Sleep and Addiction

One of the major problems that I treat in people with significant substance use disorders is insomnia of all types.  I see people who have had insomnia since childhood.  A significant number have had insomnia and nightmares since childhood.  In that case the insomnia often precedes the development of any associated psychiatric diagnoses – it is a primary problem. In many cases, it is one of the reasons that people develop a substance use problem.  Alcohol, sedative hypnotics (often benzodiazepine type drugs), opioids, and cannabis are commonly taken for sleep and typically lead to many secondary problems.  Alcohol for example, will often lead to faster sleep onset, but as tolerance develops, the person will start to make up at 2 or 3 in the morning.  With increasing tolerance, a decision about taking more drinks at that time or toughing it out until the morning will need to be made. Some people can get to the point that they ingest large enough quantities of alcohol that they sleep the entire night and wake up with elevated blood alcohol levels.  Some do not realize the problem until they are arrested driving into work the next morning for intoxicated driving.

The available medications for treating insomnia in patients with addiction are limited.  We can currently treat a significant number of patients with sleep problems but there are still many that have very difficult to treat insomnia.

Medication	Probable Sleep Mechanism of Action
Trazodone	H-1 antagonist, NE antagonist, 5-HT2 antagonist
Doxepin	H-1 antagonist, NE antagonist, Ach antagonist
Mirtazapine	H-1 antagonist, 5-HT2 antagonist
Hydroxyzine	H-1 inverse agonist, Ach antagonist
Quetiapine	H-1 antagonist, NE antagonist, Ach antagonist, 5-HT2 antagonist, DA antagonist
Ramelteon	MT-1/MT-2 agonist  MT-1> MT-2
Melatonin	MT-1/MT-2 agonist  MT-1>MT-2
Prazosin	α1- adrenergic antagonist
Gabapentin	inhibition of the alpha 2-delta subunit of voltage-gated calcium channels
Benzodiazepines (detox only)	GABAA receptor agonist
Opioids (detox, MAT)	MOR agonist

 

The general strategy of using these medications is apparent from the purported mechanisms. For example, brain histamine (H) and acetylcholine (Ach) are alerting and arousing neurotransmitter systems so that antagonists/inverse agonists would be expected to decrease arousal and facilitate sleep.  Noradrenergic (NE) systems are wake promoting so NE antagonists would be expected to decrease this function.  The compounds in the above table work the best in addictive states when a person is abstinent from intoxicants and chronic use of intoxicants and after they have been detoxed.  Benzodiazepines and opioids are in the table for that purpose.  Although I have seen detox protocols that include many of the medications listed in the table as needed for insomnia and anxiety it is unlikely that they will work until detoxification has occurred.  In many cases, the expected duration of detox is much longer than anticipated and sleep problems are a prominent reason.    

That brings me to the primary focus of this post and that is a recent paper entitled “Drugs, Sleep, and the Addicted brain.” I generally don’t get too excited about research papers these days, but after reading this brief paper by Valentino and Volkow – I was fairly excited.  In this paper the authors main goal is to demonstrate how the biological substrates that regulate sleep interact with the reward system and how they can be direct targets for substance use. 

The first system they look at is the locus ceruleus (LC)-norepinephrine (NE) system that is involved in arousal. LC-NE neurons do not fire during REM sleep.  Activation of the LC results in firing of noradrenergic neurons that activate the cortex. Corticotropin-releasing factor (CRF) leads to LC activation and heightened arousal.  Endogenous opioids lead to damped excitation and decreased arousal.  Tolerance to exogenous opioids would lead to an expected inability to dampen the LC-NE system and increased activation and arousal during opioid withdrawal.

The serotonin (5-HT) dorsal raphe nuclei (DRN) system is also a system implicated in both sleep and arousal.   5-HT neurons are active during waking and do not fire during REM sleep. 

Histaminergic (H) neurons in the tuberomammillary nucleus (TMN) have an arousal function on cortical neurons.  They are active in the awake state.

Midbrain dopaminergic neurons (DA) in the ventral tegmental are (VTA) specifically those projecting to the nucleus accumbens (NAc) increase wakefulness upon activation but activation of the other major set of DA neurons in the substantia nigra has no effect.  This is a critical circuit in substance use because this system determines the value function of stimuli in the environment including addictive compounds and affects arousal.

Cannabinoids promote sleep, sleep onset, slow wave sleep, and sleep duration.  They decrease REM sleep.  CB1 agonists and antagonists respond in the expected manner.  The effects of CB1 agonism may be mediated by adenosine which increases in response to the stimulation of this pathway.  Caffeine is an adenosine antagonist and that may be the reason is promotes wakefulness.  Endocannabinoids also inhibit orexin neurons (arousal promoting) in the lateral hypothalamus and increase the activity of melanin neurons.  These combined effects of cannabinoids on the endogenous cannabinoid system explain the expected insomnia when these compounds are stopped for any reason.

The orexin system in the lateral hypothalamus and dorsal medical hypothalamus/perifornical area is activated during wakening and silent during sleep.  It is the system that is disrupted in narcolepsy.  It is also the system that coordinates the activity of the other arousal centers in the brain including the TMN-HA, LC-NE, DRN-5-HT, VTA-DA, and cholinergic neurons in the Nucleus Basalis of Meynert (NBM-Ach).  This relationship is depicted in the following graphic from the paper and detailed in reference 3.

Orexin A and Orexin B are wake  promoting neuropeptides the general structure of which is given below.  These peptides bind to Ox1R and Ox2R G-protein coupled receptors.  Orexin A has equal binding affinity to both receptor but Orexin B preferentially binds to the Ox2R receptor.  Detailed information is available from PubChem.

Human Orexin A

The orexin system may be critical not just in arousal but also in reward.  Patients with narcolepsy have orexin deficiency and generally do not overuse opioids and are less likely to overuse stimulants even though many have been prescribed very high doses.  Opioid users have increased orexin neurons in the lateral hypothalamus.  This increase in orexin signaling may lead to profound insomnia and the associated arousal state after prolonged exposure to opioids and makes this insomnia very difficult to treat.  Orexin can directly potentiate reward in some models.  Orexin is implicated in states where a high level of motivation to acquire the target substance is required or where there are external stimuli like stress, and specific cues for drug use that lead to increased motivational states.  The authors in reference 2 refer to orexin's ability to affect the approach toward a reinforcing stimulus or active withdrawal from an aversive stimulus as motivational activation.

