Happy Labor Day 2021

 

This is my annual Labor Day greeting to my physician colleagues. I had to go back and look at last year’s greeting to see if I had factored in the pandemic or not.  It appears at the time that I was fairly enthusiastic about telepsychiatry and its applications during the pandemic. Ironically, I will be giving a presentation on telepsychiatry later this year and in reviewing a fairly massive amount of information my initial enthusiasm has been tempered. Although it appears to have had a semi-permanent effect on the regulatory environment there are still unanswered questions about its optimal applications. How it will be used by the business community is also unknown at this point.

One of the articles I reviewed in New York Magazine - outlined a pattern of questionable business practices at least as it was applied to therapists. Direct interviews with therapists suggested that they were being exploited by being paid much less than their going rate with the expectation that they would be more available after hours and by texting. Preliminary surveys indicate that there are psychiatric clinics popping up looking for psychiatrists to staff telepsychiatry visits. There are many unknowns about their practice. In another article, some employers were asking therapists to see people outside of the state they were licensed and hope that the regulatory environment would catch up with the employment practice. Those are not good signs for the labor environment.

I noticed in my 2020 post that I had an initial drawing of how the practice environment had changed and now that drawing has been expanded and includes many more details. It captures most of what I have endured as employed psychiatrist. I include a graphic below and hope that as physicians we can reverse the trend at some point.

The pandemic has clearly been demoralizing for physicians in general but much more for frontline acute care physicians responsible for COVID-19 patients and their frontline colleagues in nursing and hospital support. There has been a shortage of personal protective equipment (PPE), beds, adequate ventilation, and supportive services. There have been deaths and resignations compounding the personnel problem. As the staffing ratios worsen - the emotional stress is at an all-time high. Local disasters compound the COVID crises in many areas.  All the descriptions I see indicated that the healthcare system will end up permanently altered by this pandemic and probably not in a positive way. There seems to be no effort to incorporate a public health approach into the current subsidized business rationing approach that dominates American healthcare. That is not only detrimental to physicians and their coworkers but also the public health infrastructure in general.

A new dimension to the demoralization has been the misinformation industry associated with the pandemic. Physicians trying to provide information in good faith have been attacked and even threatened by some of the zealots associated with or affected by that misinformation. That includes some of the top experts in the world who have been active in research and teaching immunology, epidemiology, virology, and vaccine production. Physicians are given the message that is up to them to communicate to the zealots and convince them that the pandemic is real, it is a really a virus, and that immunizations are the best approach. There appears to be no convincing a large group of people that wearing masks may reduce viral transmission even though that practice was widespread in the 1918 epidemic in the US and is currently widespread in many parts of the world. Physicians are getting the message that they have to magically find a way to communicate with this group of people who have rejected all of the usual channels.

It seems obvious to me that physicians are the only group that are excluded from empathic communication. The expectation is that physicians will be all-knowing, all understanding, and that somehow will correct most of the anti-vaccine, anti-science, anti-expert, and anti-COVID sentiment out there. I think that is a fairly naïve approach and what physicians need is concrete help from politicians, community leaders, and regulators.  Social media is gradually coming around but has responded at a glacial rate. 

I also notice in my greeting from last year that I commented on an APA Presidential Task Force on Assessment of Psychiatric Bed Needs in the US.  I saw no further action and that and was not able to find it in a search. That potential bright spot maybe on hold due to the pandemic, a lot also depends on the conclusions if they are available.

Progress against the burnout industry has been maintained but it is clearly a war of attrition. Physicians in general reject the idea that burnout is due to some inherent personal deficiency and are more likely to see it as the real product of an unrealistic work environment. In many cases that unrealistic work environment has increased many-fold due to the pandemic and all of the associated problems. I hear from physicians every day who are able to exercise minimal self-care due to overwork and limited time away from work. Weight gain is common due to unhealthy diet and no time for exercise. A solution for some has been to leave those work setting behind even if it means early retirement or taking an undetermined period of time off. Many physicians who could easily have worked into their early to mid-70s are retiring at age 65.

Employers seem to be doubling down in this adverse environment. I quit my last job in January 2021. Since then, I have been actively looking for new positions. There has been a recurrent pattern of highly leveraged job descriptions, that I would accept only if I really needed employment. By highly leveraged I mean that the job description contains anywhere from 20 to 30 bullet points, the majority of which have nothing to do with being a clinical psychiatrist. To cite one example, many of the applications describe a “leadership role” where the really is none. No organization that I am aware of wants a frontline clinical psychiatrist to attempt to correct their obvious administrative problems. I received a cold call one day from a recruiter who asked me if I was interested in a “very good” inpatient position. I asked him what the productivity expectations were and he said I have the options of seeing 18 or 22 patients per day. He quoted a disproportionately greater premium for seeing 22 patients a day. He seemed convinced that I would accept the position until I asked him “When am I supposed to live or sleep?” I had the thankless job of covering inpatient unit of 20 patients for an entire year with the help of an excellent physician assistant and that almost killed me.

The unrealistic expectations being placed on physicians are still out there and they are as bad as they ever have been. It is why I used a heavy lifting graphic for this post again. Despite the pandemic the business leverage against physicians is not letting up and that is not a good sign. To make matters worse, there always seems to be room for it in the medical literature. The latest example I can think of is a recent essay in the New England Journal of Medicine claiming that digital healthcare fee-for-service payments are unsustainable and there must be a capitated system. That seems to be part of the master plan to continue a rationed-for-profit system that guarantees over-employment of bureaucrats and business managers as well as corporate profits at the cost of treating physicians like highly paid laborers as depicted in the above diagram.

I don’t think physicians will have any reason to celebrate Labor Day, until that rationed- for-profit system is dismantled.  Until then do what you need to do to take care of yourself and survive. Help from professional organizations would be useful, but there are too many conflicts of interest for that to be realized.  I am still hopeful that we can get back to the stimulating clinical environment of the 1980s, but I will be the first to admit - there is no obvious path back in the face of a trillion dollar healthcare rationing business - largely invented by Congress.

 George Dawson, MD, DFAPA

 

Graphic Credit:

Robert Yarnall Richie, No restrictions, via Wikimedia Commons. "Workers Adjusting Tracks, Texas Gulf Sulfur Company."

