ADHD - 28 Discussion Points

 

There was some of the usual controversy in the media today.  Is Attention Deficit~Hyperactivity Disorder over diagnosed or underdiagnosed?  The usual controversy contained the usual stories of how easy it is to get a diagnosis of ADHD in some places.  In some places it seems like just a matter of expense - a thousand dollar test battery. In other places there are people disabled by the condition who cannot get adequate treatment.  In the meantime there are international experts cranking out reams of papers on the importance of diagnosing and treating this condition in childhood. Occasionally an article shows up in the papiers about the cardiovascular safety of these medications. And in the New England Journal of Medicine there was a paper about a higher incidence of psychosis due to these medications.  Where does the reality lie?

I was fortunate enough to have worked at a substance use treatment center for about 12 years just prior to retiring. Only adults were treated at that facility. A significant number of them were diagnosed and treated as children. There were also a significant number of patients newly diagnosed as adults - some as old adults in their 60s and 70s. Whether or not ADHD can occur as a new diagnosis during adulthood is controversial and establishing a history consistent with childhood ADHD is problematic due to recall errors and biases. Secondary causes of ADHD in adults such as substance use problems and brain injuries increases in prevalence.  Although I am speculating, secondary causes seem a more likely cause of attentional symptoms in adults and therefore acquired ADHD without childhood ADHD if it does exist is an entirely different problem.

Prescribing stimulants to patients who may have stimulant use disorders is problematic for a number of reasons. Initially we had an administrative safeguard on the practice. Stimulant prescriptions could only be approved with a second opinion by another psychiatrist after reviewing the record. Eventually we had a core of psychiatrists who practiced the same way and the second opinion was no longer necessary.  Over the course of 12 years I developed these discussion points.  I think they are a good example of the minimum ground you need to cover in an evaluation for ADHD.  I typically had a 60-90 minute time frame to work with and could see people on a weekly basis for 30 minute follow ups. These evaluations were often controversial and resulted in collateral contacts, typically with a family member who was advocating for the stimulant prescription. 

A few basic points about ADHD and establishing the diagnosis. Like many psychiatric disorders there is no gold standard test.  Like some of the media discussions, I have been told that a person underwent days of testing before they were given the diagnosis of ADHD.  These are typical paper and pencil tests, but there have also been tests based on watching a computer screen and even crude EEG recordings. There are a few places that use very sophisticated brain imaging techniques. Unfortunately none of these methods can predict a clear diagnosis or safe and effective use of a medication that can reinforce its own use.  That leaves clinicians with diagnostic criteria and and a cut off based on functional status as a result of those symptoms.  That may not sound like much, but it eliminates a large pool of prospective ADHD patients who have no degree of impairment and those who are obviously interested in possible performance enhancement rather than ADHD treatment.  

Stimulant medications are highly abusable, as evidenced by several epidemics of use dating as far back as 1929. We are in the midst of a current epidemic.  For those reasons it is important not to add to the problem as either the individual or population levels. In my particular case, I was seeing patients who were all carefully screening for substance use and adequate toxicological screening. Since they voluntarily admitted themselves into a treatment center it was also more likely that they recognized the severity of the problem and were more open to treatment.  Even against that background - it is worth covering the above points.  Covering those points often involves repetition because of cognitive problems in detox or disagreement.

These are just a few health and safety considerations. My main concern in this area is that psychiatric treatments somehow have the reputation that they don't require medical attention. They are somehow isolated from the rest of the body. The person prescribing this medication needs to assess the total health status of the individual and determine if the medication prescribed is safe to use. Cardiac and neurological conditions are at the top of that list. I gave a blood pressure example because I have been impressed with how many people tell me that their blood pressure was not checked after a stimulant prescription or a stimulant was started despite diagnoses of uncontrolled hypertension, cardiovascular disease, cardiac arrhythmias or cerebrovascular disease.  These were typically new prescriptions in older adults with no prior history of ADHD.  

Coexisting psychiatric disorders are also problematic. Most have associated cognitive symptoms if they are inadequately treated. That is not a reason to diagnose ADHD or start a stimulant medication.  Typical symptoms that can be caused by stimulants are have to be recognized and the medication must be stopped if adjusting the dose is not helpful.

It is important to keep the range of biological heterogeneity in mind. Once you have narrowed down a population of people who most likely have ADHD, they will not all have a uniform response to medication.  They may not all want to take medication.  As adults many stopped taking ADHD medication and adapted to a work and lifestyle that works very well for them. That is a very suitable outcome for an initial assessment.  There is another group who want to try a verbal therapy for ADHD in some cases because they recognize they can no longer take stimulants because they were escalating the dose. That is also a suitable outcome for the assessment. In those people who have ADHD are want to take a medication, I think a non-stimulant medication like atomoxetine is a good place to start. In my experience it works very well.  Disagreement about stimulants, especially in people with a stimulant use disorder typically requires extended conversations with the patient and their family. A quality control initiative can provide very useful data for that conversation. I suggest that any clinic or clinician who prescribes stimulants collect outcome data on those prescriptions.  The key piece of data is a comparison of the relapse rate of those patients taking stimulants compared with patients treated with non-stimulants. Other data could be collected as well - like how long the prescriptions were refilled. There are rules about collecting that data depending on your practice setting.  Check those rules first.  Outcome data will be the best data on whether a correct decision was made about prescribing the stimulant.

I added the following slide based on polypharmacy considerations in the paper cited in reference 1.  This is a common clinical problem that needs to be approached rationally and that includes limit setting on the concept that every side effect or symptom needs to be addressed by a medication rather than a medication discontinuation, reduction, or substitution.  I always include a discussion of rare but serious side effects, synergistic side effects, drug interactions, interactions with comorbid medical problems and associated medications, and very serious interactions that could lead to hospitalization or death, like serotonin syndrome. 

