can a week of artificially sweetened soft drinks had a small increased risk of death (11-24%).  They looked at specifics and determined that 1-3 cups of regular coffee/day reduced mortality risk by 5-10% and drinking decaffeinated coffee or tea reduced risk by 5-9%.   Drinking sugar sweetened cola - had an 8% lower risk of death.  Infrequent chocolate users also had a reduced risk of death (3-9%).

Taken all together these three papers suggest that moderate levels of alcohol, caffeine, and activity are all consistent with longevity.  In order to look at the alcohol findings in perspective, I searched the literature for a meta-analysis of all of the alcohol x longevity studies and came up with an outstanding paper by Stockwell, et al  (5).  In it the authors look at and extensive analysis of existing alcohol effect on mortality studies and initially duplicated a J-shaped mortality curve based on 87 studies they included in their analysis.  They went back into that sample and corrected for abstainer biases such as including including former and occasional drinkers in the abstainer category.  They model four types of abstainer bias in their in the paper.  When those corrections are made or when only very high quality studies are used - the purported mortality advantage of moderate (1-2 standard drinks per day) - disappears completely.  I could not find any data from the LWCS studies used in this meta-analysis.  According to the author's selection criteria the LWCS data probably would have been eliminated because it was a cross sectional study.

That alcohol is not a heath food should not come as a surprise.  Any cohort of drinkers in their 90s suggests to me that they are biologically selected to survive the alcohol and that is probably why they are drinking into their 90s and not because of it.  Since the activity, caffeine, and diet soda effects noted in this study were collected using similar methodologies, that can be a cause for concern. The authors were careful to cite supporting data  and discuss the limitations.  Observational studies like the LWCS and 90+ Study add to the literature but it is necessary to keep these findings in perspective and consider the potential biases of the design.

At this time I have not found a similar meta-analysis for each of the other cases (activity level, caffeine consumption).

 

 George Dawson, MD, DFAPA


References:

All linked papers below are to free full text articles.


1: Schwarzinger M, Pollock BG, Hasan OSM, Dufouil C, Rehm J; QalyDays Study Group. Contribution of alcohol use disorders to the burden of dementia in France 2008-13: a nationwide retrospective cohort study. Lancet Public Health. 2018 Feb 20. pii: S2468-2667(18)30022-7. doi: 10.1016/S2468-2667(18)30022-7. [Epub ahead of print] PubMed PMID: 29475810.

2:  Paganini-Hill A, Kawas CH, Corrada MM. Activities and mortality in the elderly: the Leisure World cohort study. J Gerontol A Biol Sci Med Sci. 2011 May;66(5):559-67. doi: 10.1093/gerona/glq237. Epub 2011 Feb 24. PubMed PMID:21350247.

3:  Paganini-Hill A, Kawas CH, Corrada MM. Type of alcohol consumed, changes in intake over time and mortality: the Leisure World Cohort Study. Age Ageing. 2007 Mar;36(2):203-9. PubMed PMID: 17350977.

4:  Paganini-Hill A, Kawas CH, Corrada MM. Non-alcoholic beverage and caffeine consumption and mortality: the Leisure World Cohort Study. Prev Med. 2007 Apr;44(4):305-10. Epub 2006 Dec 29. PubMed PMID: 17275898.

5:  Stockwell T, Zhao J, Panwar S, Roemer A, Naimi T, Chikritzhs T. Do "Moderate" Drinkers Have Reduced Mortality Risk? A Systematic Review and Meta-Analysis of Alcohol Consumption and All-Cause Mortality. J Stud Alcohol Drugs. 2016 Mar;77(2):185-98. Review. PubMed PMID: 26997174.

The Abuse Potential of Gabapentinoids

I first started prescribing gabapentin in the 1990s, as part of an early attempt to see if it worked for bipolar disorder.  It was an off-label approach and did not have that indication.  At the time anticonvulsant approaches to bipolar disorder (valproate, carbamazepine) were being heavily used.  I was following a number of people who could not take lithium and on anticonvulsants and they seemed to do surprisingly well.  Gabapentin seemed to have significant advantages in terms of toxicity, it was well  tolerated by most people.  Unfortunately, it was completely ineffective for bipolar disorder and I stopped trying it almost immediately.

The next off label application that surfaced was for chronic pain.  Any psychiatrist is exposed to a number of patients with chronic pain or chronic pain and addictions, and it became apparent that it was being used successfully for chronic back pain, chronic headaches, and post herpetic neuralgia.  Over the next decade, gabapentin and then pregabalin was prescribed for chronic pain indications and people seemed to do reasonably well with it - even at relatively high doses.