Drapetomania - The Lack of Relevance To Psychiatry

 

I will address this issue one final time. I have written about it in the pages of this blog in past. Drapetomania was a pseudo diagnosis coined by Southern physician named Samuel A. Cartwright. He wrote the following in 1851:

“DRAPETOMANIA, OR THE DISEASE CAUSING NEGROES TO RUN AWAY.
It is unknown to our medical authorities, although its diagnostic symptom, the absconding from service, is well known to our planters and overseers...
In noticing a disease not heretofore classed among the long list of maladies that man is subject to, it was necessary to have a new term to express it. The cause in the most of cases, that induces the negro to run away from service, is as much a disease of the mind as any other species of mental alienation, and much more curable, as a general rule. With the advantages of proper medical advice, strictly followed, this troublesome practice that many negroes have of running away, can be almost entirely prevented, although the slaves be located on the borders of a free state, within a stone's throw of the abolitionists.” 

Characterizing running away from slavery as a disease and physical punishment as a treatment was certainly a radical concept even in the Southern states before the American Civil War. In subsequent paragraphs Cartwright invokes divine providence to explain why white masters are destined to remain in a superior role to slaves.  He was concerned about “two classes of person who were apt to lose their negroes – the overly permissive defined as “treating them as equals” and the cruel owners who denied slaves the ordinary necessities of life.  His solution was to treat them well enough, but not allow many freedoms, and physically punish them into a submissive state “for their own good.”  Since Cartwright wrote these paragraphs the common interpretation is that his disease characterization of a rational act is a prototypical misapplication of the disease concept.

Not much has been written about criticism at the time. Writing in the Buffalo Medical Journal Samuel Hunt provided a satirical editorial on the original paper (2):

“Our purpose in this formal introduction, is to give due importance to an article recently published in its pages by Dr. Samuel Cartwright, of New Orleans. Characterized by the same cautious induction and logical accuracy whichever attended the literary efforts of that gentleman, it deserves careful consideration of the medical philosopher, the anatomical statesman, and the benighted Saratoga convention.

Those of our readers who are in the habit of referring to Cullen’s Nosology for the definition of diseases, will find no mention there of Drapetomania. The ignorance of the ancients was surprising, and we need but refer to Drapetomania as an evidence of this progressive spirit of the age in which we live.

Dr. Cartwright has conferred this name, Drapetomania, upon a disease peculiar to the south, and which is, we believe entirely confined to that section, and only manifested at the north in certain analogous if not identical forms, which we shall have occasion to mention when we have given our readers time for the perusal the following extract from Dr. Cartwright’s able article:”

After additional sarcasm following the extract, the author goes on to close his editorial by describing a disease he calls Effugium discipulorum or a tendency of school boys to leave school and spend time in the fields and orchards of rural districts. He suggests that the same solution – whipping “have been sanctioned by ages of experience in Effugium discipulorum; thus confirming the allied nature of the 2 diseases and the correctness of Dr. C’s hypothesis.” Hunt’s satirical editorial of 1855 and additional sources describing how the paper was mocked in the northern states is an indication of how serious this “diagnosis” was taken by some physicians at the time.

Historian Christopher D. E. Willoughby (3) described a much more nuanced environment and the multiple roles that Cartwright played. He was apparently widely published on a number of medical topics and there was widespread interest in the medical community about racial differences in medicine. Cartwright portrayed himself as an expert in this area, but due to his reputation he generally received deferential treatment – even when other physicians disagreed with him.  The medical emphasis at the time was on anatomy and in terms of disease theory there was a doctrine of specificity outlining the few factors relevant to how a disease could be treated. One of those factors was race. A physician could be regarded as a quack if one of these factors was disregarded – reinforcing the role of racial medicine. Despite Cartwright’s medical and political role, Willoughby describes his drapetomania as being so far outside of the medical norms at the time that drapetomania was not adopted as a diagnosis by many physicians and it was never a psychiatric diagnosis for the obvious reason that psychiatry and its diagnostic systems did not exist.

.The sampling of how often the term was used over the intervening decades both independently and relative to actual psychiatric diagnoses is indicated in the following Google NGRAMS.  To read about the graphing procedure consult this source (4). (Click to enlarge)

It seems fairly obvious that there was a flurry of references around the time of Cartwright’s article and then a very long flat period until Szasz resuscitated it in the 1970s (5) and it was picked up by the anti-psychiatry crowd subsequent to that.  Given the Google NGRAMS approach, relative to standard psychiatric diagnoses the interest in this pseudo diagnosis was practically nil.

A critical question is how a theory largely ignored at the time, now has more references than in the past?  A lot of that may have to do with a reinterpretation of his image. The description of him as a respected surgeon who trained with Benjamin Rush at Pennsylvania Hospital was apparently due to mistakes in an early biographical history (3) and persist today in Wikipedia and many other places.  Further reading suggests that he was in medical school as a teenager, dropped out to fight in the War of 1812 where he sustained injuries and then went back to complete his medical training. Looking at that timeline does it seem plausible? (click to enlarge)

Cartwright was born in 1793. In the years 1808-1813 he would have been 15-20 years old. Benjamin Rush died in April of 1813 and had been ill since the previous November. His biographer Stephen Fried (6) described Rush writing and active doing hospital rounds during this time period but for the first time starting to miss those rounds. It seems unlikely that even in the 19th century that anyone in their late teens would have been a military veteran and in medical school between the ages of 15-19. Willoughby (3) confirmed that there was no evidence that Cartwright matriculated at Penn or that he apprenticed with Rush. There are a multitude of sites on the Internet and in papers that state otherwise. Contrary to these many references there was no connection between Cartwright or Rush and the University of Pennsylvania Medical School. He did graduate from Transylvania Medical School (Lexington, KY) in 1823.

What about the purported connection between psychiatry and Cartwright and his invented diagnosis? Per the timeline above psychiatry had not yet been invented. There was an organization of asylum superintendents at the time but they had no formal diagnostic system.  The Association of Medical Superintendents of American Institutions for the Insane (AMSAII) was founded in 1844 and it had a total of 13 members - none of them were described as psychiatrists or alienists.  Despite the fact that racism and proslavery attitudes were widespread,  none of them used the term drapetomania or admitted asylum patients on that basis. In fact, only one asylum accepted slaves with mental illnesses at that time.  