I am going to end on a note about countertransference based on a disagreement I had at a conference about my methods. The speaker advocated for prescribing stimulants as a general operating practice for anyone with ADHD. When I confronted him about the problem of substance use he claimed his motivation was that he considered it his priority to "help" people and he thought that stimulants were the most helpful medication.

Whether or not a medication is helpful for any psychiatric disorder depends on a very careful assessment and clinical expertise that considers several dimensions including the potential risks and benefits for the patient and the incorporation of the patient preferences and values into the clinical decision making process.  In my evaluations, I try to sum all of that up in an informed consent discussion. In the area of ADHD evaluation and treatment, that covers a lot of ground and there is no simple uniform recommendation.

George Dawson, MD, DFAPA

Photo Credit:  Many thanks to my colleague Eduardo A. Colon, MD for allowing me to use his photos. 

The Semi-Random Pathway To A Psychiatrist

 

Mischaracterizations about how people come to see psychiatrists are an ongoing phenomenon in the media. It is one of many false premises used to build the idea that there is a monolithic psychiatry out there that is really an evil empire. That stands in contrast to psychiatrists going to work every day and seeing a full schedule of patients that was compiled without their knowledge or input. I will try to explain what really happens in this post.  My explanation is complicated by very little research done on this topic.

In my experience and the experience of the colleagues I have worked with, it is rare for a person with mental health problems to be seen by a psychiatrist without previously having seen another physician or mental health professional. That is true for both emergent and elective situations.  It follows that those patients have also been treated with medications and psychotherapy, often many different medications from different classes and different forms of psychotherapy.  The period of treatment before seeing a psychiatrist is typically quite long. As an example, in my last job as a consultant at a large substance use treatment facility – I was seeing people in their 30s and 40s who had an onset of a psychiatric disorder in their teenage years, gone through various treatments, and were seeing me as the first psychiatrist they had seen in their life. That could have been as long as 5-6 years of illness onset with no treatment followed by another 10-20 years of ineffective or sporadic treatment.

This is a hard problem to delineate because of all the factors involved. There may be a preference to not see a psychiatrist because of the connotation that psychiatry is equated with a more serious illness or the misconceptions about psychiatry that are actively promulgated by special interests. In some cases, primary care physicians consider themselves to be the right person to manage anxiety or depression.  The recent collaborative care initiative and physician rather than patient-based consultation may reinforce that idea. I have seen patients who were in treatment with every possible alternative medicine practitioner and getting treatments that could either not possibly help them or in some cases were detrimental. Some of my patients were in cults who claimed to be helping them until they were rescued by family members and brought to psychiatric treatment. Self help is a popular approach and some of it is very good but in other cases it can also be detrimental.  When bibliotherapy is used, the advice often includes instructions on sleep, diet, and exercise.  Many people resort to self-diagnosis and self-medication. Supplements are generally expensive and ineffective. Alcohol, stimulants, cannabis, benzodiazepines, psychedelics, and other intoxicants are uniformly ineffective and often amplify the original problem or create new problems.

In some cases, the person already has a very healthy lifestyle and given popular recommendations it is tempting to just amplify the health factors.  More protein, more sleep, and more exercise. It is very doubtful that any of those factors alone or in combination will address a serious mental health diagnosis.  I have treated world class athletes in the top 1% of all exercisers who got no relief at all from exercise.

Insurance limitations and rationing has been a significant factor in the last 40 years. A study done showed that referrals from managed care companies seldom result in real appointments with psychiatrists – in many cases because the insurance company claims that psychiatrists are in their network when they are not.  These are ghost networks or phantom panels (1).

Practice setting is also an important factor. During my 22 years of acute inpatient care – all of the people I saw were either taken to the emergency department or presented there themselves.  Most were untreated for years.  Some were overtreated with medication combinations and were seeing me because of side effects. It was more likely they had seen a psychiatrist because we had an outpatient department and our colleagues’ patients were hospitalized, but reviewing those histories it was clear they had been untreated for years before being seen in the outpatient department.

I first learned about the importance of the pathway to physician care in medical school.  When you first start seeing patients, there is an excessive focus on the form of the medical evaluation rather than the phenomenology. In other words – you want to carefully document all the history, symptoms, and findings that lead to a diagnosis and treatment plan. You are under the mistaken assumption that is all there is to being a physician.  At least until your first attending asks: “Well – what is the reason this patient sought treatment at this time? Why did they decide to come into the emergency room right now?”  At that point you start to realize that there are not a set number of pathways to care and patient presentations – there are millions.  Your job is to describe that unique pathway for every individual patient that you see – no matter what the problem is.

The pathway to psychiatric care in the United States is semi-random. People rarely make a conscious decision to see a particular psychiatrist and then see that person. At some level psychiatrists are the treatment providers of last resort and you are likely to see one in an emergency that you never planned or when another treatment provider tells you that it might be a good idea.  It is likely that a lot of disability and distress occurs in the meantime, along with a lot of bad advice. I think it is reasonable to try self help and other qualified mental health professionals first.  But if you are not seeing any good results – I would not let it go on for too long.  Like most things – if what you read in the papers about how a certain treatment for your problem seems too good – it probably is.

George Dawson, MD, DFAPA

Supplementary 1: 

Here is a post from about a year ago on involuntary treatment.  Look at the diagrams to see the number of personnel and steps involved in the process - apart from the psychiatrist. In a hospital setting - activating the civil commitment process typically occurs when an emergency department doctor or hospitalist places the person on an emergency hold.  In some states only police officers can initiate an emergency hold and in others any interested person.  An entire series of decisions not made by any psychiatrist determines if that person is eventually held or released.

