Why Do They Hate Us?

The title of this column weighed heavily on the minds of some Americans immediately after the terrorist attacks of 911. I was involved in some Internet forum political debates at the time that looked at this question.  The question itself implies a lack of self analysis and misunderstanding of rhetoric and political strategy. Those same basic concepts can be applied to an analysis of psychiatry and the common political and rhetorical strategies that are used against us.

At this point some readers may suggest that this is quite a tangent for me to take given the fact that psychiatry after all is part of the medical establishment and as such should have very little to complain about.  Four or five decades of complaints from anti-psychiatry cults and about two decades of complaints from competing professionals has done little to diminish the influence of psychiatry.  If that is really the case, why has psychiatry been disproportionately affected in terms of resources available to treat patients and why are psychiatrists blamed for that?  I suggest that the discrimination against psychiatrists and their patients occurs at every level as the direct result of an antipsychiatry bias.

I first came directly in contact with hatred of psychiatrists in an unexpected setting – an academic team rounding on medical surgical patients.  It consisted of an attending, a senior resident, two interns and two medical students.  When the attending learned I was going to do a psychiatric residency, it was an opportunity for ridicule.  Didn’t I realize that psychiatrists were lazy and did not know what they were doing?  Didn’t I know that nobody with a mental health problem should consult with a psychiatrist?  The special attention focused on me peaked when this attending challenged me on the correct diagnosis of acute abdominal pain.  The patient was middle aged, obese and had acute abdominal pain with nonspecific exam findings.  What was my diagnosis?  When I said “appendicitis” – the attending said I was wrong and gave all of the reasons why the diagnosis was cholecystitis.  Several hours post op we had the diagnosis of acute appendicitis.  I learned more about what some physicians think of their psychiatric colleagues than the diagnosis of the acute abdomen during that rotation.

I came across an illuminating piece in the British Journal entitled Advances in Psychiatric Treatment. The author Claire Bithell of the Science Media Center in London showed that psychiatry was less likely to be reported on in the popular press and when it was, received treatment that was four times as negative as other medical specialties.  In an associated piece based on meetings with journalists, academics, clinicians and journalists she found problems at all levels in terms of engaging the media and one of the conclusions was that experts need to engage with breaking news stories to get important messages across to the public.

  

It is easy to prove to yourself that the same problem with the press exists in the US.  It is as easy as going to the New York Times web site and doing a quick search on psychiatry.  The search returns the articles and several commentaries on how psychiatrists are turning to medication management rather than psychotherapy,  an article on how the man accused of the mass shooting at Fort Hood was a psychiatrist, Radovan Karadzic was a psychiatrist, and an article about Carl Jung.  One of the central articles “Talk Doesn’t Pay So Psychiatry Turns Instead To Drug Therapy” gives the specific detail: “A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session”.  But at that point the author incorrectly concludes that competition from other mental health providers is the reason that psychotherapy is so poorly reimbursed.  He should have just applied his earlier conclusion that the dominance of large hospital groups and corporations in combination with the government essentially fixes insurance reimbursement to whatever the payers want to pay.  They do not want to pay for psychotherapy despite the fact that it is clearly an evidence based therapy.

The origins of bias against psychiatry are varied and include the continued misunderstanding of what we do and what our training is, fear of mental illness, and in many cases the pursuit of political goals.  We have seen attacks on psychiatrists by politicians, Hollywood stars, other psychiatrists, and of course anyone who wants to write an antipsychiatry book.  It can be very subtle such  as recognizing that there is no practical way that psychiatric services can be provided and shutting them down.  In this case it is common to blame psychiatrists for the “lack of access” rather than inconsistent and unrealistic reimbursement by payers.   I was talking to a highly reimbursed proceduralist one day who said that she didn’t mind that some of their margin was used to pay for psychiatry because it seemed like a needed service.

 At times the sheer amount of noise out there about psychiatry is deafening.  I don’t think we are alone when it comes to negative publicity.  Teachers and law enforcement come to mind.  I do not think that there is any doubt that public perception is affected by what is often false information about psychiatry. 

Apart from what is purely propaganda,  most people have an innate tendency to see themselves as armchair psychologists.  Artificial intelligence philosophers came up with the term folk psychology to discuss this tendency and its benefits.  If you are a folk psychologist you might conclude that it is so easy that a psychiatrist has nothing to add, especially when you watch other folk psychologists on television all day long.  Some of the people who have hated us the most have had their theories rejected by organized psychiatry.

From an organizational standpoint,  how do we respond to the hate?  Although it would serve us well,  I doubt the public is very familiar with the philosophical criticisms of folk psychology any more than they know the difference between a psychiatrist and a psychotherapist.  What can we do when we are being smeared on a routine basis?  Ignoring the attacks is a strategy that the APA has used for years.  From a strategic perspective – it is effective to a point.  That point is where some of our detractors gain either political advantage or there are sudden and unexpected changes.  Before that happens we need to be much more aggressive.