The American Medico-Psychological Association was established in 1892 and at that time the number of alienists versus psychiatrists was not known.  In fact, it wasn’t until a meeting of the Alienists and Neurologists of America in 1917 (7) that anyone suggested specific training was necessary to treat asylum patients.  In those proceedings there are three times as many references to alienists than there are to psychiatrists, despite Reil’s first use of the term in 1816.  No mention at all of drapetomania but an interesting section on the importance of social diagnosis and social work.  The main diagnostic focus was on alcoholism, catatonia, epilepsy, syphilis, dementia praecox, various forms of chronic illness, and intellectual disability described as “feeble mindedness”.  None of the alienists or neurologists seem remotely concerned about drapetomania.  This is the only reference to race in that 228-page document:

“Preservation of self and of the race are directly dependent upon gratification of the appetites and this fact necessitates reaction of man to his environment and appropriation of those things which serve to fulfill his desires.”

It was included in a section on “Criteria of Defective Mental Development”.

On the timeline, the initial forms of psychiatric diagnostic manuals appeared in 1918 and 1952. Neither contained any reference to drapetomania and most of the diagnoses proposed are recognized as being similar or precursors to current diagnoses. One of the often-used tactics in criticizing psychiatry today has to do with the diagnostic manual and what it means.  Contrary to the rhetoric, alienists and psychiatrists involved in asylum care were often criticized for the lack of science in those settings most notably by the neurologist Weir-Mitchell (8):

“I shall frankly have to reproach many of those who still bear the absurd label of ‘medical superintendents'. Where are your annual reports of scientific study of the psychology and pathology of your patients? We commonly get as your contributions to science, odd little statements, reports of a case or two, a few useless pages of isolated post mortem records and these are sandwiched among incomprehensible and farm balance sheets”.  He went on to state that neurologists believed asylum care was care of “last resort”.

From the start psychiatric diagnostic manuals had the dual role of diagnostic description and data collection in asylums, specialty hospitals, specific populations, and for research purposes. Contrary to modern antipsychiatry philosophy there was no goal to increase diagnoses or the number of people with a diagnosis and no goal of social control through diagnosis.

I have established that Cartwright had no connection to Benjamin Rush of the University of Pennsylvania medical school. I have also established that drapetomania was certainly not accepted as a diagnosis and was probably widely derided in some areas.  It was essentially a product of the racist south, inadequate diagnostic theory and medical racism, had medical and political implications, and was written by a physician who owned 14 slaves and had a personal interest maintaining that practice.  I have also established that it has nothing to do with the field of psychiatry or its intellectual roots. It is only through massive misinformation that these false ideas persist. That misinformation landscape if so large at this point that it is not likely to ever be corrected. I certainly doubt that this blog will have much of an effect against what is now decades of drapetomania misinformation.  Many of the people spreading that misinformation are doing it in bad faith and by definition are not interested in correcting it.  There are also many (presumably) good faith errors such as recent statements from within organized psychiatry and in texts. A psychology colleague posted that every undergraduate Abnormal Psychology text uses drapetomania as an example of coercive psychiatry. Hopefully the good faith errors will correct themselves.  

The modest goal of this post is to hope that I can keep all of this misinformation out of the psychiatric literature.  That will be no small task. Szasz is already published despite the fact that he has been widely discredited. Even last month I was reading the American Journal of Psychiatry (9) and came across this statement:

“Over 60 years after the ratification of the US Constitution, physician Samuel Cartwright played a prominent role in the rise of racism in psychiatry.  His descriptions and characterizations of mental health conditions in enslaved Africans, particularly drapetomania which he described as the illness of enslaved people wanting to run away and escape captivity, and dysaethesia aethopica, a disease of ‘rascality’, were the beginning justifications of pathologizing normal behavioral responses to trauma and oppression.”

Based on everything I have established this is an inaccurate statement. Cartwright was not a psychiatrist or even an alienist. He was not trained in researching or diagnosis any mental health conditions and essentially made these up. His isolated racist ideology has nothing to do with the subsequent development of psychiatry or the way psychiatry is practiced today. Cartwright and drapetomania have become a convenient meme with the imitators using it as an indictment of psychiatry or the psychiatric diagnostic system – even though it is unrelated to both.  The latest application has been the use of this meme by psychiatrists to acknowledge systematic racism within the field as a basis for future correction. I have no problem with acknowledging that racism in psychiatry and society exists – but let’s make that acknowledgment on a realistic basis not an unconnected anecdote.

I expect a fair amount of opposition to this post. I base that on a reaction I got in a psychiatry listserv when I suggested that professional organizations should suggest the Rosenhan paper be retracted. Although I got several very supportive replies and replies from people who were shocked about the facts, there was also a very vocal contingent proclaiming they want social justice. Social justice cannot be predicated on a misinformation, even if that misinformation seems consistent with your overall message.  And there is a much better way.  That better way was in this weeks New England Journal of Medicine (10) in an article highlighting the work of W.E.B. Dubois and his colleagues who accomplished what can only be described as landmark work in the area of structural racism. In it DuBois and colleagues concluded that the excess mortality from tuberculosis in the black community was a product of racial disparities secondary to social forces. The report was published in 1899.  DuBois also successfully countered the theory of an insurance company actuary who suggested that black people were “ill adapted to freedom but also doomed to imminent extinction because of their biological differences from white people.” (note the parallels with drapetomania). Dubois successfully refuted these claims and showed that heredity could explain only a small part of differential mortality between groups and that social inequity accounted for most differences. The work of these social scientists and theorists is a solid place to start.

The solid scientific ground that we are on today is that we know race is a non-specific factor and that biologically all of mankind comes from the same place.  We are much more biologically similar than different. Discrimination and the resulting outcome disparities based on racism are the real problems to be addressed and there has been a scientific basis for that since 1899.    

 

George Dawson, MD, DFAPA

 

References:

1:  Cartwright SA.  Diseases and Peculiarities of the Negro Race.  De Bow's Review. Southern and Western States. Volume XI, New Orleans, 1851  Link

2:  S. B. Hunt (1855). "Dr. Cartwright on "Drapetomania"". Buffalo Medical Journal. 10: 438–442. (full text). https://books.google.com/books?id=coBYAAAAMAAJ&pg=PA438#v=onepage&q&f=false

3:  Willoughby CDE.  Running Away from Drapetomania: Samuel A. Cartwright, Medicine, and Race in the Antebellum South. Journal of Southern History
The Southern Historical Association Volume 84, Number 3, August 2018 pp. 579-614; 10.1353/soh.2018.0164

4:  Younes N, Reips UD. Guideline for improving the reliability of Google Ngram studies: Evidence from religious terms. PLoS One. 2019 Mar 22;14(3):e0213554. doi: 10.1371/journal.pone.0213554. PMID: 30901329; PMCID: PMC6430395.