Supplementary 2:

This is a graphic that I made from another application showing some alternate pathways to psychiatric treatment.  In almost all cases there is no psychiatric contact until the tier of treatments designated by white and green rectangles and possibly in the team approaches.

References:

1:  Malowney M, Keltz S, Fischer D, Boyd JW. Availability of outpatient care from psychiatrists: a simulated-patient study in three U.S. cities. Psychiatr Serv. 2015 Jan 1;66(1):94-6. doi: 10.1176/appi.ps.201400051. Epub 2014 Oct 31. PMID: 25322445.

 

Everything You Wanted To Know About Psychiatry In 30 minutes or Less....

 

It has been a week since I gave a presentation to the Philolectian Society in Anoka, Minnesota.  The Philolectians are primarily retired educators and their colleagues who decided they wanted to promote education in their county. They do this by topical discussions on a monthly basis and fund raising for scholarships that they award to high school students.  They were founded 134 years ago.  I gave them a presentation on substance use disorders about 5 years ago – but my current presentation was entitled “Everything You Wanted To Know About Psychiatry In 30 Minutes of Less.”  It was the mile high view – but that is the one that is typically lacking in American culture.

The venue was a sports bar conference room in an old building. There was no projection equipment and it had spotty WiFi coverage so I decided I should test it out ahead of time. I opted to use a Chromecast device to the television HDMI port – but did not realize at the time that it does require WiFi in order to work.  Connection to my home TVs was not a problem but there is continuous WiFi as the background.  Failing the Chromecast, I was given an LED projector that also required WiFi. I ended up printing out hand outs for the attendees. The 12 slides follow and total time was about 45 minutes – 30 minutes of presentation and a 15 minute Q & A.  My presentation style is to focus on slide design.  For that reason I avoid the standard templates and try to cover as much of the slide with graphics as possible when they are used.  My second overall principle is to free associate to the slides and never read them. They are there to keep me on track.  What I actually end up saying varies considerably from lecture to lecture – modifiable by various factors including what the group has indicated what they want to hear, what I have been thinking about that day, and what I have been reding that week. The process is like Frank Zappa described his guitar playing. Every live performance is unique – no set of notes is identical.  I can’t claim mastering lectures like he mastered the guitar but there is some creative process involved in lecturing.

The title slide uses a background of abstract art taken off of one of my paintings at home. The artist is Stephen Capiz.  It represents a very small area of a larger abstract painting with the tile information superimposed. The title was chosen to keep the atmosphere casual. I wanted people to be comfortable that this was not a presentation to mental health professionals but to a general audience.

Slide number 2 is a critical three - fold message that is frequently missed or distorted.  Psychiatric disorders have been observed and discussed since ancient times.  That means they are easily recognizable to people with no training. It means that they are real and can’t be explained away.  You must be incredibly naïve or sheltered to not have that experience.  Psychiatrists only exist because they were the doctors interested in treating these disorders. That is as true today as it was in the 18^th and 19^th century.  The only difference is that modern psychiatrists have uniform training. And finally as you would expect, the diagnostic system has undergone successive refinement over the centuries.  The DSM is used as an example here but the ICD could be used as well. (with all slides click on them to expand and get a better quality graphic - this is apparently an artifact of the blogger format).

 

Slide 3  provides a little more detail on the evolution of the DSM systems. Counting the total diagnoses is always a point for rhetorical digressions.  I finally figured out how to do it and listed my specific technique in this post.  To a professional audience, I might include studies on how many of the diagnoses are actually used.  This audience did not find any of this controversial.

Slide 4 is a great timeline of how psychiatry developed from a discipline that Kendler refers to as protopsychiatry to the modern era starting in about 1920 in the US and about 40 years earlier in Europe.  The audience was extremely interested in the low percentage of physicians attending medical schools in 1900 and that lectures could be attended by purchasing tickets. The transition from asylum doctors with no particular training to psychiatrists was also a focal point.

Slide 5 was necessary because there is still a lot of emphasis on Freud. I remembered that Freud was an important figure to my college English professors and that some of the teachers in the audience were about that age. I emphasized that Freud was an important figure in psychoanalysis, but that there were many European psychiatrists that provided knowledge, literature, and training to their American counterparts and that many were self-taught and active across the fields of psychiatry, neurology, neuropathology, and neuropsychiatry.

Slide 6 is a very brief outline of the basic educational milestones of the various mental health disciplines.  Minnesota has a confusing array of designations including unlicensed mental health practitioners so I kept it simple.  In the previous slide on the psychiatry timeline I did mention how in the early 20^th century most practitioners considered themselves neuropsychiatrists and practiced both neurology and psychiatry. When the American board of Psychiatry and Neurology informed practitioners that they would need to take board exams in both psychiatry and neurology the era of separate specialties was begun.

Slide 7 is one of my favorite graphics.  It is produced from the current educational requirements for residency training and Melissa Farmer, PhD greatly assisted me with the graphic design. My overall emphasis was to point out how these training requirements should result in a physician who is not only an expert in diagnosis, but also interviewing, maintaining relationships over time, and capable of therapeutic discussions.

Slide 8 attempts to capture the pattern matching aspects of psychiatric practice and why training and experience are necessary.  It illustrates how previous exposure to various diagnostic and therapeutic elements can lead to problem recognition and resolution.

Slide 9 is a rough sketch of the diagnostic process and how it has to be adapted to the situation.  I provided several examples of referrals that I saw as referrals who needed immediate emergency medical attention.  We discussed how that can occur.

Slide 10 is a list of psychiatric subspeciality care.