Suvorexant is an interesting compound in that it antagonizes Orexin A and Orexin B wake-promoting neuropeptides and prevents them from binding to Ox1R and OXxR receptors decreasing wakefulness.  It is currently FDA approved as a treatment for insomnia, but the authors propose that it is a compound of interest in that it can potentially counter the arousal and reward potentiation associated with drug seeking states.  If that is the case it could be a useful treatment for both insomnia and the primary addictive disorders.

When I look at possible treatments for insomnia in addiction, a central question is whether or not they will potentially worsen the addictive state.  That is why there are no specific benzodiazepine related sleep compounds in the table at the top of this post.  The benzodiazepines listed there are all basically used on a short term basis for detox and then tapered and discontinued.  In the case of mu-opioid receptors (MOR), medication assisted treatment with both buprenorphine and methadone are possible on an ongoing basis. The package insert for suvorexant suggests possible problems in that subjects with recreational polydrug use rated their "liking" of the drug as being similar to zolpidem 15 and 30 mg doses.  Zolpidem is a standard sedative hypnotic that can be used to treat insomnia.  It definitely has abuse potential and in some cases patients can end up taking very high doses per day until they can be detoxified.  That is not reassuring in terms of safety for persons with substance use problems but I would not take it as proof that it cannot be safely used.  According to the DEA, suvorexant is currently a Schedule IV drug or low potential for abuse or dependence. Some articles on insomnia suggest that despite what appears to be a comprehensive mechanism, the short term efficacy of suvorexant is no greater than zolpidem but at a much greater cost.

I am currently looking at the medicinal chemistry and clinical trials literature to assist me decision making on orexin receptor antagonists and just how much of withdrawal related insomnia is due to orexins. The other important question is whether it will also decrease drug seeking states and withdrawal avoidance.   

George Dawson, MD, DFAPA

References:

All full text and all excellent

1: Valentino RJ, Volkow ND. Drugs, sleep, and the addicted brain. Neuropsychopharmacology. 2020;45(1):3–5. doi:10.1038/s41386-019-0465-x

2: James MH, Mahler SV, Moorman DE, Aston-Jones G. A Decade of Orexin/Hypocretin and Addiction: Where Are We Now?. Curr Top Behav Neurosci. 2017;33:247–281. doi:10.1007/7854_2016_57

3: Peyron C, Tighe DK, van den Pol AN, et al. Neurons containing hypocretin (orexin) project to multiple neuronal systems. J Neurosci. 1998;18(23):9996–10015. doi:10.1523/JNEUROSCI.18-23-09996.1998

Graphics Credit:

The brain graphic is from reference 1 and is used here without modification per the Creative Commons Attribution 4.0 License.

Disclaimer:

This post may change significantly over the next two weeks.  I had to put it up to see what it looks like and plan to elaborate the behavioral pharmacology of orexin and the pharmacology of suvorexant.

MPS Meeting on Emergency Department Congestion

From the Flyer for this Meeting - Not an indication that MPS has anything to do with the opinions that follow. 

I attended the Minnesota Psychiatric Society 2019 Fall Program last weekend. The theme was addressing Minnesota’s Mental Health Access Traffic Jam: Coming Together to Build a Better Roadmap. That traffic jam has been there for the duration of my career in Minnesota and that is approaching 30 years. 

When I looked at the agenda and the speakers my first association was “stakeholders”. That jargon has found its way into the administration of medical and psychiatric systems over the past 20 years. It is basically a codeword to suggest that administrators, politicians, and everybody in between somehow has a “stake” in medical care and the relationship of physician has with the patient and their family is peripheral to all of these outsiders.  Nothing could be farther from reality – but that is the attitude we have to deal with from politicians and administrators.

The keynote speaker was the director of Psychiatric Emergency Services at the Denver Health Medical Center – Scott Simpson, MD. He was not able to make and his presentation was given by a colleague - Kristie M Ladegard, MD. Denver Health is a 525 bed Level I Trauma center. Psychiatric Emergency Services has a 17-bed psychiatric unit and a 60-bed detox unit.  The Emergency department also has mobile crisis services and consultation services.  For the last data they had in 2013 a little over half of their emergency visits were for “depression, anxiety, or stress reactions”. About 40% were for substance use disorders. An additional 20% were for psychosis or bipolar disorder. As expected, suicidal ideation led to a more complicated disposition plan. The incidence of delirium in elderly patients remaining in the emergency department and the high mortality rate of missed delirium was discussed. Factors leading to boarding in the emergency department were discussed. An interesting approach to substance use treatment was the “No Wrong Door” approach. Using approach intake for substance use treatment occurred right in the emergency department or at other points of contact within the medical system.  Medication Assisted Treatment for opioid use disorder was also started in the ED, with buprenorphine inductions. That resulted in a greater number of inductions and greater percentage of people retained in treatment.

Emergency services lecture also talked about four goals of implementation including access, quality, cost, and provider resiliency. The most interesting method discussed knew the end of the lecture was Dr. Simpson’s paper on single session crisis intervention therapy (1). The specific techniques are given in the open access paper in reference number one, and they should be familiar to people who are involved in crisis intervention especially with people who are suicidal in those situations. It was part of the overall message that I don’t think is emphasized enough. That message is-interventions need to be incorporated into the clinical assessment and not compartmentalized into the few minutes at the end. Experienced clinicians should be able to forgo entire sections of a standard template if an intervention is necessary and they can use the time to provide it.