5: Szasz TS. The sane slave. An historical note on the use of medical diagnosis as justificatory rhetoric. Am J Psychother. 1971 Apr;25(2):228-39. doi: 10.1176/appi.psychotherapy.1971.25.2.228. PMID: 5553257.

6:  Fried S. Rush: Revolution, madness & the visionary doctor who became a founding father. Crown Publishing Group, a division of Random House LLC; New York, 2018.

7:  Alienists and Neurologists of America: Proceedings of Sixth Annual Meeting.  Chicago, IL  July 10-12, 1917.

8:  Shorter E.  A History of Psychiatry: from the era of the asylum to the age of Prozac.  John Wiley & Sons, Inc. New York, 1997: p.68

Weir-Mitchell’s criticism was delivered in 1894.

9: Shim RS. Dismantling Structural Racism in Psychiatry: A Path to Mental Health Equity. Am J Psychiatry. 2021 Jul;178(7):592-598. doi: 10.1176/appi.ajp.2021.21060558. PMID: 34270343

10:  White A, Thornton RLJ, Greene JA.  Remembering Past Lessons about Structural Racism — Recentering Black Theorists of Health and Society.  New England Journal of Medicine August 26, 2021 385(9):850. doi: 10.1056/NEJMms2035550

11:  Callender JH.  History and Work of the Association of Medical Superintendents of American Institutions For The Insane - President's Address.  Am J Insanity. July 1883: p. 1-32.

In this reference, the Association President reviews the first 40 years of progress and points out that 13 members started in 1844 but by 1880 there were 115 members representing 130 public and private institutions in the US or Canada and a total of 41,000 patients.  In this same document the President refers to the distinguished members of the organization as alienists rather than psychiatrists. Gonaver (see below) refers to the physicians of the AMSII as "asylum doctors" or "psychopathists" but also points out that many had no specialized training at all in the treatment of the mentally ill.

Supplementary 1:

This reference was posted to me on Twitter.  In it the author points out that the term drapetomania was not a diagnosis in the only asylum that treated slaves during the time when there was peak interest in the term:

"Readers may be therefore surprised by the conspicuous absence of these so-called conditions in the only insane asylum in which  slaves were patients."

Gonaver W. The Peculiar Institution and the Making of Modern Psychiatry, 1840–1880. University of North Carolina Press, 2019.

Supplementary 2:

The nosology text by Cullen referenced in the satirical critique of Cartwright's work is available online through the National Library of Medicine.  The only references to mental disorders were mania, melancholia, and bulimia.  

Cullen W (1710-1790).  Synopsis and nosology: being an arrangement and definition of diseases. Hartford : Printed by Nathaniel Patten, MDCCXCII [1792]: 80 pages.  Link to NLM

Supplementary 3:

 

I got this book in the mail today and read it.  It is a 1918 edition "prepared for the Committee on Statistics by the American Medico-Psychological Association" - see timeline. The text is 40 pages long, contains 21 diagnoses in the classification system and was designed to facilitate data collection for statistical analysis. There was a detailed section on race and ethnicity that would not be included in any modern analysis.  Drapetomania was not listed anywhere in this volume.

Supplementary 4:

Precursor organizations to the American Psychiatric Association published a journal - The American Journal of Insanity that encompassed the period of time when drapetomania was proposed. In order to see if there was any recognition of drapetomania in the line of journals that the APA considers related to psychiatry I went back and looked at one 1850s decade of the American Journal of Insanity and then did a search on the APA web site validated against terms like sitomania discovered in that decade of material.

On the APA web site, the time span of journals is indicated below:

American Journal of Insanity vol. 1 no 1 (July 1844) to vol. 99 no. 6 (May 1943)

American Journal of Psychiatry vol. 100 no. 1 (July 1943) to current time.

There were no references to drapetomania in the interval 1851-1859.

The search engine was validated to discover relevant diagnoses in the American Journal of Insanity.

The search of APA journals yielded 19 references dating back to 1971.  The first two references from that year were both written by Thomas Szasz.  The references in general have to do with racism in medicine including a recent number of references, some book reports including one about ADHD that for some reason contains the word drapetomania. 

The exercise in this supplemental information confirms that drapetomania was never considered a diagnosis in what are considered the early journals of psychiatry.  In my reading of the American Journal of Insanity I also found much to support Weir-Mitchell's 1894 criticism of the field (see above and reference 8).

Supplementary 5:

I received the following book in the mail today after a Twitter colleague referenced it.  The author Wendy Gonaver is a historian who had access to a significant volume of records from the only asylum that treated and accepted slaves and free black persons as patients and employed slaves as caregivers.  So far I have read the 18 page introduction and the writing and rationale are excellent.  She introduces a level of insight and objectivity that is rarely seen in the content that she is covering. On page 6 and 7 she debunks the importance of drapetomania that occurred right in the middle of the years she is covering for this book (1840-1880). In commenting on the complete absence of Cartwright's invented diagnoses:

"For good reason, Cartwright's work has become synonymous with all that was horribly wrong with both slavery and spurious science.... but Cartwright's posthumous notoriety does not appear to match his reputation during his lifetime.  His fabrications were, at least for Southern doctors who considered themselves serious practitioners, more rhetorical proslavery provocation than legitimate diagnoses." (p. 6-7).

She points out that Cartwright was not a "mental health specialist", never attended a meeting of The Association of Medical Superintendents of American Institutions for the Insane the only professional organization at the time, his work was never discussed at those meetings, and there were no records to suggest that slaves were admitted for running a way or that they were whipped.  There is also no mention of a connection to Benjamin Rush - another frequent error when Cartwright is discussed.

At the same time Gonaver points out that previous historical documents ignored race as a dimension for analysis and illustrates some of her insights in that area in the introduction.  I look forward to completing the book. 