Slide 11 is an explanation of the current workforce and how the practice environment has deteriorated over the past 40 years. I emphasized rationing as the main problem and several audience members were aware of the shortage of psychiatric beds and state hospital closures.  The city of Anoka has one of the few remaining state hospitals – Anoka Metro Regional Treatment Center. In the future if I am projecting - this slide would be split to 2 separate slides. 

Slide 12 – I had to leave the audience with a reason why they are exposed to antipsychiatry rhetoric and discussed the basis for it, the special interests involved, and in most cases - the lack of any basis in reality.

The presentation went very well. There was additional interest in the medical and psychiatric effects of the pandemic.  Several audience members were interested in my opinions about the Department of Human Services in Minnesota and how they factor into the current rationed system of care. I am currently expanding some of the graphics in case there is any additional interest and as an outline for some of my other writing.

 

George Dawson, MD, DFAPA

A Confluence of Factors - Why There Is No Functional System of Care for Severe Mental Illnesses

 

 This post was stimulated by a confluence of factors.  I had no real concerns about what I would do in retirement and it seems that I have as much to think about as I did when I was working.  The factors included:

1.  A post by one of my esteemed colleagues on Twitter – Emily Deans, MD.  I have never met Dr. Deans and know her work primarily through her blog, Substack, and Twitter posts.  I cannot recall ever disagreeing with her.  Today she began a thread with: “The US allows people with terrible brain illnesses to languish on the streets and get murdered on the subway.”  She built upon that theme.

2.  I was working on a presentation for Friday May 5 on “Everything You Wanted To Know About Psychiatry in 30 Minutes or Less.”  That got me into a historical frame of mind.

3.  I had the occasion to pick up my copy of Sylvia Nassar’s biography of John Nash “A Beautiful Mind” and reread the description of his civil commitment to a state hospital where he received insulin shock treatments at age 33.

4.  During my work on the presentation I suddenly got the bright idea to create a couple of new timeline graphics – one of which was about European influences on American psychiatry (protopsychiatrists, transitional self-taught psychiatrists, and psychiatrists) and that led to thinking about the current state of psychiatric affairs in the United States.

That all came together to produce the following paragraphs that I have discussed here before but seems reinforced by the current confluence of information.

Psychiatric care in the US is abysmal and it is not due to the lack of bright and highly motivated psychiatrists.  It is due to a lack of access.  It is possible to find those psychiatrists and get treatment but good luck with that.  Dr. Deans is correct that people are currently dying due to the lack of humane laws to treat people with severe mental illnesses. In many jurisdictions those laws are interpreted in the context of the lack of resources.  In other words if there are no facilities available, legal action is dropped. That problem lies squarely on several entities that are far outside of psychiatry. The problem is so chronic it is hard to prioritize which of these entities came first and is the worst (although I have provided a few timelines). Let me take them point by point as they come to mind.

The antipsychiatry movement needs to finally get credit for its destructive nature. Psychiatrists tend to respond either by ignoring them and hoping they will go away or by wasting their time trying to argue against their repetitive rhetoric.  The pandemic and the last election highlighted the use of misinformation in social media. The antipsychiatry movement are experts in misinformation and they have been using the same tactics for the past 50 years.  Part of those tactics include getting their rhetoric and opinions in the mainstream psychiatric literature. In 1986, Martin Roth and Jerome Kroll had the following observation:

“We have argued in this section that the concept of mental illness has definable boundaries and that medical forms of care are appropriate and efficacious only in circumscribable portions of those who present a danger to society. But recent trends if allowed to continue, can only culminate in a society in which prisons again contain a large portion of those who suffer from mental illness because there is no appropriate or alternate form of care or accommodation for them. If such a situation should materialize, the distinction between prison and hospital will become once again blurred and obliterated like it was 133 years ago when Bucknill held out optimistic hopes of a new era in which science and humanity would jointly seek to surmount the problems presented by morbid mental suffering. The hard-won and remarkable progress achieved by psychiatry during the past half century in particular, will then have been set into reverse.” (p. 114).

There has not been a more prophetic statement in the field.  The largest psychiatric hospitals in the United States are currently county jails. The state hospital systems that were in some cases flagships for treatment of people with severe mental illnesses are no longer functional and exist at the margins to alleviate pressure on community hospitals to accept involuntary patients.  It is more of a blockade than a bottleneck since the latter would suggest movement once the obstacles have been passed.  There is no movement and the association of state mental health directors has made it very clear they are not interested in movement.

The basic paradox of the system is that the necessary infrastructure necessary to treat even average numbers of persons with severe mental illnesses and those who are under civil commitment is not there.  It is atrophied or rotten and there has been no wide sustained effort to improve it since The Community Mental Health Act of 1963. Even though the Mental Health Parity and Addiction Equity Act (MHPAEA) was passed in 2008 – it is clear to anyone working in the field that there is no enforcement to ensure mental health parity or adequate substance use treatment. The healthcare industry has sent a clear message that it takes more than a law on the books – it takes concerted and very expensive legal action.  In the past some activist attorney generals had some success – but there are not many of them around anymore.

It is not hard to imagine how a fragmented system of care has withered during a time of continuous antipsychiatry rhetoric.  Money is always cited as a limiting factor, but the amount of money especially compared with the ballooning number of administrators at the state and health plan levels does not seem great. State hospitals and departments of human services seem to run on a managed care rationing model rather than a model focused on helping the most vulnerable citizens. It is not a coincidence that both antipsychiatry and business rationing for profit both depend on Libertarian values – the most basic being “you are only worthwhile if you are living what I determine to be a worthwhile life.”  That same value system criminalizes aggression and violence secondary to mental illness and sees incarceration as the only beneficial outcome. That is consistent with the current model of county jails as psychiatric hospitals that do not deliver any psychiatric care.