Since my early days of involvement with the Minnesota Psychiatric Society,  we have always believed that getting our message out to the public was a critical first step.  I was the Public Affairs Director in the 1990s and coordinated several of the initial National Depression Screening Days.  Today the majority of depressed people I see have been treated for at least 10 years by family physicians and although they were reluctant to see a psychiatrist , they really had no idea that I was a medical specialist.  MPS recently tried to get a letter published by local media on the mass shooting phenomenon.  We co-authored the letter with two mental health public service organizations and it was rejected at a time when there was peak speculation about whether or not the alleged perpetrator was mentally ill and others  were identifying heroes and suggesting that we move on.   Depending only on a biased press is a recipe for continued failure.

We need to start by recognizing that we all have a common interest here and it is called the psychiatric profession.  That is true if you are employed by a health care organization, the government or self employed.  That is true if your job is primarily research, patient care, or administration.  That is true if you are a medical student who has just been accepted to psychiatric residency.  When we are under constant attack – a short term solution is to cut and run.  That will not work in the long run.  We are currently the standard bearers for the kind of care that is possible and apart from our colleagues in other countries we are often shouting alone in the woods.  It is very clear that state and national governments and their allies in the business world do not care about reasonable standards of psychiatric care and in many cases have codified that.  Other advocates are often left to play one side against the other on an artificial playing field of constrained resources.  Psychiatrists have a common interest in making a stand against unfair treatment by both the government and the health care industry.

The other issue is how to make that stand.  We currently have political strategies with politicians and other groups with similar interests.  Those groups are not interested in our standards and we need to take those arguments directly to the public.  We have to let them know what inpatient units and state hospitals are capable of doing.  We need to let them know what state of the art community psychiatry looks like.  We have to let them know that outpatient psychotherapy for depression is actually more than a session or two and coming back every month or two to see somebody about medications.  We have to speak out on every topic of mental health interest in the media and presenting it ourselves rather than expecting the media to pick it up.  That is our job in the near future.

That is also in part what this blog is all about.

Is it the economy?

The lead story in this week's Psychiatric Times was sent to me in e-mail this morning under the subject "Economy Threatens Psychiatry Programs". It provides the news that the Cedars-Sinai Department of Psychiatry and Behavioral Neurosciences is essentially being phased out except for "staffing of psychiatric support that is an adjunct to patient care throughout the medical center." It quotes an unnamed academic psychiatrist as saying that the real reason that psychiatric programs are getting the axe is that they are the least profitable services offered at any hospital. The article goes on to suggest that declining Medicare funding of Graduate Medical Education may threaten additional programs.

The only real explanation and dose of reality in that article was the quote from their anonymous source. Psychiatric programs and bed capacity have been closing down for the past 20 years. It is the direct product of managed care strategies either being applied directly by the managed care cartel or through their friends and allies in the government. I have previously posted on this blog how psychiatric services have been marginalized from an economic standpoint.  That should be obvious from surveying any acute care hospitals in your state. In the state of Minnesota for example, a minority of the total hospitals have psychiatric units and fewer are staffed for chemical dependency services.  That has resulted in the need to transfer patients in crisis in emergency departments across the state or in some cases in different states. As a result any involved family members have to travel hundreds of miles to maintain contact with that person.  The economy for psychiatry has been bad for the last 20 years.

The evolution of this process is apparently so insidious that nobody pays attention to it. The only way that the minority of hospitals with psychiatric units can continue to operate and staff those units with psychiatrists is if they do a high volume, low quality DRG based business or they are subsidized to some degree out of the profit margin of other departments. In that case, an economic argument can be made that more severely ill psychiatric patients or medically ill psychiatric patients would never leave medical or surgical units if there were not psychiatric units available to receive them in transfer.

This process is easily reversed by providing adequate compensation for psychiatric care. The reimbursement levels for inpatient care are so trivial that an inpatient psychiatric unit is currently the least expensive place to maintain the patient.  At some point, treatment on a DRG based inpatient unit is cheaper than a group home and much cheaper than a state hospital.  That creates additional incentives and barriers to discharge from the hospital.

The bottom line is that it is not the economy.  There has been a systematic bias against mental health services for at least 20 years.  It is well past the time for psychiatrists and other advocates to remove the term "cost effective" from their dialogue. Psychiatric and mental health services have been the most cost effective medical services for at least the past 20 years and there is no reason for expecting them to get less expensive. Reversing that trend and providing compensation that is at least on par with the rest of medicine will allow for quality psychiatric hospital services and outpatient clinics.

George Dawson, MD

Stephen Barlas. Elimination of Psych Services at Cedars-Sinai Could Foreshadow Similar Cutbacks Elsewhere.  Psychiatric Times Vol 29, No2, February 8, 2012 

Endnote:  According to the Minnesota Hospital Association 29 of 136 acute care hospitals have beds staffed for mental health care and 6 of 136 have beds staffed for chemical dependency care.