A brief synopsis of the book follows:

After some consideration, I elected to post a synopsis of the book rather than each chapter due to the length of that document. The book is based on archives of the Eastern Lunatic Asylum (ELA) as reviewed by the author historian Wendy Gonaver. The descriptions of the state of the asylum, administration, staff including the enslaved staff, and the patient population role based on detailed notes by the asylum superintendent during the time interval of interest (1840-1880). Most of the material consisted of records written by John Galt, the superintendent. He was appointed age 22 and 1841 after studying at the University of Pennsylvania. He remained the superintendent until his death by suicide on May 18, 1862. Although the author refers to her book as a study of the “broader ideological underpinnings of early psychiatry” - the asylum doctors were clearly not psychiatrists. They are typically referred to as “asylum doctor” or “psychopathist”.  He was a member of the Association of Medical Superintendents of American Institutions for the Insane (AMAAII). This association was founded in 1844 and at that time it had 13 members. The only real connection to psychiatry is that the American Psychiatric Association uses this date to claim that psychiatry was the first medical specialty. That is a questionable claim on multiple levels.

The ELA itself was housed in an inadequate physical plant even in the pre-Civil War era. Sanitation was clearly a problem with inadequate drainage and sewerage systems. Potable water was also problem. There were a large number of fires on the campus for heating purposes until central heat could be installed. Nutrition was also a problem. Although the patients got about a pound of meat 5 days a week and fish 2 days a week several patients were diagnosed with scurvy. That led to an emphasis on expanded gardening of fruits and vegetables. Children of staff living on campus were not served regular meals but had to subsist on scraps.

One obvious conclusion is that there is much material in this book that could be used to blame psychiatry in much the same way that drapetomania has been used. But there are many qualifiers. Racism both overt and covert were clearly present in both the northern and southern states. Even though much of the events described in this book occurred 30 – 70 years after Benjamin Rush’s death there were no true abolitionists, not even reformer Dorthea Dix.  John Galt supported his enslaved staff in many cases humanistically but from a pragmatic rather than a moral perspective. He clearly believed that blacks were socially and intellectually inferior, but he realized that his institution could not run without enslaved blacks.  That led him to defend the quality of care provided by the enslaved staff at his institution. Racial stereotypes cut across the dimensions of religion, gender, and culture with African Americans receiving the harshest treatment and the greater work load. When John Galt died and the Civil War ended, the integrated ELA also ended and black patients were transferred to a segregated institution where their care was noticeably worse.  During a transition period, multiple military physicians with no training in asylum care were appointed to run the ELA.

Politics factored prominently in the workings of the ELA and whether Galt received any recognition for his work of ideas.  Shortly after his arrival, a conflict developed with the asylum board when they removed his hiring ability and blamed him for the resulting problems. He was also resented by AMAII colleagues over his advocacy for integrated asylums and eventually an outpatient community-based model. Despite praise for innovation at their meetings he was never credited for his ideas or his death mentioned in one of their meetings.

The author is a critical presence in this book. In places, she is clearly suggesting that stressors, abuse, domestic violence, war, and other forms of trauma may be the most important factors in why someone, but particularly white, black, and enslaved black women ended up in the ELA. She acknowledges that there may be a role for severe post-partum states. As I read though these case reports, I had questions about the degree of detail available as well as the primitive to non-existent diagnostic system. If all of the details of stressful events were there – could they really not be considered given the primitive state of medicine that was being used?  The only treatment being supplied was basically moral therapy and environmental containment to reduce the risk of aggression, suicide, and starvation.  There were no trauma or stress based therapies available in the mid-19^th century. If there were it would take a much larger professional staff to administer them.

All things considered, the logical conclusion is that the ELA, like most institutions was not able to rise above the prejudices of the population where it was located. The practices described in the book are common overt and implicit racist themes – even today. Covert segregation still exists even though school segregation ended in 1954. In keeping with the timeline of this book, the Civil Rights Act of 1875 was supposed to have ended racial discrimination but the Supreme Court overturned it in 1883 saying that individuals and private business could discriminate on the basis of race.  

The Peculiar Institution is a very scholarly work. It is well written and I encourage anyone with an interest in the history of this time or discrimination based on race or gender to read it.  My only other concern is with the extended title – The Making of Modern Psychiatry.  I would submit that it really contains very little to do with modern psychiatry – and like Cartwright’s drapetomania diagnosis is more the product of racism, politics, and an inadequate system of care. 

Supplementary 6:

The state of Virginia lists Eastern State Hospital as the first mental hospital in the United States dating back to October 12, 1773 and states that at one point it was called the Eastern Lunatic Asylum.  There is some history available on this Virginia State web site including commentary on Dr. Galt.

Supplementary 7:

The journal Alienist and Neurologist: a quarterly journal of scientific, clinical and forensic psychiatry and neurology was published between 1880 and 1920 when publication ceased.

Full text of this journal is available via the HathiTrust web site. 

Supplementary 8:

Drapetomania errors on the Internet - needless to say there are many.  I thought I would catalogue them but do not have the time. Unless the use is restricted to Cartwright and not applied to psychiatry it is probably safe to say it is being used rhetorically. 

Beauty Contest or Cynical Marketing Scheme?

 

Beauty Contest or Cynical Marketing Plot?

Well this is the United States so it is a safe bet that the answer will be “cynical marketing plot”, but even then the beauty contest may not be an independent variable.  I just listened to a story on public radio today about how government contractors in Afghanistan basically had blank checks for the services they provided to American troops. We live in a land where the government basically stacks the deck in favor of corporations and there is no clearer example than the healthcare industry.

Today I received a letter in the mail that said

“Dear Dr. Dawson - we are pleased to include you among the Top Doctors to be featured as a Top Neurologist representing Circle Pines, MN.  We will be featuring you in our 2021 Top Doctor list which will appear both online in our nationally syndicated publications. Your expertise in Neurology and dedication to upholding the highest standards of patient care in the diagnosis and treatment of neurological disorders and diseases is something to be recognized. This four-color wall plaque is a beautiful addition to your wall of achievements. Signed, the Selection Committee”.