There was a complementary panel in the afternoon that consisted of two psychiatrists and two emergency medicine physicians in a dialogue about what each discipline wanted to tell the other. Early in my career it was often a source of conflict. There always questions about “inappropriate admissions” psychiatry. Those questions faded away without any psychiatric presence in the emergency department. People were admitted to my service irrespective of their associated medical complexity. It was often my job to determine whether or not they needed to be transferred to a medical or surgical service. With this panel there was not a lot of controversy. Much of the concern had to do with nursing home and group home patients being sent to the ED with no hope that they could be placed anywhere quickly. The ED physicians had a very valid argument that it is no environment for boarding people until placements are available. The spaces are confining and there is very little to do. Communication about these patients and what the outpatient staff’s expectations are is critical. One of the psychiatric panelists pointed out during the session that all of the presentations indicated that additional beds within the system were necessary - but the state and managed care representatives were denying that basic fact.  This was later denied by a state representative who tried to say that there are a lot more beds that are not being counted but the basic fact is that just in terms of state hospital beds Minnesota ranks 49/50 states.

There was a Forensic Assertive Community Treatment (FACT) team representative there as well. There are currently 56 ACT teams in 43 counties in the state of Minnesota. There are approximately 90 patients per team. The FACT team specializes in seeing patients with severe mental illness who also have probation officers. The leader that team talk briefly about forensic cognitive behavioral therapy (CBT). Therapy focuses on a number of maladaptive cognitions that typically promote repetitive criminal behavior. One example was the error of “super optimism” or “negative consequences of this behavior do not apply to me”. Since the therapy for repetitive criminal behavior is generally considered futile to try to locate literature on this type of therapy but was not successful. The psychiatrist who headed the FACT team also talked about the importance of “felony-friendly housing” and “felony-friendly supportive services”. Both of the social features are critical for stabilizing people in the community but these resources are rare.

On the darker side there were presentations from both the MN Department of Human Services and managed care representatives.  Not a great deal of detail was provided by DHS.  They briefly described improvement in the physical environment of their forensic units.  They gave the current bed capacity of Anoka Metro Regional Treatment Center (AMRTC) – the largest non-forensic state hospital.  They described the number of facilities for the treatment of psychiatric and substance use disorders as including AMRTC, 6 much smaller Community Behavioral Health Hospitals (CBHHs), 5 Community Addiction Recovery Enterprise (CARE) programs, and 4 Minnesota Specialty Health System (MSHS) Programs.  AMRTC has a 96-bed capacity and has been under significant stress since a Priority Admission Statute allowed county sheriffs to send patients who were incarcerated but mentally ill as direct admissions. That results in longer lengths of stay for committed patients in community hospitals.  Compared with previous statistics provided by Kylee Ann Stevens, MD - Chief Medical Officer, Minnesota Department of Human Services, the bed capacity at AMRTC has decreased from 110 to 96 beds.  A newer Child and Adolescent Behavioral Unit is being built but there is no net increase in bed capacity.  There was no comparable data to the January 2018 post beyond that.

The DHS presentation emphasized the 40% of the patients at AMRTC Did Not Meet Criteria (DNMC) to be there. As a Medicare PRO reviewer for Minnesota and Wisconsin one of my jobs was to review patient stays in their hospitals and determine if they were actively being treated or it was more of a rehabilitative stay. The point at which clear progress was not occurring was an endpoint beyond which hospital care was no longer covered. The problem is that this is an almost totally subjective determination in patients with chronic mental illnesses.  If for example a person is highly aggressive and no medical treatments have worked – is that an acceptable end point to say they should no longer be hospitalized. I don’t think that it is. I have concerns about the robustness of the 40% figure for DNMC.  They presented some graphs of a Continuous Improvement Project that increased patient flow and decreased the DNMC to 19%.  Some external validation that large community acute care hospitals like Regions and Hennepin County medical Center were noticing the effect of this project would have been useful.

DHS also presented a few slides about “innovation” within the system.  They discussed Lean Six Sigma training as adding value in that it provides business skills to clinicians and leads to innovation. I remember they told me the same thing when we got that training in the managed care company where I worked. The problem is that managed care companies don’t really want to hear any ideas from physicians at least none that are not reflected back from management.   There were three bullet points on Michael’s Game, Ligature Mitigation, and Harnessing the Power of the EHR.  They suggested the Michael’s Game was useful to treat delusions for the purpose of competency restoration.  The only available literature I could find suggests it is useful to try cognitive behavioral therapy (CBT) in people with psychosis, especially if there is little familiarity with the technique. Ligature Mitigation is basically a Centers for Medicare & Medicaid Services (CMS) mandate to ensure the safety of the inpatient environment by policies and environmental inspection.  It seems more like a requirement than innovation.  In terms of the power of the electronic health record – I think there is finally a consensus that it is more of a burden than anything else. If there is some power there within the state hospital system – please demonstrate that.

There were a number of other speakers from the managed care industry and affiliated organizations.  There were diagrams about patient flow in the ED and what service availability can do to reduce ED congestion.  There were no inpatient psychiatrists there. The people with the most insight into the problem were absent.  After being an inpatient psychiatrist myself for 22 years I thought about why that might be.  Inpatient docs after all are subjected to all of the unrealistic expectations of everyone else.  Toward the end of my inpatient career I was being sent patients with severe medical problems and either no psychiatric disorders or stable psychiatric disorders.  I was getting these folks because everybody knew that they would get the care they needed – and the case managers who were ordering hospitalists to discharge people would be out of the loop. Inpatient psychiatry became a place where in addition to acute care psychiatry – everybody’s problems could be worked out there. And I had the added advantage of a case manager sitting in my team meeting reporting back to administrators on whether I got people out in 4 or 5 days.  The discharge process was intolerable because there were no discharge resources.  The availability of state hospital beds and group home beds were all shut down by many of the agencies represented in the room. Managed care was responsible for the intolerable work environment and a policy of discharging people before they were stable in order to optimize billing.  Basically, many of the people in the room who created the problem were now saying they could solve it. And I have heard these refrains for the past 20 years.

In a form of ultimate irony, there was a rumor at the meeting that one of the Twin Cities metro hospitals was going to be shut down by the managed care company that owned it taking another 105 psychiatric and substance use beds off line.  Since this question entered the Q & A session it seemed more than a rumor.  There was no comment from the managed care people.  