At some point, physicians working in detox and the addiction field started to use gabapentinoids for chronic pain, anxiety, and withdrawal.  It is not uncommon to see patient with all of these problems who is not able to tolerate antidepressants for those symptoms or who needs more immediate relief.  In fact, in residential addiction treatment it is common to see patients come in on high doses of gabapentin for chronic back pain.   They are there for treatment of an opioid use disorder, but during that time have not escalated the gabapentin dose.

In the literature reports of gabapentin misuse have been surfacing over the past 5 years (1-7).  A large review (4) suggests that 1.3% of the treated population is at risk for gabapentinoid misuse with the number being much higher is some populations such as opioid users.  There is a report (3) that patients with opioid use disorder will attempt to augment the eurphorigenic effect of methadone in a similar way that they use benzodiazepines.  Benzodiazepine use with methadone in methadone maintenance clinics is a chronic and at times lethal problem.  There is a report from Norway (5) that gabapentinoids may be useful is reducing benzodiazepine use.  The report generally suggests that the abuse potential is low and greater for pregabalin than gabapentin.  There is an insurance database report (6) that looks at an overuse metric comparing gabapentinoids to other abused drugs.  Goodman and Brett (7) comment on the epidemiology of gabapentinoid prescribing, specifically an increase in gabapentin prescriptions from 39 million in 2012 to 64 million in 2016 with an associated doubling in the sales of pregabalin during the same period.  They attribute the increase to attempts to treat chronic pain without opioids in primary care, suboptimal non-opioid medications (acetaminophen and NSAIDs). They cite mixed evidence in clinical trials, side effects, misuse or diversion, and an excessive focus on pharmacological measures for pain as being concerns.       

Are there biases in these report?  There certainly are.  I don't have access to the full text of the most comprehensive paper (2), but I would be interested in looking at the actual numerator and denominator for their numbers and how much was based on actual pharmacovigiliance/pharmacosurveillance as opposed to case reports, case series and reports of complications.  The other issue is that all of these papers seem to come from the same publisher.  I have not encountered that before.

The only study that I could find that looked at the direct question of concomitant use of opioids and gabapentin came from Canada (8).  It studies a large group of patients on a database that records the prescriptions and looked at all opioid users that died of opioid related causes between 1997 - 2013.  The big picture is that there were a total of 2,914,971 opioid users during the study time frame and 6,745 died of opioid related causes.  Then by selection criteria they identified 1,256 cases and matched them to 4,619 controls. They defined gabapentin exposure as concomitant gabapentin use in the 120 days preceding the index date.  They also looked for a dose response relationship of gabapentin doses considered as low (<900 mg daily), moderate (900 to 1,799 mg daily), or high (≥1,800 mg daily).  They also did a comparison with nonsteroidal anti-inflammatory drugs (NSAIDs) used as an adjunctive pain medication instead of gabapentin.  Their results are summarized in the following tables excerpted directly from the article (click to enlarge):

 
As noted from the data and analysis, 12.3% of the controls and 6.8% of the cases were prescribed gabapentin in the 120 days, representing a 50% increased risk of death in the gabapentin treated cases.  In the case/control comparison both groups have roughly the same levels of mental illness but the case group had higher utilization of antidepressants (all types), benzodiazepines, and other drugs/CNS depressants. They were also taking substantially more high dose opioid therapy (>200 MME).  Higher dose gabapentin nearly doubled the risk. There was no added effect from NSAID use.  The authors conclude that caution needs to be exercised in deciding to prescribe this combination (opioids + gabapentin) and that if that decision is made it needs to be carefully monitored.  From my perspective I had some concerns about the controlling for benzodiazepine use in the case/control comparison and did not see any risk attributable to benzodiazepines.  The authors do cite a reference that led to FDA warnings about the benzodiazepine-opioid combination. 

Given the concerns about gabapentin why use it at all?  The main reason is that it is effective for some of the most difficult problems in medicine.  It is very difficult to see people with extreme anxiety and insomnia go for weeks without sleep and experience continuous panic attacks all day long.  When a person stops taking benzodiazepines that they have been taking for years that is a frequent result.  The same is true for people who have decided to stop drinking and suddenly have very high levels of anxiety and insomnia now that their baseline anxiety is back.  More to the point, unless something can be done to provide them with timely relief, relapse to drug and alcohol use is certain.  Finally does high levels of abuse by some patients with addictions suggest that the medication is unsafe?  It is probably safer then other medications in this population and extremely safe outside of those populations.  In either case safety depends on whether there is a physician involved or the medication is acquired from nonmedical sources.   