That brings me to the Nash biography. He was hospitalized in about 1961 at Trenton State Hospital.  According to Harcourt’s graphs of deinstitutionalization – this was the beginning of a time of rapid decline in mental hospitalization rates that has continued unabated to the present time. Trenton was overwhelmed by the large number of patients seeking help there – 4,000 after World War II dropping and then rising again in the 1960s to about 2,500 when Nash was there. Psychiatrist staffing ratios varied from 1:100 patients in the acute ward to 1:500 patients in the chronic ward.  Length of stay for most patients was about 3 months. Rationing clearly existed even before deinstitutionalization. One of the psychiatrists who worked there described the environment as “crummy.”  In terms of personal relationships with patients – it could be expected to be rare with those staffing ratios.  Nasar describes the hospital as “overcrowded, underfunded, and understaffed.”

Figure 1. Rates of Institutionalization in Mental Institutions and State and Federal Prisons (per 100,00 adults) from the paper by Bernard E. Harcourt, " REDUCING MASS INCARCERATION: LESSONS FROM THE DEINSTITUTIONALIZATION OF MENTAL HOSPITALS IN THE 1960s," 9 Ohio St. J. Crim. L. 53 (2011), available at: https://scholarship.law.columbia.edu/faculty_scholarship/639

The exception noted was the insulin unit.  Apparently, Nash was recommended to go to this hospital because it had this modality.  It was a 44-bed unit – half men and half women in separate wards. Patients on that unit received special diets and special recreation.  That is where Nash got insulin treatments 5 days a week for the next 6 weeks. Nash later described the agony of these treatments in detail including what may have been long tern effects on his dietary pattern.  In retrospect, the question is whether it was necessary or not.

Manfred Sakel had discovered insulin shock treatments (IST) in 1935 by accidentally administering too much insulin to a patient with morphine addiction resulting in seizures and a coma.  The patient awoke with more mental clarity.  That led to further trials and wider application. Nassar suggests that by 1960, IST had been phased out in most hospitals and replaced with electroconvulsive therapy (ECT).  Max Fink did a direct study of chlorpromazine versus IST in 1958 (2) and noted that the results clearly favored chlorpromazine.  That resulted in the IST unit at his hospital closing within 6 months (3). Even though Nash had not been able to work for the previous 3 years he was widely regarded and his intelligence was described as a national security asset. As he was recovering, he started a paper on fluid dynamics while he was at Trenton that he subsequently finished and published in 1962 French mathematical journal. He was awarded the Noble Prize in economics for game theory in 1994. His original two page paper at age 22, was part of the basis for the Nobel determination (5,6).    

Nash’s tenure at Trenton is a good example of rationing prior to managed care. The rationing resulted in both the abysmal conditions and a lack of state-of-the-art care. Some might say that you can’t argue with results.  Nash recovered and was able to go back to research and publishing in mathematics, despite his dissatisfaction with treatment.  Later in his biography he was treated with a number of second generation antipsychotic medications that were described as helping him stay out of the hospital but  “have not given him a life.”

That brings me back to Dr. Dean’s comment at the top of this post. We have people with severe mental illness dying on the streets. A small number become aggressive and violent, but a much greater number are victims of violence and exploitation. They do not have stable living situations and there are associated problems with substance use disorders. This is a gross level of neglect compared with way other healthcare problems are addressed requiring more resources than psychiatric care. About 1 in 300 people get retinal detachments during their lifetime. In any mid-sized city in the United States access to state-of-the-art retinal care is not a problem. The same thing is true for orthopedics, gastroenterology, and cardiology. Psychiatric care is fragmented across private pay systems, public pay systems, and managed care systems.  The last two are managed by large bodies of administrators that are focused on rationing rather than an adequate system of care. In many ways, the landscape of psychiatric care is approached with the same level of recklessness as firearms. We all have to pretend that something useful can never be done and therefore maintain the status quo.

 

George Dawson, MD, DFAPA

 

References:

1:  Roth M, Kroll J.  The Reality of Mental Illness.  Cambridge University Press. Cambridge, England 1986: 82-144.

2:  Fink M, Shaw R, Gross GE, Coleman FS. Comparative study of chlorpromazine and insulin coma in therapy of psychosis. J Am Med Assoc. 1958 Apr 12;166(15):1846-50. doi: 10.1001/jama.1958.02990150042009. PMID: 13525160.

3:  Fink M. Meduna and the origins of convulsive therapy. Am J Psychiatry. 1984 Sep;141(9):1034-41. doi: 10.1176/ajp.141.9.1034. PMID: 6147103.

4:  John F. Nash Jr. – Facts. NobelPrize.org. Nobel Prize Outreach AB 2023. Sun. 7 May 2023. https://www.nobelprize.org/prizes/economic-sciences/1994/nash/facts/

5:  Holt CA, Roth AE.  The Nash equilibrium: A perspective.  PNAS. 2004; 101 (12) 3999-4002.  https://www.pnas.org/doi/10.1073/pnas.0308738101

6:  Nash Jr JF. Equilibrium points in n-person games. PNAS. 1950 Jan;36(1):48-9. https://www.pnas.org/doi/full/10.1073/pnas.36.1.48

Graphic Credit:

I took this photo of the Rum River Dam in Anoka, MN about 30 minutes after I gave my presentation on May 5, 2023.  Anoka happens to be where the Anoka Metro Regional Treatment Center is located.  It is the last state mental hospital in Minnesota.  Since 1978 Minnesota has closed 10 of its 11 state hospitals and only AMRTC remains.  There have opened 6 - 16 bed units called  Community Behavioral Health Hospitals that have reduced capacity and apparently do not accept referrals from major metropolitan hospitals. https://mn.gov/dhs/people-we-serve/adults/services/direct-care-treatment/programs-services/community-behavioral-health-hospitals/

Medical Library Access - Revisited

 

It has been 2 years since I posted about the problems with medical library access if you are not faculty or adjunct faculty at your state medical school.  In that previous post I detailed all of the considerations and you can review them in that post. Several of us lost access during some turmoil at the University and my understanding is that we were taken off the necessary status by an interim department head who was not a psychiatrist.  My basic argument is that every physician in the state needs access for quality care purposes and if the medical school was no longer willing to provide that access, I would be happy to purchase it.  I was given a quote of $1,000 per year and let everyone who needed to know that I was willing to pay it. No response from anyone.