Besides the ACT psychiatrists there was another bright spot.  Dave Hutchinson, the Hennepin County Sheriff described the progress he was making at the policing level. Deputies were getting crisis intervention training (CIT). He made the point that I think a many don’t consider – crisis calls about obvious psychiatric problems that are being observed by the public go to the police twenty-four hours a day. He described the toll on the police including the statistic that 80% of officers who are involved in the use of deadly force – never return to work.  The jail in Hennepin County – like everywhere is inhabited by a large number of people with mental illness. Sheriff Hutchinson was very clear about the fact that this is a suboptimal situation and he would prefer that these people are in settings where they can get adequate care.

At the end of the session, I met briefly with one of my former residents.  She was a panelist for the meeting. She asked me what she was missing: “It seems that all indications point to needing more beds.”  I reassured her that she didn’t miss a thing.  It was the elephant in the room.  I have seen two decades of smoke and mirrors about why more beds aren’t necessary. It doesn’t seem that the state of Minnesota is any closer to recognizing that this is a real problem. It doesn’t seem that professional psychiatric organizations are any closer to confronting managed care or opaque state bureaucracies about how they are at the minimum unhelpful to people with serious mental illnesses and at the maximum harmful.

    

George Dawson, MD,

References:

1:  Simpson SA. A Single-session Crisis Intervention Therapy Model for Emergency Psychiatry. Clin Pract Cases Emerg Med. 2019;3(1):27–32. Published 2019 Jan 10. doi:10.5811/cpcem.2018.10.40443D

2: Khazaal Y, Favrod J, Libbrecht J, et al. A card game for the treatment of delusional ideas: a naturalistic pilot trial. BMC Psychiatry. 2006;6:48. Published 2006 Oct 30. doi:10.1186/1471-244X-6-48.   

3: Melnick ER, Dyrbye LN, Sinsky CA, et al. The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among US Physicians [published online ahead of print, 2019 Nov 12]. Mayo Clin Proc. 2019;S0025-6196(19)30836-5. doi:10.1016/j.mayocp.2019.09.024



Supplementary:

There are many estimate of optimal bed numbers and Minnesota does not come close on a number of them.  The Treatment Advocacy Center has a number of documents on their site that list Minnesota as 40/50 in 24 hr hospital inpatient and rseidential treatment setting beds, 41/50 in inpatient beds, and estimates that the state needs to add 1,165 beds to the system to establish an adequate base rate of available beds.

This document from the Pew Charitable Trust looks only at state hospital beds and shows Minnesota at 3.5 beds per 100,000 population with a ranking of 49/50 states.  

At least two panels of experts have concluded that 50-60 publicly funded beds per 100,000 is necessary to provide the same level of medical services and wait times for psychiatric patients in emergency departments as medical/surgical patients. 

Identity Chart for Psychiatrists

Adapted from drawing of Dr. M.A. Farmer (see Supplement 2)

My theme lately has been about how other people tend to characterize the identity of psychiatrists. The argument is that psychiatrists have some kind of "identity crisis".  This argument is invariably advanced by antipsychiatrists who distort psychiatric training and attitudes.  There are other interests who also want to distort the core identity of psychiatrists.   Health bureaucrats both in the government and in managed care systems would like to say that our role is to ration and undertreat people consistent with their goals of corporate profits or diverting tax revenues to their favorite cause.  They use the euphemism "managing resources" when psychiatrists frequently start out in these organizations with no resources.  The legal profession including legislators has forced a law enforcement role on us in the form of duty to warn - even though this is clearly a job for trained law enforcement officers. The most depressing identity arguments are made by people who should know better like the recent NEJM editorial.  This editorial used an argument by a journalist author who was clearly not familiar with how psychiatrists are trained or their skill set..  These numerous intrusions on the psychiatrist identity are presented as though they have something to do with the profession and they do not.

To make this diagram I read through the first two documents on the reference list below.  In order to make the diagram, only the broad intent of the detailed training criteria are included.  I could use a much smaller font and more detail, but the concept of a quick read of the basic elements would be lost.

The diagram could be much more complex since every psychiatrist (like everyone else) has a unique conscious state.  In the case of a psychiatrist, there is an interaction between professional identity and general identity and personality.

I am posting this for the purpose of educating nonpsychiatrists and for further collaboration with psychiatrists. Please feel free to send me training requirements for psychiatrists that are unique to your institution or country and I will include them here.  From my read of the top two references, there appears to be broad agreement at least across the Atlantic.  Also feel free to refer to this page when people inside or outside of the field mischaracterize what psychiatrists do or suggest that we are having an identity crisis.

I have been in the field over 35 years and my professional identity was firmly established in medical school and residency.  I have made the same intergenerational observations about my colleagues who range in ages from 30 to 85.


George Dawson, MD, DFAPA

 Professional Identity of Psychiatrist - the detailed references:

ACGME – the current real training and skillset https://www.acgme.org/Portals/0/PDFs/Milestones/PsychiatryMilestones.pdf?ver=2015-11-06-120520-753

RCP - A Competency Based Curriculum for Specialist Core Training in Psychiatry   https://www.rcpsych.ac.uk/docs/default-source/training/curricula-and-guidance/core_psychiatry_curriculum_may_2019.pdf?sfvrsn=f8594b3e_2

Royal College of Physicians and Surgeons of Canada Specialty Training Requirements in Psychiatry

http://www.royalcollege.ca/rcsite/documents/ibd/psychiatry_str_e

http://www.royalcollege.ca/rcsite/ibd-search-e?N=10000033+10000034+4294967084


Supplementary 1:

This is the original Visio drawing that I made based on the references.

Supplementary 2:

I was surprised and very pleased to receive a photo of a graphic that will replace mine.  It was done by Dr. Melissa A. Farmer and I think it is better than my original because it was designed to show the relationship among the variables.  A higher resolution graphic will be posted at some point and my thanks to Dr. Farmer!