Standard practice with gabapentin should be to tell all patients (in addition to the usual discussion and detailed information) the following information.  I point out here that I do not prescribe pregabalin:

1.  Take this medication exactly as it is prescribed.
2.  Do not accelerate the dose of the medication.
3.  Do not mix this drug with alcohol or any other intoxicants or street drugs.  If a relapse occurs call to discuss and set up a plan as soon as possible.
4.  Do not stop the medication abruptly it needs to be slowly tapered.  There is a seizure risk if it is not.
5.  This medication is potentially addictive to some people. If you notice any tendency to take more of this medication than prescribed contact me immediately.
6.  This medication is monitored on the state Prescription Monitoring Program and all prescriptions are recorded even though it is not technically a scheduled drug at this time.

At least that is the way that I think it should be handled.  If I was still seeing a lot of patients with chronic pain on moderate to high doses of opioids I would add in a line or two about the the Canadian study (9) and greater chances of death from the gabapentin + opioid combination.  In my current practice, psychiatric treatment is split off from buprenorphine detox and maintenance treatment - but I still see a lot of patients on buprenorphine + gabapentin and can attest to the fact that in a controlled environment we have not observed the complications suggested by the Canadian study over a period of months.  None of these patients receive benzodiazepines or sedative hypnotics beyond a period of detox.  In fact, doing that study might be a significant contribution to the research.  It also probably means that those patients when they are discharged should hear that the risk of taking that combination may increase substantially in the outpatient setting.

There is plenty of politics and confusion surrounding the gabapentinoids issue.  It should not be surprising that this medication is showing up in the toxicology of opioid overdose victims. It should not be surprising that some people try to get "high" on it, even though the people doing that do not have typical ideas about the utility of medications. It should not be surprising that people try to use gabapentin like benzodiazepines to augment the effect of what they are using to get high especially opioids.  It should not be surprising that when some people decide to stop buprenorphine or methadone that they will buy somebody's gabapentin to try to treat withdrawal effects.  It should not be surprising that in some areas it is currency on the street (What can I get for a month's worth of gabapentin?).  It should not be surprising that it has become a political football in the social media on pain ("See it's not opioids as the problem - it is gabapentin") or the social media on weed ("See these are Big Pharma solutions, marijuana is much safer").  It should not be surprising that you can read about it on drug culture web sites where everyone is an expert pharmacologist and provides you with anonymous advice on how to get high. It should not be surprising that you can buy it online and have it delivered to your door, although you can never really be certain that it is the same stuff you get at Walgreens.  I am always amazed at how easy it is to sell some Americans drugs, if they think there is the slightest possible chance they can get high on it. That is also why it should not be surprising that children and teens will take it out of medicine cabinets - use it to get high and brag about it even though there were probably not high at all.

The features about the gabapentinoids that make sense to me is that they are medically useful  and have low toxicity, for people with nearly impossible problems in desperate situations.  It is a less toxic drug on the street than those mentioned in the above paragraph. Even then these drugs need to be carefully prescribed and closely monitored.  And even then some people will escalate the dose. There are no perfect solutions in medicine and in this area in particular - nothing seems to be coming down the pike.  The probability statement is always - does the use of gabapentin result in more people with improved symptoms, better quality of life and less addiction?  At this time unless presented with compelling evidence I would say that it does with the qualifier that its application needs to be carefully done by a physician who knows what they are doing and is aware of the potential for misuse. In  the current era, that can all be subject to the next social media fad.

There is not a big push by the pharmaceutical industry at this time to discover a drug that has limited toxicity that can be used for severe chronic pain, insomnia, and anxiety associated with addictive disorders.  There is also the question of what medications are being used for these problems if not gabapentin.  The answer is atypical antipsychotics (mostly quetiapine), hydroxyzine (a first generation antihistamine), and clonidine (primary use is hypertension and opioid withdrawal).  If the comprehensive toxicology of overdoses is available I would expect to see these compounds listed.  In any search of drug interactions both quetiapine and hydroxyzine are flagged as potentially affecting cardiac conduction. Clonidine can cause hypotension if used excessively and rebound sympathetic symptoms (tachycardia, hypertension, diaphoresis).  Looking at that group of medications gabapentin would appear to have the preferred side effect profile.