Since that original post, I contacted my state representatives. I got the usual “I agree with you and will look into it and get back to you.” But nothing beyond that. Nobody got back to me. Despite a good response from a post to the original nothing else happened.

I joined the University of Minnesota Alumni Association because I was told that would allow some access to the online library but nobody could tell me how much access I would have to the Health Sciences Library (formerly known as the Biomedical Library). I ended up with no access to anything.  Even though I clearly met alumni criteria nobody was ever able to send me what I needed for access.

While all of this was going on – I had to get access where I could. That typically involves an initial Google Scholar search looking for links to full text access in that format. A major online resource that was linked to Google Scholar removed that access last year. The links remained for a while but it was apparent you needed a subscription to access them and it was impossible to apply without a university affiliation. If Google Scholar fails I check Medline (PubMed) to see if full text is available.  Failing that I will go to Research Gate to see if full access is available there. When that does not work I will send an email to the corresponding researcher either on Research Gate or directly to an email address listed in the original paper. I have paid the charge for paywalled research only once, but I did subscribe to the Nature journals package for $30/month. So add $360/year to my previous total for journals access. It is not unusual to find out that you don't really have access to all of the Nature journals that you need. 

Many colleagues with medical library access from across the country volunteered to send me the articles I wanted for whatever I was researching at the time. I am very grateful for those offers – but the practical issue is the amount of reading I do.  It is impractical to ask anyone to provide that level of access unless they are being paid to do it.  The other issue is legality. Every library originated paper even in the electronic format – comes with a legal statement about copyright laws and something to the effect that I am the only end user and it will not be posted in an electronic format or shared with anyone else.  

I also tried county libraries to see if I could get access to medical journals.  Two years ago I applied – and went to their online site and there was nothing.  This year I reapplied for a library card and this time it was linked to a metropolitan county library with digital access to journals. There is a lengthy request form for every article accessed and that form times out quickly and erases all of the data that you entered.  If you can get past that point and the journal is in their database  – you can get a PDF of the requested paper. The turnaround time is 2-3 days and the barriers are such that it keeps the levels of requests low. So far, in the past 6 months I have requested and received about 10 papers.  I am hoping some day that they streamline the process.

That has been the battle for access to technical information on medicine and psychiatry. The county library access was a pleasant upside. The University’s Heath Science Library still looms large. I think the notion of a large taxpayer funded library for health sciences students and trainees that is only available to them when they are students, trainees, or faculty is an antiquated idea. Physicians are trained in lifelong learning.  To accomplish that goal – lifelong access to information is needed. Access is currently given to adjunct uncompensated faculty as a perk and that may be the real reason for not allowing a physician to pay for access. In other words it is a business management strategy. If access is controlled - the service becomes more valuable and it seems like uncompensated adjunct faculty are really getting something for their time.  I doubt that there would be a tremendous increase in utilizing the services even if they were free. It would be much more efficient because it would not require library staff somewhere – to read and decipher all of the requests when the physician could just find the journal and get exactly what they need. If you are reading this from a state other than Minnesota – I am very interested in hearing how you access the medical literature online if you are not medical school staff and do not have a subscription to the journal you want to access.

In the meanwhile – I will keep plugging away at my work arounds.

George Dawson, MD, DFAPA

Success Rates In Psychiatry

 

Today's comment is on a brief editorial in JAMA Psychiatry about the evidence of success of psychiatric treatments (1). The authors present an even handed argument for establishing systems that would allow for the determination of success rates of psychiatric care. They point out the obvious limitations of developing these systems in the United States but may not have gone far enough. In the US - our healthcare data is considered proprietary by the health care company who owns the electronic medical record that the data is recorded in. Patients often find themselves in varying negotiations in order to get access to their own records. They may find some data is not accessible at all. If they venture into another system of care that uses the same electronic health record (EHR) – they may have to repeat significant portions of their record (current medication list, allergy list, immunization record, test results) that should have easily transitioned. Within a typical metropolitan area in the US – there may be many EHRs that cannot communicate with one another at a level that would allow determination of success rates. As a result, the authors conclude most of the success rate data in psychiatry comes from clinical trials.  That data is limited by selection biases and brief periods of treatment.

The authors also look at Specific Success Rates (SSR) and Aggregate Success Rates (ASR) as population-based quality measures. To the best of my knowledge there are no corporations currently using these measures. That lack of usage is based more on medical tradition than usefulness of quality measures. Current hospital and clinical measures typically sample worst possible outcomes or so-called sentinel events. This is the business approach to mortality and morbidity conferences in medicine and surgery that were detailed discussions of deaths and complications. The thinking has typically been to learn from worst case scenarios or your colleagues’ obvious mistakes. The problem with those conferences is that they provide little guidance about the best treatment for most other patients.  For many years Medicare used the same system.  I was a Medicare Quality reviewer for 2 states and their focus was on process rather than outcomes and success rates were never discussed.  Major quality events like a death on a psychiatric unit would trigger a detailed quality review.