I was very skeptical of this letter from the outset for obvious reasons.  First, I am not a neurologist. Second, I do not live or work in Circle Pines, MN.  I considered reasons for the letter the most obvious one that it was simply an error. Sarcasm came to mind as I reflected on the many people over the years who told me I was too preoccupied with either neurology or medicine for a psychiatrist.  Was this a sarcastic joke based on that criticism?  Finally, I have encountered some people who think it is hilarious that you are assigned a job title in error. Was this an attempt to do that?  Finally - the marketing aspects.  I had received many solicitations to get listed in various Who's Who publications.  This was probably the medical version.  I have never been compelled to get a copy of Who's Who to find out who the prominent people are.  They are usually obvious - at least the ones that I am interested in.

I don’t know exactly when the “Top Doctors” lists started to appear. The past 15 years - I have received a mailing encouraging me to nominate certain doctors for this award. Lists are compiled by specialty and they don’t seem to change much every year. I glance at the list from time to time and agree with about 20% of the rankings. But in their defense, how should a “Top Doctor” be ranked? When I am personally looking for a “Top Doctor” for my own medical care or the care of my wife I am interested in what their results are. That applies to both medical and surgical care. That data is extremely hard if not impossible to find. Do the physicians doing the voting know these details? In some cases they might. I depend on my primary care physician and his experience with surgical referrals and the results that he sees from those referrals. In the case of nonsurgical care my speculation is that those results are more nebulous. In that case do the rankings have anything at all to do with outcomes or quality of care?

It reminds me of the type of rankings I got every year when I was an employee for a managed-care company. They could fluctuate 180 degrees from one year to the next because they were totally subjective.  One year I was ranked number one in documentation and coding according to subjective chart audits. The next year I was dead last even though nothing had changed in the interim. We also had an anonymous “360° evaluation” where other staff were encouraged to critique us and say just about anything they wanted whether it was relevant to work quality or not. The entire exercise lacked accountability and was demoralizing.  In my annual reviews I started to refer to it as “the beauty contest” reflecting its subjectivity and fickleness. My boss thought that I was joking - but I was not.

These political subjective ratings have a goal to elevate organizations that are run by business administrators while maintaining leverage over the physicians who work in them. There is no clearer example than driving through Anytown in the USA and noticing that they all have a top ranked hospital or medical clinic. There just are not that many top ranked hospitals and medical clinics in the country.   The “Top Doctors” list may be another one of these trends. Some of these lists tend to have many specialists from same clinic.

The beauty contest concept brings to mind Atul Gawande’s essay The Bell Curve from 2004.  He develops the premise that there is very little objective measurement of physician outcomes and even less disclosure. With that data it would be possible to construct a bell-shaped curve and find out where physicians are plotted against their peers. This would be an ideal route to find the Top Doctors list but he is more focused on what happens if you find out you are just average. In any statistical compilations people are bound to be average and even below average, but Gawande points out that settling for average is the problem and he even rolls in the idea of the beauty contest:

“And in certain matters - looks, money, tennis - we would do well to accept this.  But in your surgeon, your child’s pediatrician, your police department, your local high school? When the stakes are our lives and the lives of our children, we expect averageness to be resisted.”

Even though that essay was from 2004, the actual measurement of doctors remains elusive except for a very few instances. Gawande points out some of the reasons including what to measure, who is doing the measurement, what is all means, and what the implications are. He does not comment on the major extraneous factors that may shift the curve. In the last 30 years, the single largest factor is the business management of healthcare and the move away from substance – in particular quality – to advertising and fluff. There is probably no better example than my Top Doctors letter.

I want to be clear that the letter I got was all about signing up for a meaningless plaque to recognize me as the wrong doctor from the wrong specialty in order to get money. Are there other  doctors out there going along with this? Are there doctors who are purchasing meaningless plaques and putting their names on meaningless lists to enhance their resume? That is an investigation that I don’t have time for. This post is all about getting the message out that rankings and proclamations that doctors, hospitals, and clinics are “top rated” is not necessarily something you can hang your hat on.

Be very skeptical of ranking systems especially ones that are self-proclaimed - and try to get reliable information on what counts. With physicians that would include their outcomes, their thoroughness, and the relationship they are able to establish with their patients.  Gawande’s essay points out that relationship may not always be comfortable

Don’t get pulled into a beauty contest…..even though in today’s healthcare landscape they seem unavoidable.

 

George Dawson, MD, DFAPA

 

 

References:

Atul Gawande.  The Bell Curve.  The New Yorker.  November 28, 2004

Graphics Credit: 

Bathing Beauty Contest 1920.  National Photo Company Collection, Public domain, via Wikimedia Commons:  

https://upload.wikimedia.org/wikipedia/commons/0/01/11_women_and_a_little_girl_lined_up_for_bathing_beauty_contest_LCCN2001706323.jpg

Updated Medication Checklist for Psychiatrists

 

I decided to update the medication list that I posted here last February.  Not much has changed but I am using it for another couple of projects that I am working on. I am currently working on a detailed look at medications psychiatrists prescribe that may interact with medications used to treat atrial fibrillation (see previous post). I am also going to try to arrange the medications on this list according to the purported mechanisms of action.  The current available systems include the Neuroscience Based Nomenclature (NbN) and the Anatomical Therapeutic Chemical (ATC) Classification.  Both of these systems will involve many more categories and reformatting of the document.  I would like to retain the single page format for convenience.

Per the previous posts on this blog, I devised this sheet in order to get a more accurate idea about what my patients had taken in the past.  I found that they were able to recall many more previous treatments by reading through the list and that it was relatively efficient. I posted this list to Twitter to solicit recommendations and corrections and made some of those changes.  Several people suggested alphabetizing the lists, but I typically put the most recent medications at the top of the list and medications that made be no longer manufactured or more rarely prescribed at the bottom. There were some recommendations for medications that are available in other countries but not the US. I would be amenable to modifying the list for specific countries if someone could edit the current list and make sure it was corrected for the country that you are practicing in.  You could also just type up your own list.  You will also find several medications that have been discontinued either for safety or economic reasons. They are on the list because there are still relevant to the medication history of many patients.

I found that this list was also useful for research projects.  I was involved in a research project last year where there was some confusion about what psychiatric medications would be allowed in a study that looked at antidipsogenic medication. I showed my list to the Principle Investigator and other colleagues working on the project and we decided in a brief meeting the drugs that would be included or excluded in the protocol by just going through the document and checking them off. 