There also appears to be a big push to make gabapentin a controlled substance according to the Controlled Substances Act (CSA).  Pregabalin is currently a Schedule V drug (see page 14) or considered to have the lowest abuse liability.  Getting on that list depends on how the DEA currently sees the addictive behavior towards gabapentin versus pregabalin.  Putting a drug on Schedule V will probably have no impact on how it is used in medical practice or out on the street.  The fact that pregabalin is ranked so lowly is a sign of regulatory opinion on abuse liability.

That's my current opinion on the topic.  I may add more to this post in the future or to a post I am working on about the basic science of gabapentinoids.


George Dawson, MD, DFAPA


References:

1:  Schifano F. Misuse and abuse of pregabalin and gabapentin: cause for concern? CNS Drugs. 2014 Jun;28(6):491-6. doi: 10.1007/s40263-014-0164-4. Review. PubMed PMID: 24760436.

2:  Chiappini S, Schifano F. A Decade of Gabapentinoid Misuse: An Analysis of the European Medicines Agency's 'Suspected Adverse Drug Reactions' Database. CNS Drugs. 2016 Jul;30(7):647-54. doi: 10.1007/s40263-016-0359-y. PubMed PMID:27312320.

3:  Baird CR, Fox P, Colvin LA. Gabapentinoid abuse in order to potentiate the effect of methadone: a survey among substance misusers. Eur Addict Res. 2014;20(3):115-8. doi: 10.1159/000355268. Epub 2013 Oct 31. PubMed PMID: 24192603.

4:  Evoy KE, Morrison MD, Saklad SR. Abuse and Misuse of Pregabalin and Gabapentin. Drugs. 2017 Mar;77(4):403-426. doi: 10.1007/s40265-017-0700-x. Review. PubMed PMID: 28144823.

5: Smith, R. V., Havens, J. R., and Walsh, S. L. (2016) Gabapentin misuse, abuse and diversion: a systematic review. Addiction, 111: 1160–1174. doi: 10.1111/add.13324.

6: Bramness JG, Sandvik P, Engeland A, Skurtveit S. Does Pregabalin (Lyrica(®) ) help patients reduce their use of benzodiazepines? A comparison with gabapentin using the Norwegian Prescription Database. Basic Clin Pharmacol Toxicol. 2010 Nov;107(5):883-6. doi: 10.1111/j.1742-7843.2010.00590.x. PubMed PMID: 22545971.

7: Peckham AM, Fairman KA, Sclar DA. Prevalence of Gabapentin Abuse: Comparison with Agents with Known Abuse Potential in a Commercially Insured US Population. Clin Drug Investig. 2017 Aug;37(8):763-773. doi: 10.1007/s40261-017-0530-3. PubMed PMID: 28451875.

8: Goodman CW, Brett AS. Gabapentin and Pregabalin for Pain - Is Increased Prescribing a Cause for Concern? N Engl J Med. 2017 Aug 3;377(5):411-414. doi: 10.1056/NEJMp1704633. PubMed PMID: 28767350.

9: Gomes T, Juurlink DN, Antoniou T, Mamdani MM, Paterson JM, van den Brink W.  Gabapentin, opioids, and the risk of opioid-related death: A population-based nested case-control study. PLoS Med. 2017 Oct 3;14(10):e1002396. doi: 10.1371/journal.pmed.1002396. eCollection 2017 Oct. PubMed PMID: 28972983; PubMed Central PMCID: PMC5626029.

Graphics Credit:


Figure 2 about is excerpted directly from the work in reference 8 above per the Creative Commons Attribution License.  The authors are listed as the copyright holders.


Supplementary:

Publication from the above content?  If you are a psychiatrist or pharmacologist and think you can rework the above article into a publication.  Contact me and let's write that paper!

One Small Step For Physician Autonomy

Physicians have been oppressed in the United States for the past 30 years - nearly the entire length of my career. That is not rhetoric. It is a fact. The oppression has occurred at the level of federal and state governments and eventually the businesses that those governments actually support.  A lot of it is documented on this blog and I am not going to repeat it here.  The most recent twist on that oppression has been in the form of maintenance of certification (MOC) actively promoted by the American Board of Medical Specialties (ABMS).  All medical specialty organizations in the United States are members of the ABMS and are forced to abide by its rules.  Some specialty organizations  started their own MOC that did not involve ABMS procedures and they were told they had to all go through the same process.  That process involves testing and intrusive measures into a physicians practice.  It is a major departure away from life-long learning that physicians aspire to and use to shape their individual practices.