As a long time follower of the work of Tiihonen, the first flaw that I noticed was that none of his work was referenced.  Tiihonen has a long track record of looking at outcomes using observational studies (2-12) and has commented on both the limitations and advantages of these studies (17). One of the critical advantages of doing research in Scandinavian countries is access to nationwide databases or registries that include the usual demographic patient information but also diagnoses, treatments, medications and outcome data.  Those data include hard outcomes (suicide, all cause mortality, disability) and soft outcomes (drug discontinuation, rehospitalization, symptom checklists, side effects checklists, psychosocial outcomes).  Similar data is available in other studies such as long acting injectable (LAIs) antipsychotic medications back to the 1980s, treatment cohort studies (Schou, Winokur, Guze, Angst) from similar periods and various sampling studies that look at surveys of medical clinics.  There are also the statistics from the 19^th century protopsychiatry era.  My favorite one is from Luther Bell (15) describing the outcomes of delirious mania:

“A subsequent case series published by Luther Bell in 1849 described 40 patients with the condition among 1700 admissions to McLean Hospital (Bell, 1849). He reported a mortality rate of 75% in these patients."

Today - nobody dies from delirious mania or the more common forms of mania that frequently led to deaths from congestive heart failure during the protopsychiatry era.  That is an improvement in mortality on par with any other medical specialty and it is due to improvements in psychiatric care.

But nothing can replace the rigor and data of registry studies from Scandinavia. By rigor I mean the results of treatment of unselected real-world patients in real world systems of care, very large data sets, and no missing data. Clinical trials can't compare when as many as 80% of real-world patients are omitted from consideration (16) and those patients may be at higher risk for morbidity and mortality outcomes.

Psychiatric treatment success rates are available if you look for them.  I am not as negative about observational or registry studies when I consider the advantages about knowing real world outcomes and how they diverge from relatively brief randomized controlled trials that do not choose real world patients and are biased at times to the point of being irrelevant by drop outs over time. Additional considerations in terms of the goals of this post include experienced psychiatrists themselves are the typically the best critics of the field. Critics who maintain a specific obvious viewpoint will generally continue to repeat the same criticisms they have been repeating for decades and cannot be considered reliable.  All psychiatrists have varying experiences clinically, in research, and in the literature of the field. An extensive review of psychiatric outcomes over time would seem to be indicated – but there is a lot of applicable research out there right now.  In terms of generating more thorough success rates several biases described above need to be overcome including viewing the necessary data as proprietary or the disingenuous application HIPPA regulations that seem to allow mass marketing of patient data but not allow adequate population-wide quality measures.  I would go as far as establishing a nationwide pharmacosurveillance/pharmacovigilance system to get adequate real world pharmacology data. 

In ending this note I will say that the editorial generated predictable rhetoric.  I typically find myself responding to rhetoric on this blog – but in this case another blogger stepped in and did the heavy lifting.  For anyone interested in the rhetorical side I refer you to the commentary by Awais Aftab, MD who provides excellent responses. Psychiatrists are trained in critiquing their own literature and provide the best legitimate criticism.  A lot of critics outside the field basically repeat what they have been saying for decades.  Those responses tend to be impervious to criticism reflect a general lack of knowledge about the field.  The original editorial by Freedland and Zorumski has merit. It was not intended as a blanket condemnation of the field.  I hope to have fleshed it out a bit in this post and suggested both sources of current data and next steps.

 

George Dawson, MD, DFAPA

 

Supplementary 1:  I am very interested in a large review of psychiatric outcomes.  If you have similar interests and expertise – send me your favorite references or suggestions on how we can collaborate.

 

References:

1:  Freedland KE, Zorumski CF. Success Rates in Psychiatry. JAMA Psychiatry. 2023 Mar 22. doi: 10.1001/jamapsychiatry.2023.0056. Epub ahead of print. PMID: 36947055.

2:  Taipale H, Tanskanen A, Mehtälä J, Vattulainen P, Correll CU, Tiihonen J. 20-year follow-up study of physical morbidity and mortality in relationship to antipsychotic treatment in a nationwide cohort of 62,250 patients with schizophrenia (FIN20). World Psychiatry. 2020 Feb;19(1):61-68. doi: 10.1002/wps.20699. PMID: 31922669; PMCID: PMC6953552.

“These data suggest that long-term antipsychotic use does not increase severe physical morbidity leading to hospitalization, and is associated with substantially decreased mortality, especially among patients treated with clozapine.”

3:  Tiihonen J, Tanskanen A, Taipale H. 20-Year Nationwide Follow-Up Study on Discontinuation of Antipsychotic Treatment in First-Episode Schizophrenia. Am J Psychiatry. 2018 Aug 1;175(8):765-773. doi: 10.1176/appi.ajp.2018.17091001. Epub 2018 Apr 6. PMID: 29621900.

“Whatever the underlying mechanisms, these results provide evidence that, contrary to general belief, the risk of treatment failure or relapse after discontinuation of antipsychotic use does not decrease as a function of time during the first 8 years of illness, and that long-term antipsychotic treatment is associated with increased survival.”

4:  Tiihonen J, Wahlbeck K, Lönnqvist J, Klaukka T, Ioannidis JP, Volavka J, Haukka J. Effectiveness of antipsychotic treatments in a nationwide cohort of patients in community care after first hospitalisation due to schizophrenia and schizoaffective disorder: observational follow-up study. BMJ. 2006 Jul 29;333(7561):224. doi: 10.1136/bmj.38881.382755.2F. Epub 2006 Jul 6. PMID: 16825203; PMCID: PMC1523484.

16 yr study

“The effectiveness of first and second generation antipsychotics varies greatly in the community. Patients treated with perphenazine depot, clozapine, or olanzapine have a substantially lower risk of rehospitalisation or discontinuation (for any reason) of their initial treatment than do patients treated with haloperidol. Excess mortality is seen mostly in patients not using antipsychotic drugs.”