I wrote a more detailed post on this list last February with some disclaimers.  The same disclaimers apply. I don't make any guarantees that it is comprehensive or that you will find it useful. I think it does a fairly good job of illustrating the kinds of medications that psychiatrists prescribe, but that is always relative to the practice setting. During 22 years of inpatient practice, I was responsible for prescribing all of the medications that the patient was taking.  I had access to very good consultants, but had to do the initial treatment, medication reconciliation and adjustments as well as trying to address any new medical disorders. You certainly learn a lot of medicine and pharmacology in that setting, but on the other hand it is extremely time-consuming and with today's productivity demands - I would not recommend it. Nobody pays you for doing the job of two people, even though it is very efficient and patient-centered.  

The only major class of medication excluded from the table are acetylcholinesterase inhibitors ACHEIs) including donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne).  These medications are used in the treatment of Alzheimer's Disease along with the NMDA receptor antagonist memantine (Namenda).  Psychiatrists prescribe these medications and the only reason they were not included in the table is space and the fact it would have required major formatting changes. 

Watch this space for further updates.  I will date and post links to new updates in the space below with the dates that the update occurred. I will also post the table looking at drug interactions with medications used to treat atrial fibrillation in the previous post.

George Dawson, MD, DFAPA

Link to Updates:

I have received a fair number of emails requesting this document from GDRIVE.  This link seems to work for me and it is publicly available. If it does not work for you email me and I will send you the most recent document.

Medication Checklist 07.11.2021 Link 

Medication Checklist 07.11.2021 Link  (Corrects valproate/divalproex section)

Medication Checklist 07.11.2021 Link  (Corrects misspelling of Caplyta)

An Outstanding Paper on Atrial Fibrillation

 

I have been fascinated by atrial fibrillation since I was a third-year medical student. I was doing a Medicine rotation and examining a middle-aged man.  Listening to his heart sounds was the first time I heard the irregularly irregular heart rhythm characteristic of atrial fibrillation. It was such an outrageous and unexpected sound compared to what I was used to that I felt a little panicky. Why wasn’t this patient experiencing more symptoms and even more unexplainably – why doesn’t he sense that there is something wrong with his heart beat?  Since then, I have treated hundreds of patients with atrial fibrillation.  I ask them all if they can sense the irregular heart beat and in the people I see about half of them can.  Being a psychiatrist, diagnosing and treating atrial fibrillation is technically not my “job”.  But it is currently such a prevalent condition that a brief examination typically triggered by vital signs and noting a pulse irregularity followed by an electrocardiogram is all that is needed. Atrial fibrillation has considerable mortality and morbidity associated with the most feared complication of stroke. A good friend of mine developed renal failure from a combination of atrial fibrillation and atrial flutter and required ablation procedures to restore normal sinus rhythm.  Two relatives had strokes associated with atrial fibrillation resulting in disability and ultimately death. Both had atrial fibrillation for about 30 years.  One of them was 92 years old, using digoxin for rate control, and not on anticoagulants. The other was 92 years old, using diltiazem for rate control, and on warfarin at therapeutic doses. He had two strokes about 10 years apart on the warfarin and multiple episodes of nuisance bleeding or excessive bleeding from minor injuries due to anticoagulation that did not require medical attention.   Another friend had pulmonary complications from an antiarrhythmic drug that he was taking for a new onset of atrial fibrillation and died as a result of those complications. Sixteen years ago – I developed lone atrial fibrillation while speedskating and have been on antiarrhythmics since that time.

When you see all of those problems associated with a condition and have had it yourself, you tend to read more about it than the average person.  Reading about atrial fibrillation is generally a frustrating task. The evidence base for treating the condition seems to be in a state of flux. For years the research seemed to say that rate control and rhythm control led to equivalent outcomes. When life style measures were included, the rhythm control strategies seemed superior. Even the question of anticoagulation with novel oral anticoagulants of NOACs for stroke prevention based on a scoring system has been called into question recently.

That brings me to the topic of this blog post and that is the single best summary of information about atrial fibrillation that I have seen anywhere - at least for nonspecialists in that area.

The paper was written this year in the New England Journal of Medicine (1). It starts out with a case description of a 63-year-old man with a new onset of atrial fibrillation. The authors discuss the disease in detail and treatment recommendations consistent with their discussion. What I really like about this paper is that they are discussing phenotypes of atrial fibrillation and I do not see that happening very often in real clinical situations. The phenotypes they discuss are paroxysmal atrial fibrillation, persistent atrial fibrillation, and long-standing persistent atrial fibrillation.  They have an excellent figure in their paper that was unfortunately prohibitively expensive for me to try to post here, but the basic idea is that there are distinct anatomical and electrophysiological substrates for each of those phenotypes. In the paper the phenotypes are labeled as “clinical profiles”. His phenotypes have prognostic considerations since the authors make the point that there is a gradation in the likelihood of conversion to normal sinus rhythm and maintaining that rhythm with paroxysmal atrial fibrillation being the most likely to convert and maintain a normal sinus rhythm and long-standing persistent atrial fibrillation being the least likely to convert. Just knowing that much about atrial fibrillation is a significant advance compared with most of the clinical discussions that I hear.

The second feature in this paper that I really like is that atrial fibrillation is not necessarily a benign condition. For years the discussion has been controlling the rate or rhythm and in most cases they have been considered to be equivalent. Many clinicians have their first experience with atrial fibrillation like I had. They are doing a physical examination outpatient for another reason and they notice they are in atrial fibrillation. Depending on physiological factors that patients irregularly irregular heart rate may already be rate controlled. I have talked with many people over the years who knew that their heart rate was irregular because their spouse noticed it and they did not do anything about it for years. Atrial fibrillation is a risk factor for embolic strokes as well as dementia, death, and heart failure. Persistent tachycardia can cause cardiomyopathy and reduced cardiac output can lead to renal failure.  The authors suggest that a heart rate of 110 bpm or greater might lead to cardiomyopathy but they also suggest it can occur at a lower rate. This is an interesting observation because the most recent review in UpToDate on sinus tachycardia suggests it is generally a benign condition, however an irregular tachycardia because of reduced cardiac output is likely a different matter.