The move to MOC was initiated by ABMS on their own and well before there was any debate of the evidence.  As an example, I was board certified by the American Board of Psychiatry and Neurology (ABPN) in 1988.  There was no time limitation on the original certifications until 1990.  I was certified Added Qualification in Geriatric Psychiatry in 1991; but that certification was time limited 1991-2001.  I was re-certified in Geriatric Psychiatry ten years later and that certificate states Recertified 2000-2010.  I was also certified Added Qualifications in Addiction Psychiatry 1993-2003.

Somewhere around the time I was due for certification for Addiction psychiatry, I asked myself: "Why are you doing this?" It costs a thousand dollars to take the test.  The test did not confer any special status, privileges, or salary.  It did not change any study habits at all.  I was still attending quality CME courses, reading the literature, and incorporating it into my practice. I was teaching and that is always associated with needing to know a lot more about current debates in the field as well as the representative scientific literature.  Even though I have never failed one of these board exams, there is a ritual of needing to take time off and study material that may not be immediately relevant to your practice - medical and psychiatric trivia that is an essential part of standardized test gamesmanship.  So I decided no - I am a professional. I am at the top of my game and all indications are that things are going well.  Even if they weren't, a thousand dollar board exam or even MOC procedure is not remedial.  It does not provide any feedback. It is essentially a prep school exercise of jumping thorough another hoop.  You either make it or you don't.  At that time there had been 7 hoops* and that was enough.  I stopped the process at that point. 

My guess is that a lot of other physicians saw the light the same way that I did.  My further speculation is that the ABMS reacted by increasing their leverage first by not issuing lifelong original certifications like they gave me back in 1988 and then making those re-certifications as onerous as possible.  I am not being dramatic when I use the term onerous.  I thought about getting back into the current MOC stream about a decade ago at an APA convention and talked with the ABPN representative at their booth. At the time, he literally could not tell me what I had to do to resume the endless cycle of paying fees and taking tests only that there was even more to do than that.  Not an inspiration to get back into the process.

Since then the ABMS has become much more strident about the MOC process.  They were playing the odds.  Physicians and their professional organizations are generally politically clueless and ineffective.  The best evidence of that is their inability to prevent managed care advocates in both government and business from taking over the field and dramatically decreasing the quality care.  They made arguments about how it was necessary to maintain quality and knowledge in a field.  How does that happen by taking a trivial pursuit style exam with no feedback and a very high pass rate?  How does that happen by basically doing patient satisfaction surveys on my patients - a procedure that is rapidly falling into disrepute in clinical settings. 

In the interest of brevity, I am not going to point out all  of the logical errors or overt conflict-of-interest in the ABMS arguments.  There are many bloggers out there who have done outstanding job of that including Cardiologist Westby G. Fisher, MD, FACC and Psychiatrist Jim Amos, MD.  In the literature the standard bearer against the MOC process has been Cardiologist Paul Tierstein, MD who was instrumental in founding the alternate board certification process through the National Board of Physicians and Surgeons (NBPAS). 

My conclusion after wading through all of the politics for that past decade was to get re-certified though NBPAS for several reasons including:

1.  Meaningfulness -  the existential equivalent of that word meaninglessness has been with me since I read Yalom's classic book Existential Psychotherapy in 1982. Yalom referred to it as the fourth ultimate existential concern - right after death, freedom and isolation.  Becoming a practicing physician is an exercise in delayed gratification.  As an intern and a resident the term "busy work" is used to designate tasks that have to be done but don't seem to advance true knowledge or understanding. It is really not clear what your professional life is going to be like until you are in the field interacting with colleagues and patients and practicing medicine.  Physicians as a group are overachievers, overwork, and compulsively question themselves about their decisions.  They are not work averse at all.  One of the motivators to expend this kind of energy is doing meaningful work.  Dr. Tierstein emphasizes this on the last slide in his lecture.  MOC is busy work and its meaning is arbitrarily defined by outsiders. 

2.  It reflects the original ABMS process - we certify you to go out in the world, practice medicine, and keep up with the theoretical and clinical aspects on your own as a professional.  Working with very bright colleagues providing excellent care for 30 years validates that approach.