5:  Taipale H, Lähteenvuo M, Tanskanen A, Mittendorfer-Rutz E, Tiihonen J. Comparative Effectiveness of Antipsychotics for Risk of Attempted or Completed Suicide Among Persons With Schizophrenia. Schizophr Bull. 2021 Jan 23;47(1):23-30. doi: 10.1093/schbul/sbaa111. PMID: 33428766; PMCID: PMC7824993.

6:  Tiihonen J, Mittendorfer-Rutz E, Majak M, Mehtälä J, Hoti F, Jedenius E, Enkusson D, Leval A, Sermon J, Tanskanen A, Taipale H. Real-World Effectiveness of Antipsychotic Treatments in a Nationwide Cohort of 29 823 Patients With Schizophrenia. JAMA Psychiatry. 2017 Jul 1;74(7):686-693. doi: 10.1001/jamapsychiatry.2017.1322. PMID: 28593216; PMCID: PMC5710250.

7:  Heikkinen M, Taipale H, Tanskanen A, Mittendorfer-Rutz E, Lähteenvuo M, Tiihonen J. Real-world effectiveness of pharmacological treatments of alcohol use disorders in a Swedish nation-wide cohort of 125 556 patients. Addiction. 2021 Aug;116(8):1990-1998. doi: 10.1111/add.15384. Epub 2021 Jan 14. PMID: 33394527; PMCID: PMC8359433.

8:  Lähteenvuo M, Tanskanen A, Taipale H, Hoti F, Vattulainen P, Vieta E, Tiihonen J. Real-world Effectiveness of Pharmacologic Treatments for the Prevention of Rehospitalization in a Finnish Nationwide Cohort of Patients With Bipolar Disorder. JAMA Psychiatry. 2018 Apr 1;75(4):347-355. doi: 10.1001/jamapsychiatry.2017.4711. Erratum in: JAMA Psychiatry. 2022 May 1;79(5):516. PMID: 29490359; PMCID: PMC5875349.

9:  Puranen A, Koponen M, Lähteenvuo M, Tanskanen A, Tiihonen J, Taipale H. Real-world effectiveness of mood stabilizer use in schizophrenia. Acta Psychiatr Scand. 2023 Mar;147(3):257-266. doi: 10.1111/acps.13498. Epub 2022 Sep 14. PMID: 36065482.

10:  Tiihonen J, Haukka J, Taylor M, Haddad PM, Patel MX, Korhonen P. A nationwide cohort study of oral and depot antipsychotics after first hospitalization for schizophrenia. Am J Psychiatry. 2011 Jun;168(6):603-9. doi: 10.1176/appi.ajp.2011.10081224. Epub 2011 Mar 1. Erratum in: Am J Psychiatry. 2012 Feb;169(2):223. PMID: 21362741.

11:  Tiihonen J, Tanskanen A, Hoti F, Vattulainen P, Taipale H, Mehtälä J, Lähteenvuo M. Pharmacological treatments and risk of readmission to hospital for unipolar depression in Finland: a nationwide cohort study. Lancet Psychiatry. 2017 Jul;4(7):547-553. doi: 10.1016/S2215-0366(17)30134-7. Epub 2017 Jun 1. PMID: 28578901.

12:  Tiihonen J, Lönnqvist J, Wahlbeck K, Klaukka T, Tanskanen A, Haukka J. Antidepressants and the risk of suicide, attempted suicide, and overall mortality in a nationwide cohort. Arch Gen Psychiatry. 2006 Dec;63(12):1358-67. doi: 10.1001/archpsyc.63.12.1358. PMID: 17146010.

13:  Kisely S, Preston N, Xiao J, Lawrence D, Louise S, Crowe E. Reducing all-cause mortality among patients with psychiatric disorders: a population-based study. CMAJ. 2013 Jan 8;185(1):E50-6. doi: 10.1503/cmaj.121077. Epub 2012 Nov 12. PMID: 23148054; PMCID: PMC3537812.

14: McMahon FJ. Prediction of treatment outcomes in psychiatry--where do we stand ? Dialogues Clin Neurosci. 2014 Dec;16(4):455-64. doi: 10.31887/DCNS.2014.16.4/fmcmahon. PMID: 25733951; PMCID: PMC4336916.

15: Bell, L., 1849. On a form of disease resembling some advanced stageof mania and fever. Am. J. Insanity 6, 97–127. 

16:  Taipale H, Schneider-Thoma J, Pinzón-Espinosa J, Radua J, Efthimiou O, Vinkers CH, Mittendorfer-Rutz E, Cardoner N, Pintor L, Tanskanen A, Tomlinson A, Fusar-Poli P, Cipriani A, Vieta E, Leucht S, Tiihonen J, Luykx JJ. Representation and Outcomes of Individuals With Schizophrenia Seen in Everyday Practice Who Are Ineligible for Randomized Clinical Trials. JAMA Psychiatry. 2022 Mar 1;79(3):210-218. doi: 10.1001/jamapsychiatry.2021.3990. PMID: 35080618; PMCID: PMC8792792.

17: Taipale, H. and Tiihonen, J. (2021) “Registry-Based Studies: What They Can Tell Us, and What They Cannot,” European Neuropsychopharmacology, 45, pp. 35–37. doi: 10.1016/j.euroneuro.2021.03.005. 

18:  Lähteenvuo M, Paljärvi T, Tanskanen A, Taipale H, Tiihonen J. Real-world effectiveness of pharmacological treatments for bipolar disorder: register-based national cohort study. Br J Psychiatry. 2023 Oct;223(4):456-464. doi: 10.1192/bjp.2023.75. PMID: 37395140.