Rosenhan Uncovered

I have been on record for many years regarding the Rosenhan experiment. To briefly recap, that was a paper published in Science in 1973 (1). In the paper the author described how eight pseudopatients were admitted to psychiatric hospitals and the treatment they received. He describes their varied backgrounds. He says that they were admitted to 12 hospitals in five states on the East and West Coast. The hospitals also varied from research institutions to institutions with much fewer resources. Most importantly he describes the script that each pseudo-patient is supposed to adhere to in order to get admitted and how they are supposed to behave post admission. 

Specifically:

“After calling the hospital for an appointment, the pseudopatient arrived at the admissions office complaining that he had been hearing voices. Asked what the voices said, he replied that they were often unclear, but as far as he could tell they said "empty," "hollow," and "thud." The voices were unfamiliar and were of the same sex as the pseudopatient. The choice of these symptoms was occasioned by their apparent similarity to existential symptoms.” (p. 251)

Apart from the false symptoms, false name, false vocation, and false employment the social history provided by the pseudopatients was supposed to be identical to their real social history. After gaining admission so patient was supposed to “cease simulating any symptoms of abnormality.”

From the purported data, Rosenhan pointed out that none of the pseudo-patients were discovered, they were hospitalized for varying lengths of time, they were given medications that they may have been trained to not take and spit out, and they made a number of observations inside the hospital. Rosenhan concluded that “It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals”.  He also uses at least half of the article for highly speculative observations on powerlessness, depersonalization, and labeling none of which really pertain to the study.

I just finished reading Susannah Cahalan’s new book The Great Pretender. It is about Rosenhan’s study and Rosenhan himself.  She has quite a lot to say about him including how this paper changed the face of psychiatric care and was a major factor in closing down psychiatric institutions.

Let me start by describing what I experienced at that time. In 1973, I was just finishing an undergraduate degree and although I was a science major - heard nothing about this paper. I was reading Science and Nature at the time. I did medical school and residency training between the years 1978 and 1986 and again heard nothing about Rosenhan - even during psychiatry rotations and seminars. That was a controversial time in psychiatry because of the tension between biological psychiatry and psychotherapy. The controversy seemed to be largely from the psychotherapy side of the equation. Psychiatry residents were pulled to one side or the other. It was always clear to me that both modalities were critical. I got what I consider to be good psychotherapy training at two different Midwest residency programs.

A unique aspect of my training happened at the University Wisconsin training program. Community Psychiatry was a mandatory six-month rotation that consisted of an outpatient clinic, crisis intervention training, and an active seminar every week. One of the leaders of that seminar was Len Stein MD. Dr. Stein was a major force and originator of Assertive Community Treatment (ACT) and other forms of community treatment that were focused on maintaining people with severe mental illness in the community. To this day I can recall a slide from one of his presentations that showed a gymnasium sized room at the local state mental hospital. In that room were cots arranged edge to edge across the entire floor. Rows and rows of these cots covering the entire floor. The men who slept on those cots were standing in the foreground. They were all wearing the same pajamas. After showing that slide, Dr. Stein would point out that this was one of the motivators that led him to help people get out of hospitals into their own apartments.  His goal at the time of Rosenhan’s paper, was to develop a way to help people with severe mental illnesses live independently in the community.  He was not only successful at it – he trained psychiatry residents how to do it. After completing my training, I went to a community mental health center and helped run an ACT team for three years.  We were highly successful at maintaining people outside of the hospital and helping them function independently.

My introduction here is to illustrate that one of the main theses of The Great Pretender, namely that Rosenhan’s experiment was one of the main forces in deinstitutionalization and closing down psychiatric hospitals is something that I disagree with. It seems to be a good theory if you want to suggest that psychiatry only changes from the outside and the change happens by people who are not psychiatrists. You can probably make that argument if you don’t know psychiatrists like Len Stein and all of the other community psychiatrists out there who were highly motivated to maintain people outside of state hospitals because it was the right thing to do. It was the right thing to do because states ration resources to the mentally ill. They always have and they always will.  Politicians don't really care about anyone with severe mental illness. Community psychiatrists know that. They know the only way to provide good treatment to those patients is to make sure that public funds follow the individual patient.

In her book Susannah Cahalan, spends a lot of time describing how seminal the Rosenhan study was. She has numerous testimonials from important psychiatrists at the time. There is even a suggestion that Robert Spitzer, MD used the study politically to advance his own agenda in writing more precise diagnostic criteria for the DSM-III. I can state unequivocally that I had not heard of this experiment until I started encountering anti-psychiatrists. That didn’t happen much until I started this blog in 2012.

What did I like about the book? I was impressed with the investigative aspects of the book. She carefully details how Rosenhan’s original description in Science does not accurately reflect what actually happened. There is not enough information available to verify whether or not the entire pseudoexperiment was completed as written. In addition to that research, she has detailed impressions of Rosenhan from fellow faculty members, coworkers, friends, and family members who knew him well. Many of these people had reservations about him and his work. Many believed that there were problems with the original paper. Many had concerns about his character that are clearly described in this book. In brief, there is plenty of circumstantial evidence in addition to the direct evidence that something was wrong with this paper.  I take this circumstantial and character evidence with a grain of salt. In any clinical or academic settings, there are always plenty of personality conflicts and politics. There is one scene in the book where Rosenhan is throwing a party and tells a colleague that he had a wig made for the pseudopatient role (Rosenhan was bald). Cahalan confirms by photo and the attending psychiatrist’s notes that he was bald and not wearing a wig during the hospitalization. I also do not consider that to be a big deal. He was described as a raconteur who liked to hear himself talk. Making up stories at parties to keep people engaged is what raconteurs and extroverts do.  

She also builds a careful case of additional red flags along the way. Rosenhan apparently achieved celebrity status for brief period of time. When that occurs he got a book deal and was advanced substantial sum of money. He also wrote several chapters that were read by Cahalan. He never finished the book even when he was sued by the publisher.  He never did any further research on the subject of pseudopatients getting into psychiatric hospitals or psychiatric hospitals at all. He had an active correspondence with Spitzer and one point recruited psychiatrists to convince Spitzer not to publish criticisms of his paper. Spitzer was very content with his criticism, but Cahalan points out that he may have had direct information at the time to refute the paper entirely. Rosenhan clearly broke the protocol that he described as evidenced by the medical record. The treating psychiatrist apparently sent Spitzer a copy of those records showing that as the original pseudo-patient, Rosenhan broke protocol. In addition to describing vague auditory hallucinations he added historical data that would have resulted in him being hospitalized anywhere.  Excerpts from the exact medical record are included in the book on pages 184 and 190. The author concludes (and any reader can do the same) that the facts were intentionally distorted by Rosenhan primarily with more elaborate delusional material and suicidal thoughts including the statement “everyone would be better off if he were not around.” What is recorded in the actual medical record is a person feigning a much more serious mental illness than “existential symptoms.”