3.  It certifies my ongoing work - I hope it is apparent from this blog that I am not a casual reader of the psychiatric literature.  I study it at several levels. I have two rooms in my home that are covered from ceiling to floor with medical and psychiatric literature.  I correspond with interested colleagues around the world.  I attend conferences.  I am working on current research.  I teach. I consider all of this life-long scholarship.  At one point the ABPN suggested they were going to put an asterisk (*) next to the names of lifetime certificate holders unless they participated in MOC.  To me that is an insult to my current work and professionalism. It's like designating me as some kind of steroid user.

4.  The NBPAS certifies continuing medical education credits (CME) - my state medical board asks me to report the total number every three years.  There is a suggestion that they will audit all of my certificates, but in 30 years that has never happened.  NBPAS does not certify you until you meet their CME requirement and send them all of the certificates via their web site.  They have an excellent website that can accept uploads of at least 10 of these documents at a time.  So here is a powerful reason for every state medical board to use NBPAS certification.  It immediately means that CME requirements are met very 2 years and they are certified.     

5.  It reflects what I do in my clinical work - sub-specialization in any field is always controversial.  Does there need to be another division in the field?  Is there enough evidence that it is far enough away from what everyone else is doing to be a separate body of knowledge?  After 30 years of work - I say no.  I still see geriatric patients, patients with general psychiatric disorders, patients with addictions, and patients with medical problems every day.  It's not like I can go to a magical clinic somewhere and just see a patient who only has one problem affecting their brain.  To do a good job, you have to continue to know it all.  It is hard work and there are often not a lot of clear answers, but that's why it is called practice and that's why we love medicine.

6.  It is tremendously cost effective considering what gets certified - the financial incentives for the MOC movement are huge and funded by physicians.  Stepping out of the MOC loop makes a clear statement.

7.  It is view consistent with my political philosophy -   I am from blue collar roots and was socialized to suspect the motives of politicians, businessmen, and even union organizers.  Very little of my experience as an adult seems to counter that perspective.  I see health care being run by the same mechanisms as the financial services industry and not for the benefit of physicians or their patients.  NBPAS certification is an antidote to the ABMS Big Brother approach.  In Dr. Tierstein's video he points out why it is no accident that healthcare companies insist that any physician working for them have MOC.  It is all part of the conflict-of-interest driven ruling class approach to business and regulation that we should expect.

That is why I got the NBPAS certificate.  I understand that there are early career physicians locked into some HMO who are told they need to be in the MOC cycle or they will lose their privileges and job (further evidence BTW of what MOC really is).  I can't understand younger physicians who don't recognize splitting when they see it.  I have read their opinions about how some think they know more than older physicians and how they are more tech savvy and how they are not averse to managed care manipulations.  I will just say that being an expert takes more than writing a smart phone app or thinking that you know every thing in the field after passing the initial board exams.  The true innovators and experts that I know have been doing what they innovated for the past 20-30 years.

The bottom line for this post is irrespective of where you are in medicine, if you ignore the politics you do so at your own peril.

Currently MOC is at the top of that list. 


George Dawson, MD, DFAPA




References:

1: Teirstein P, Topol EJ. Maintenance of Certification Programs and the Interstate Medical Licensure Compact--Reply. JAMA. 2015 Sep 1;314(9):952. doi: 10.1001/jama.2015.8912. PubMed PMID: 26325571.

2: Teirstein PS, Topol EJ. The role of maintenance of certification programs in governance and professionalism. JAMA. 2015 May 12;313(18):1809-10. doi: 10.1001/jama.2015.3576. PubMed PMID: 25965219; PubMed Central PMCID: PMC4751049. 

3: Teirstein PS. Boarded to death--why maintenance of certification is bad for doctors and patients. N Engl J Med. 2015 Jan 8;372(2):106-8. doi: 10.1056/NEJMp1407422. PubMed PMID: 25564895.

Supplementary:

*  The 7 hoops included part 1, 2, an 3 of the National Board Exams to qualify for a medical license and the subsequent 4 certifications and recertifications by the ABPN.  After thinking about this there were actually 8 hoops because there were actually 2 ABPN ceritifying examinations for psychiatry.  Part One was a written exam on psychiatry and neurology including imaging questions.  Part Two was an Oral Board exam that consisted of two parts.  One half of the day was an examination based on an observation of a videotaped interview. The other half of the day was an examination based on your observed interview of the patient.  Part Two had a higher failure rate probably due to a high degree of subjectivity.  I knew people who failed it more than once. So that is really a total of 8 tests altogether.


         

The NYTimes Editorial On Why Mental Health Can't Stop Mass Shooters -What's Wrong With It?