In addition, the patient can be symptomatic from reduce cardiac output with lightheadedness, dizziness, fatigue, decreased exercise tolerance, palpitations, hypertension, and an exacerbation of symptoms of underlying coronary artery disease. The lesson for psychiatrists is if you notice that a patient has atrial fibrillation it cannot be approached casually. Atrial fibrillation is associated with significant medical comorbidities such as underlying structural coronary disease, obesity, sleep apnea, hypertension, hyperlipidemia, and diabetes mellitus. If the patient has had limited contact with primary care physicians the comorbid conditions may have gone unnoticed. It makes sense to ask about additional symptoms in the review of systems as well as family history and whether that patient is seen primary care physician or cardiologist recently.  I would have no problem referring a patient with tachycardia, expected symptoms, or risk factors to an emergency department for acute stabilization if I could not get them seen in a primary care clinic.

The authors go into treatment of atrial fibrillation as basically a rate control strategy, a rhythm control strategy, and a strategy to address comorbid medical conditions.  They review rate control with beta-blockers and calcium channel blockers and prefer beta-blockers. They consider a number of antiarrhythmics and the risks and benefits of those medications.  They consider catheter ablation - either radiofrequency pulmonary vein isolation or cryoablation as being more effective for treating and preventing recurrent atrial fibrillation. The recurrence rates are relatively high even after the ablation procedures, so continued antiarrhythmic medications may be necessary.

Once a patient has stable treated atrial fibrillation, the main task for the psychiatrist is to make sure that any prescribed medications do not interfere with the cardiac medications at either the pharmacokinetic or pharmacodynamic level. QTc prolongation is a primary consideration since several of the agents used prolong the QTc interval or affect other cardiac conduction.  At the pharmacokinetic level there is the possible risk of decreased metabolism of beta-blockers and increasing bradycardia and hypotension. If I have any doubts all about medication combinations I am usually in touch with the patient’s cardiologist or primary care physician before making those changes. All of the patients I see with atrial fibrillation also have their blood pressure and pulse taken at every visit along with the description of symptoms and potential medication side effects. That means I never practice in an environment where I can't do that. I will also review how well their comorbid conditions are being treated particularly hypertension, sleep apnea, and diabetes mellitus. I will provide them with concrete advice on how to approach those problems and whether or not they need to be seeing their primary care physician sooner than scheduled.

This is also an opportunity to discuss any comorbid substance use problems. Alcohol is a definite precipitant of atrial fibrillation. I have had patients never experience another episode by stopping alcohol. I have also had patients report that they can tell when their alcohol level reaches a certain point because they will go into atrial fibrillation for several hours until that alcohol is metabolized. Stimulant medications are also a risk because they increase sympathetic tone, increase heart rate, increase blood pressure. All three of those changes can trigger an episode of atrial fibrillation.  Cannabis can have a fairly potent sympathomimetic effect by acutely lowering blood pressure leading to a reflex tachycardia. Atrial fibrillation has been reported as one of several cardiac arrhythmias associated with cannabis use (2). Interestingly, the authors of the NEJM article state that caffeine is not a precipitant. There are no qualifiers on that statement and I think it is based primarily on epidemiological evidence. Caffeine intake is always important to quantify because of its wide variability across the population and general reputation of being a benign compound. There are segments of the population that consume large quantities of caffeinated beverages every day and experience the expected side effects of anxiety (in some cases panic attacks), agitation, insomnia, and hyperadrenergic effects but they seem unaware that these symptoms are related to their caffeine consumption. Certainly consumption at that level can directly or indirectly precipitate an episode of atrial fibrillation.

That is my brief review of the NEJM article in atrial fibrillation. I encourage all psychiatrists to get a copy of this paper, read it, and keep it for reference. I am not suggesting that psychiatrists treat this condition.  I am suggesting that they recognize it - even if it has not been diagnosed and know what to do when that occurs. The reality is that in adult psychiatry no matter what your practice setting there will be a significant number of people with atrial fibrillation and other arrhythmias as well as all of the known comorbidities. You cannot treat those people unless you know about these conditions, the comorbidities, and how to avoid complications.

 George Dawson, MD, DFAPA

 

References:

1:  Michaud GF, Stevenson WG. Atrial Fibrillation. N Engl J Med. 2021 Jan 28;384(4):353-361. doi: 10.1056/NEJMcp2023658. PMID: 33503344.

2:  Richards JR, Blohm E, Toles KA, Jarman AF, Ely DF, Elder JW. The association of cannabis use and cardiac dysrhythmias: a systematic review. Clin Toxicol (Phila). 2020 Sep;58(9):861-869. doi: 10.1080/15563650.2020.1743847. Epub 2020 Apr 8. PMID: 32267189.

Supplementary:

Common and uncommon medications listed in this article used in atrial fibrillation for rate control, antiarrhythmic properties, and anticoagulation.  I added additional warnings and general type of medications that might require avoiding based on pharmacokinetic or pharmacodynamic considerations. Important to keep in mind that all medications vary in their ability to affect these mechanisms as well as therapeutic mechanisms. That includes significant differences between medications in the same class. That leads to qualifiers like "all possible mechanisms leading to complications or serious adverse effects may not be listed" (in this package insert or computerized drug interaction program). Almost every time I am seeing a patient on these medications - it requires a study of the medication combination, even if they are taking a psychiatric medication that appears to be working. Baseline cardiac symptoms related to the arrhythmia also need to be established as well as the patient's plan to obtain assistance if they worsen.

Additional qualifier (if it is not obvious). Psychiatrists prescribe beta blockers (metoprolol, propranolol, pindolol, etc). Psychiatrists can diagnose atrial fibrillation. Psychiatrists do not manage atrial fibrillation but need to know what to do acutely and how to avoid complications of the following medical therapies from drug interactions with psychiatric medications. Practically all of the antiarrhythmics in the following table are prescribed by Cardiologists and subsequently managed by primary care physicians although many patients continue to see Cardiologists in follow up. Like all areas of medicine the limits of technical expertise need to be recognized.  I worked with Cardiologists who became psychiatrists and they restricted their practice to medications prescribed by psychiatrists.  

Graphics Credit:

Bunch TJ, Cutler MJ. Is pulmonary vein isolation still the cornerstone in atrial fibrillation ablation? J Thorac Dis 2015;7(2):132-141. doi: 10.3978/j.issn.2072-1439.2014.12.46

Open Access per this Creative Commons License: https://creativecommons.org/licenses/by-nc-nd/4.0/