Cahalan was able to locate two more pseudopatients, but one of them was not included in the study. Cahalan was unable to locate any of the other six pseudo-patients described in the Science paper despite an intensive effort.  Rosenhan also removed the data from the ninth pseudo-patient. The data from the ninth pseudo-patient was inconsistent with the others in that this patient liked his experience in the psychiatric hospital and in fact found to be very positive. He liked it so much that he published that positive experience in Professional Psychology in February 1976 (2) including the following conclusion “He recommends stressing the positive aspects of existing institutions in future research.” (p 213).

Cahalan approached Science directly. She asked them directly why they published this article in the first place given the concerns she outlined in her book. They refused to discuss their editorial process. A psychologist speculated that the submission to Science would be less rigorously reviewed because they probably did not have the top peer reviewers in the field. Although Cahalan uses a fair amount of anti-psychiatry rhetoric in her book, and seems to talk authoritatively about that field, there is no speculation that bias against psychiatry may have been involved in publishing this article.  Given what we know about general bias against psychiatry, that would seem to be a real possibility to me.

I am already on record saying that there is enough information in this book to retract the original article. I admit I don’t know the criteria for retractions or whether there is any time limit. Having been a Science subscriber for decades I know that it certainly does not meet their typical standards. I will happily go back and read articles from medicine and psychiatry in their 1973 editions to illustrate that fact if there is a shot at retraction.

Retraction would certainly create a furor in the anti-psychiatry community. Their arguments rest almost entirely on false premises and pseudoscience. As I noted in my post from seven years ago, anyone can walk into a medical facility and lie about a condition for any number of motives. In my current field, I have talked with hundreds of people who tell me they asked for a second or third opioid prescription when they did not need it for pain. They were taking it to get high. Before that I did consults in a general hospital, we were often asked to see people with factitious disorders who are feigning some medical illness. We also saw significant numbers of people who had medical symptoms but were not consciously feigning illness. The author mentions some of this but is usually quick to make it seem like psychiatry is the wildcard relative to the rest of medicine. 

I have had several people ask me if they should buy this book. I have also been asked to write a book review for newsletter.  My response is consistently, buy the book if you want to see the clear evidence that the Rosenhan experiment was more than seriously flawed – the protocol was violated by the author himself and the evidence is there black on white. A second protocol violation occurred when the Rosenhan decided to eliminate the experience of the pseudopatient who enjoyed being in the hospital and found it to be useful. I will say again that I am not an expert in retractions but believe that papers are retracted today for violations of data integrity.

Don’t buy this book if you are expecting to read a valentine to psychiatry. The author's previous book was about her episode of inflammatory encephalitis that was misdiagnosed as a psychiatric disorder. She mentions it several times to point out her credibility as a person who has experienced severe psychiatric symptomatology. At one point in the book she undergoes a SCID (Structured Clinical Interview for DSM-IV) evaluation by a psychiatrist who had a lot of input into DSM-5. After a tedious exchange he tells her that his going charge for the exam is $550. When I read that, I asked myself why would this psychiatrist go along with a SCID when he knew it was irrelevant to Cahalan’s diagnosis? Several other prominent psychiatrists are quoted in the book in a way that fits Cahalan’s thesis that psychiatry is in fact a weak link in medicine and even though Rosenhan’s pseudoexperiment was grossly flawed there is a still some valuable lesson there.

I would suggest that is really not the case. I don’t know why anyone would want to try to resuscitate this work and I sure don’t know why Science wants to keep it in a reputable journal.  The original responses over 40 years ago pointed that out. I would highly recommend reading the  original responses by Spitzer.

George Dawson, MD, DFAPA

References:

1: Rosenhan DL. On being sane in insane places. Science. 1973 Jan 19;179(4070):250-8. PubMed PMID: 4683124.

2: Lando H. On being sane in insane places: a supplemental report. Professional Psychology, February 1976: 47-52.

Additional Reference posted on July 17, 2021:

Justman, Stewart, "Below the Line: Misrepresented Sources in the Rosenhan Hoax" (2021). Global Humanities and Religions Faculty Publications. 13. https://scholarworks.umt.edu/libstudies_pubs/13

This author fact checks Rosenhan's references and footnotes and finds they do not support his points.

There Is No Identity Crisis in Psychiatry

The New England Journal of Medicine published an opinion in their October 31, 2019 edition titled “Medicine and the Mind-The Consequences of Psychiatry’s Identity Crisis” (1).  Claiming that psychiatry (meaning organized psychiatry and all psychiatrists) has some sort of an identity crisis is a favorite editorial topic these days. It lacks face validity considering over 40,000 psychiatrists go to work every day, have working alliances with their patients, treat problems that no other doctors want to treat, and get results. Furthermore, most psychiatrists are working in toxic practice environments that were designed by business administrators and politicians. As a result, psychiatrists are expected to see large numbers of patients for limited periods of time and spend additional hours performing tasks that are basically designed by business administrators and politicians and have no clinical value.

The authors in this case fail to see that problem. In their first paragraph they critique “checklist amalgamations of symptoms” as if that is psychiatric practice or what psychiatrists are trained to do in their residency programs. I happen to be an expert in these checklists because I have been critiquing them from the outset. The state of Minnesota mandates that all patients being treated for depression in primary care settings have to be rated on these checklists over time, and that data is supposedly analyzed as a quality marker. Anyone familiar with the analysis of longitudinal data will realize that cross-sectional data points on different patients at different points in time are meaningless. But that doesn’t prevent politicians in Minnesota from dictating psychiatric practice and it doesn’t prevent these authors from blaming psychiatry for it.