There was a New York Times editorial titled "The Mental Health System Can't Stop Mass Shooters" dated February 20, 2018.  It was written by Amy Barnhorst, MD, a psychiatrist and vice chairwoman of community psychiatry for University of California, Davis.  Since it popped up it is being posted to Twitter by more and more psychiatrists.  It does contain a lot of accuracy and realism about the issue of assessing people acutely and whether or not they can be legally held on the basis of their dangerous behavior.  Dr. Barnhorst gives examples of people who allegedly make threats and then deny them.  She discusses the legal standard for commitment and its subjective interpretation.  For example, even though a statute seems to have a clear standard they are many scenarios in the grey zone, where a decision could be made to err on the safe side.  That involves hospitalizing the patient against his or her will because the risk is there and their behavior cannot be predicted.  If hospitalized, she anticipates the outcome when the patient appears in front of a hearing officer and gets released.  That last scenario is very real and I would guess that the majority of decisions on the front end in these cases take into account what might happen in court.

If the hypothetical patient did get committed he would not be able to acquire a gun with a functional background check system. That system does not currently exist. If guns were involved in his case before hospitalization, the police may have confiscated them.  Unless his legal status changes they may give him the guns back.  In some cases the patient is told to ask their psychiatrist to write a letter to get their guns back.  I am not aware of any psychiatrist who has done that.  The FBI NICS system lists all of the conditions that would prohibit a point of purchase gun sale (assuming a check is done).  That list includes: "A person adjudicated mental defective or involuntarily committed to a mental institution or incompetent to handle own affairs, including dispositions to criminal charges of found not guilty by reason of insanity or found incompetent to stand trial."   Various crimes including domestic abuse can also trigger a failure of the NICS check and when that happens the gun sale is cancelled.  Unfortunately not all states participate in this check system and there are numerous exceptions if they do.

I have diagrammed the various levels of arguments that apply to a psychiatrist doing a crisis evaluation on a person brought to the emergency department for making threats with firearms.  At the political level there is no nuance.  At this level the degree of distortion is the greatest.  The usual arguments about guns not killing people is a good example, but it extends even this morning to President Trump suggesting that more mental health resources will solve the mass shooting problem, when it clearly will not.  The legal arguments are slightly more informed, but still fairly crude.  Like most legal arguments they threaten or reassure.  For example, most psychiatric crisis statutes hold harmless anyone who reports a suicidal or aggressive person to the authorities.  On the other hand, if a psychiatrist places a person on a legal hold because they are potentially dangerous - it is typically illegal for that same psychiatrist to extend the hold if the court system has not done anything by the time it expires.  The civil commitment system has a way of starting to make decisions based on available resources and in many cases the statutes seem reinterpreted that way.

At the medical level, psychiatrists are left living with the legal and political arguments no matter how biased they may be and trying to come up with a plan to contain and treat the aggression.  It is not an easy task given the resource allocation to psychiatry - but after doing ti for 20 years - it is fairly obvious that acute care psychiatrists know what they are doing.  They are successful at stopping violence acutely and on a long term basis.  Given the legal biases they cannot do it alone.  There needs to be cooperation from the courts and the legal system and some patients should be treated in the legal rather than the mental health system. 

Getting back to Dr. Barnhorst's article one sentence that I disagreed completely with was:

"The reason the mental health system fails to prevent mass shootings is that mental illness is rarely the cause of such violence." 

She cites "angry young men who harbor violent fantasies" as basically being incurable.  The problem with mental illness and gun violence is that it is dealt with at a political level rather than a medical and diagnostic one.  The facts are seldom considered.  There are political factions that see violence as stigmatizing the mentally ill and political factions who want to scapegoat the mentally ill and take the heat off the gun advocates.  The reality is that people with severe mental illness are overrepresented in acts of violence compared with the nonmentally ill population. It is a small but significant number. In studies of mass homicides the number increases but it depends on the methodology.  There are for example school shooter databases that record events as anytime a firearm is discharged in a school.  That results in a very large number of weapon discharges but most where nobody is injured.  There are databases that just list events but there is no analysis of whether mental illness was a factor or not.  In mass shootings in half the cases the shooter is killed or suicides.  Even when the shooter survives the data is affected by the subsequent hearings - so there is rarely a pure diagnostic interview available.  The data analysis depends on making sure that both the events and the mental health diagnoses are as accurate as possible.