Their additional opening critique on “medication management” ignores the fact that this procedure was invented by the federal government. This procedure and all the associated billing codes did not exist in psychiatry until HCFA thought it was a good idea to assign these codes to psychiatrists and call them “medication management”. It was only recently that psychiatry could use the same E & M codes that the rest of medicine uses for the provision of complicated care including psychotherapy. Instead of just stating that the authors say “We are facing the stark limitations of biological treatments, while finding less and less time to work with patients on difficult problems”.  Apart from the rhetoric I don’t know what that means. If I have a patient with a difficult problem - I make the time to work on it.  If there were any stark limitations in psychiatry – they occurred before the invention of biological treatments. In those days, people died from severe psychiatric disorders and the associated effects of severe hyperactivity, starvation, and dehydration.  Many people also had their lives disrupted when they were sent to state mental hospitals for years or in some cases decades.  Those were the historic limitations in psychiatry.

They move onto a critique about diagnosis and their opinion that “the solution to psychological problems involves matching the “right” diagnosis with the “right” medication". I don’t know where the authors went to psychiatry school but that is a new one on me.  At a different point in their opinion piece they critique the current diagnostic manual. If they read that manual they would notice there are conditions with strictly psychological and social etiologies that do not require medical treatment. They also minimize the role of tertiary consultants like myself. I see thousands of people who were started on psychiatric medications by non-psychiatrists. There is clearly a lack of expertise prescribing those medications and I make the necessary adjustments including stopping medications that were inappropriately prescribed. I also prescribe the indicated treatment when it was never provided in the first place. That all happens in the context of a therapeutic relationship and providing necessary psychotherapy.

Somehow the authors conclude that a lack of “scientific and intellectual integrity” does a disservice to patients, practicing psychiatrists, and medical colleagues. They suggest that medical colleagues are striving to provide the best possible and “most humane care to people with medically and psychologically complicated conditions”. I don’t know who the authors think is holding up the psychiatric and psychological end of that treatment. I worked in a multidisciplinary clinic with every imaginable consultant for 22 years. Nobody hesitated to refer patients to me for psychiatric care. They knew it would be comprehensive, that the assessment would be exhaustive, and that the treatment plan would be beneficial. We also had an active consultation-liaison team that provided active ongoing consultation to a large medical-surgical hospital. Without those psychiatric services there is no “humane care” to the medically complex psychiatric patient. This psychiatric function is widely known and these treatment plans can be read directly from the pages of the NEJM.

The authors provide a one sentence sketch of brain function and how the external world affects our “brain-minds”. They grudgingly acknowledge that basic science may be a necessity. They bemoan the fact that advances in neuroscience “are still far from offering real help to real people in hospital, clinic, and consulting room”.  That is not what I observed in 35 years of practice. There has been a steady improvement in psychopharmacology both in terms of safety and selectivity. There have been major advances in neuromodulation -both electroconvulsive therapy and transcranial magnetic stimulation. There have been pharmacological advances in addiction psychiatry with more medication assisted treatments. There have been advances in specific conditions like severe psychiatric disorders associated with pregnancy and various forms of catatonia. The diagnostic advances related to basic science research have been stunning. When I first started consulting in nursing homes 35 years ago - every diagnosis was either “senility”, “senile dementia”, or “atherosclerosis”. There were no science-based diagnoses of dementia in those days. We currently have a comprehensive approach to detailed dementia diagnoses as well as a comprehensive approach to diagnosing 127 different conditions associated with substance use disorders all neatly detailed in the diagnostic manual that they seem to have a problem with. Hopefully there is no more “senility” in nursing homes.

The authors attack neuroscience in the usual ways. They state they agree that discoveries in neuroscience are exciting but on the other hand “are still far from offering real help to real people in the hospital, clinic, and consulting room.” They restate that twice in the space of this brief essay. Is that true?  Some reading in the area of translational psychiatry might be in order. Every week I assess many patients for anxiety disorders. A significant number of them have been anxious their entire life. There are currently no good conceptualizations and indicated treatments that separate this group from people who develop anxiety later in life. From the work of Kalin and others (3,4), the biological basis of anxious temperament and potential solutions to lifelong anxiety is now becoming a possibility. Progress in neuroscience has gone from receptors and neuroendocrinology in the 1980s to genetics and multiomics in the 21^st century. Now there is more than speculation and empirical trials. Entire mechanisms that include genetics, transcription, anatomic substrate and the impact of the environment on brain systems are determined.

There is in fact a group dedicated to bringing neuroscience into the clinical realm – The National Neuroscience Curriculum Initiative. It is possible to think of a neuroscience-based formulation as easily as one might think of a psychodynamic formulation.  The point of neuroscience research in psychiatry is the same as it is in any other specialty with one exception - the organ being studied is more complex and generates a conscious state. The basic science of practically every other field has been studied more intensely and with more resources than brain science has been studied. Many other fields have not produced miracle cures when it comes to chronic illnesses and the basic treatments of these illnesses have been static for decades. The cures or disease altering interventions often occur after much more time has been spent studying them then we have spent studying the brain. In that context, basic science brain research is as on track as any other field

The most erroneous opinion advanced by these authors is that psychiatry has somehow abandoned the social and psychological elements of care. They cite an author who is a historian and who suggests that psychiatrists should limit their scope to “severe, mostly psychotic disorders”. There are many authors with similar irrelevant opinions about psychiatry but they generally aren’t quoted in an opinion piece for the NEJM. Nothing that author says is realistic or accurate in this article, but that is typical of the so-called critics of psychiatry. The authors own proposals for change in psychiatry are similarly irrelevant because it is apparent that they have a limited understanding of what is going on in the field or what psychiatrists do on a day-to-day basis.

The next section of their opinion piece is about funding and how biological funding has “replaced all other forms of psychiatric research”. They provide no evidence in terms of actual numbers. I expended some effort to try to do that.  I asked NIH, NIMH, SAMHSA, one of my US Senators and I tweeted the director of the NIMH to get an answer to the question about the proportion of funding for basic science versus psychosocial mental health research. I also searched the AAAS research reports to see if anything was listed there. What I got back was largely devoid of any useful data.  The above links were sent to me by a public affairs specialist at the NIH.   