The most parsimonious assessment of this data was published by Michael Stone, MD in 2015 (1).  The paper is fairly exhaustive and I am not going to discuss the obvious pluses and minuses.  I do see it as a break from the usual sensational headlines and the analysis of the trends in mass homicide over time, especially associated with semiautomatic firearms - leaves no doubt that this is a large problem.

He identifies 235 mass murderers, and estimates that 46 (22%) of them were mentally ill.  His definition of mentally ill as essentially being psychotic.  He goes on to say that in the remaining fraction and additional 48 had paranoid personality disorder, 11 were depressed, and 2 had autism spectrum disorders. In other words another 26% of the sample had significant mental disorders that were not considered in the analysis because he did not consider them to be psychotic.  Another 45 (19%) has either antisocial personality disorder or psychopathic personality disorder - both mental conditions associated with criminal activity and thought to have no known methods of treatment.  Using this conservative methodology - it is apparent that mental illness in this population is not rare at all.  What should not be lost is that although mass shootings are very noticeable events - they are rare and therefore any overrepresentation of mental illness in this group, is diluted by what happens across the entire population where the majority of violent activity is associated with people having no mental illness and the overall trends in violent crimes are at a 20 year low.

My proposed solutions to the problem of semiautomatic weapon access and mass shooters/murders is approached this way:

1.  Increase the purchase age to 21 years.  Eliminate access to military style weapons.

2.  All purchases must be cleared through the NICS system.  All states must participate. Currently only 12 states participate in full point of contact background checks on every gun sale.

3.  The NICS system should include terroristic threats, stalking, and any gun confiscation by the police because of mental health grounds as exclusion criteria.  In other words, you are eliminated from gun purchases if you have been reported for these problems.  That may sound a bit stringent but I think there is precedent.  You cannot make threats about air travel at an airport.  If you have been charged with domestic abuse (Misdemeanor Crimes of Domestic Violence (MCDV)
 the are special instructions on what it takes to keep firearms from you.  I consider the safety of children in schools to be on par with these two cases (air travel and domestic violence threats).

4.  At the level of law enforcement, any firearms confiscated during a threat investigation should not be returned and that person should be investigated and reported to NICS Database.

5.  Uniform protocols need to be in place for terroristic threat assessment.  It is no longer acceptable to wait for a person to commit an act of aggression before there is a law enforcement intervention.  The person making the threat should be removed from that environment and contained pending further investigation.

6.  On the mental health side - rebuilding the infrastructure to adequately deal with this problem is a start.  Hospitals with large enough mental health capacity should have a unit to deal with aggression and violence.  There should be specialty units that collect outcome data on the diagnoses represented and work on improving those outcomes.

7.  On the law enforcement/corrections side there needs to be recognition that not all mental health problems can be treated like mental health problems.  Violent people with antisocial personality disorder and psychopathy are best treated in law enforcement setting and not in psychiatric settings.  In psychiatric setting they have a tendency to exploit and intimidate the other patients in those settings as well as the staff.  They should be treated by psychiatrist with expertise in these conditions and been seen in correctional settings.  Probation and parole contingencies may be the best approach but I am open to any references that suggest otherwise.

8.  In the early years of this blog - I was an advocate for violence prevention and I still am.  Violence and aggression have the most stigmatizing effects of any mental health symptoms.  I think it is safe to day that most psychiatrists actively avoid practicing in setting where they may have contact with aggressive patients.  It needs to be seen as a public health problem and education and prevention are a first step.

Those are my ideas this morning.  I may add more to this page later.  If you have a real interest in this topic Dr. Stone's paper is a compelling read.  If I find others of similar quality I will post them here.  Don't hesitate to send me a reference if you have one.

The bottom line is that no psychiatrist can operate in the current vacuum of realistic options and hope to contain a potential mass shooter.  And yet there is a clear overepresentation of mental illness in this population.  Some level of cooperation as suggested above will result in a much tighter system for addressing this issue.  We do it in airports and in domestic violence situations.  We can also apply more uniform and stringent expectations to schools.


George Dawson, MD, DFAPA


References:

1:  Amy Barnhorst.  The Mental Health System Can't Stop Mass Shooters.  New York Times February 20, 2018.  Full Text Link

2:  Stone MH.  Mass Murder, Mental Illness, and Men.   Violence and Gender. Mar 2015: 51-86. Free Full Text Link



Graphics Credit:

Photo of the M4 Assault Rifle is per Shutterstock and licensed through their agreement.

Layered arguments graphic was done by me in Visio.