I remembered reading about an analysis in American Psychologist suggesting that 30% of the $1.6B NIMH budget goes to psychosocial research. I was able to find the article (2) and it was not straightforward as most advocates of increased psychosocial research think. That 30% figure comes from a graphic generated by a review of research abstracts of 15% (2,028) of all funded studies from 1997-2015. They were coded on a 1 - 5 scale by doctoral level students where 1 = entirely focused on biomedical topics to 5 = entirely focused on psychosocial topics.  There was a positive trend in favor of biomedical research but the authors point out several limitations in the data and areas for further study. And they make this important comment:

“A test of the differences in regression slopes indicated that there was, however, no difference in the increase in award size for R01 grants, F(1,475) = 3.97, p = ns, suggesting that the proportion of biomedical grants awarded increased, but they did not receive disproportionately larger awards than psychosocial grants. This is notable given that biomedical research is often more costly because of expensive procedures and larger research teams.” (p. 417-418)

This reference provides a very balanced look at the issue including a discussion of the significant limitations of psychosocial treatments - something that you do not see in the NEJM piece or from the people claiming that basic science research is clinically worthless. 

Although the authors are critical of neuroscience results, they don’t seem to mention the lack of innovation in psychotherapy and other psychosocial therapies. More significantly they ignore the fact that these therapies are routinely not funded by managed-care companies, government insurers, and responsible counties. They blame psychiatry for the “abandonment and incarceration of people with chronic, severe mental illness” when in fact the necessary psychiatric beds and inpatient facilities as well as community housing for these patients has been actively shut down by businesses and governments over the past 30 years.  It seems that counties have adapted managed-care practices that includes rationing services for the chronically mentally ill to the point that they end up in jail. The authors seem to conveniently blame psychiatry for that. Once again they could read about what psychiatry really does in the pages of the NEJM and how these very patients are served by ACT teams. The treatment approach was invented to improve the quality of life of people with chronic mental illness and support them in independent living. It does not work in a vacuum and there has to be a funding source.

The authors suggest that psychiatry needs to be “rebuilt”. From their suggestions about training programs I wonder if they participate in training programs, teach residents, and work on resident curricula.  And if they do - I wonder what that training program looks like. I say that because all the suggestions they have seem to have been in place for decades. In fact, their entire argument is reminiscent of the old "biological psychiatry versus the therapists" argument from about 1984. That argument should stay firmly planted in the "old history" folder.

Their concluding paragraph is a extension of earlier rhetoric.  They talk about psychiatry having an exclusive focus on “biological structure” rather than meeting the needs of real people. I go to work every day and talk to real people all day long. I know quite a lot about the biological structure the brain and its function. I must because I don’t want to be treating a stroke, brain tumor, a traumatic brain injury, or multiple sclerosis like a purely psychiatric problem. I also realize that if I conceptualize the psychiatric disorder as a specific brain area or network - that is still occurring in a unique conscious state. That conscious state is generated by the most complex organ in the body. It is an organ with tremendous computational power. All psychiatrists are treating people with unique conscious states and there is no specialty more aware of that. And in that complex setting psychiatrists are focused on helping the people they are seeing. They are the only ones accountable.

There is no “identity crisis” in psychiatry. Making that claim requires a suspension of the reality about how psychiatrists are trained and the grim practice environments that many of us face. Those grim practice environments are the direct result of governments and businesses actively discriminating against psychiatrists and their patients. That has resulted in discrimination that is so gross that county jails are now regarded as the largest psychiatric hospitals in the USA.  Pretending that these problems are the result some flaw in psychiatrists one of the greatest medical myths of the 21^st century.  These authors and the New England Journal of Medicine are promoting it.  This opinion piece is so poorly done it makes me wonder what the editorial staff at NEJM are doing. It is as bad as another opinion piece that should never have been published in the psychiatric literature.   

The real message from the profession that should be out there is:

“Give us a practice environment where we can do what we are trained to do! Get out of the way and let us do our work! Give us the resources that every other medical specialist has!”

Very few of those environments exist.  They have been rationed out of existence by politicians, bureaucrats and administrators.  People who know nothing about the field seem to be totally unaware of that problem and like these authors they never comment on it. Only people lacking that awareness would believe an article like this - or write it.

George Dawson, MD, DFAPA

References:

1: Gardner C, Kleinman A. Medicine and the Mind - The Consequences of Psychiatry's Identity Crisis. N Engl J Med. 2019 Oct 31;381(18):1697-1699. doi:10.1056/NEJMp1910603. PubMed PMID: 31665576.

2: Teachman BA, McKay D, Barch DM, Prinstein MJ, Hollon SD, Chambless DL. How psychosocial research can help the National Institute of Mental Health achieve its grand challenge to reduce the burden of mental illnesses and psychological disorders. Am Psychol. 2019 May-Jun;74(4):415-431. doi: 10.1037/amp0000361. Epub 2018 Sep 27. PubMed PMID: 30265019.  

I thank these authors for making this paper available on ResearchGate.

3: Kalin NH. Mechanisms underlying the early risk to develop anxiety and depression: A translational approach. Eur Neuropsychopharmacol. 2017 Jun;27(6):543-553. Doi: 10.1016/j.euroneuro.2017.03.004. Epub 2017 May 11. Review. PubMed PMID: 28502529; PubMed Central PMCID: PMC5482756.

4: Fox AS, Kalin NH. A translational neuroscience approach to understanding the development of social anxiety disorder and its pathophysiology. Am J Psychiatry. 2014 Nov 1;171(11):1162-73. doi: 10.1176/appi.ajp.2014.14040449. Review. PubMed PMID: 25157566; PubMed Central PMCID: PMC4342310.



Supplementary:

The Psychiatry Milestone Project: an indication of what psychiatry residents are evaluated on in their training programs. Link.

Graphic Credit: 

The graphic was downloaded from Shutterstock per their standard user agreement.