Managed Care 101 – The Prior Authorization Hoax

As managed care organizations worked on how they could prioritize pricing over medical decisions they came up with various plans to “manage” how physicians prescribed medications.  I was a member of two Pharmacy and Therapeutics Committees (P & T) that  both had this as a goal.  One of those committees had a much stricter mandate in terms of saving money.  The basic strategy used by that committee was to place a drug “on formulary” or “off formulary”.  If it was “off formulary” it was not available to any doctors within the HMO to prescribe.

The idea that all drugs within a class that had the same purported mechanism of action ruled the day.  As an example, all of the selective serotonin reuptake inhibitors (fluoxetine, paroxetine, sertraline, citalopram, escitalopram, fluvoxamine) would be considered equivalent medications and the committee would decide to place the least expensive ones on the formulary.  At the time, the major controversy was fluoxetine because there was no generic brand available and the company that produced it was notorious for not negotiating prices with hospitals and health care systems.  There was an eventual appeal by psychiatrists who presented to the committee on the unique qualities of fluoxetine.  At the time it was the only medication studied in adolescent depression for example.  Eventually a rule was passed that it was nonformulary for any physician who was not a psychiatrist.

The total cost of the drug was more of a consideration than the absolute price.  Very expensive drugs were approved that had questionable endpoints based on the fact that utilization would be low and that advocates for a particular untreatable illness would want it.  So the decision of the committee and their mandate was to reduce the use of relatively more expensive drugs that would be used fairly frequently.  In some cases, the off formulary drugs were available by “prior authorization” meaning that the prescribing physician needed to usually write up an appeal and fax it to the pharmacy or health plan and in some cases make additional calls.

The health care business has a long history of introducing layers and layers of management driven largely by the amount of money involved.  If you can successfully insert more management for even a small percentage of the available health care dollars you will potentially have a multi billion dollar business.   The management of pharmaceuticals is no exception and the Pharmacy Benefit Manager or PBM was born.  The task of the PBM like the task of a P & T Committee is to control the prescribing physician and force them to choose a medication based on the lowest cost.  Individual variation between patients and all of the other variables that physicians have to take into account do not matter.  If the physician or the patient thinks that they do – it will take a prior authorization for the alternate medication.  

The PBM model was designed from the outset to take a central role in the management of prescription drugs by replacing the relationship that the patient has with their health plan, their pharmacist, and even their physician.  How do I know this?  Take a look at their game plan from an internal memo in the diagram below.  This diagram was taken from an internal memo from over 15 years ago.  The structure depicted in the diagram is the system of care that exists today and the one that 95% of patient have their benefits managed through 

The prior authorization fallacy is essentially the same as the utilization review fallacy.  The most charitable interpretation is that it assumes that a person who is not necessarily a physician and who has no personal responsibility for your care can substitute their judgment based on a cost consideration.    

The diagram is also instructive in the way that the prescribing decision (and the dispensing decision) is trivialized as a "habit" rather than a decision that takes into account the evaluation and personal knowledge of the individual patient.

Today all physicians are routinely subjected to prior authorization procedures that waste significant amounts of their time and the time of their staff in order to make seem like the PBM decision has some degree of medical legitimacy.  The cost to medical practices is huge and completely unnecessary.  If PBMs are really businesses there is really no legitimate reason that they need to include physicians in their decisions of what medication should be covered.  They just need to plainly state that to their patients and deal with the public relations problems instead of wasting about one million hours of physician time per week.  In the weeks that follow I will demonstrate just how far this business plan has infiltrated medicine and psychiatry and what the response has been to date.

George Dawson, MD

Critical Article on the Efficacy of Psychiatric Medication

There is a seminal article in this month’s British Journal of Psychiatry by Leucht, Hierl, Kissling, Dold, and Davis.  The authors did some heavy lifting in the analysis of 6175 Medline abstracts and 1830 Cochrane reviews to eventually compare 94 meta-analyses of 48 drugs in 20 medical diseases and 33 meta-analyses of 16 drugs in 8 psychiatric disorders.  The authors have produced a graphic comparing the Standard mean difference of effect sizes between the general medicine drugs and the psychiatric drugs.  It is apparent from that graphic that the psychiatric drugs are well within the range of efficacies of the general medical drugs.

This is an outstanding study that merits reading on several levels.  The authors have used state of the art approaches to meta-analysis following suggested conventions.  They provide the summary of the studies reviewed and actual details of their calculations in the accompanying tables. (the document including references and PRISMA diagrams is 59 pages long.)  They have a comparison of standard criticisms of psychiatric drugs and illustrate how the criticisms are not fair and the toxicity considerations are often greater in the general medicine drugs than the psychiatric drugs. 

This paper should be read by all psychiatrists since it is an excellent illustration of an approach to large scale data analysis using modern statistical techniques.  It is a good example of the application of the discussion by Ghaemi of hypothesis testing statistics versus effect estimation.  The authors also have an awareness of the limitations of statistics that the detractors of psychiatric care seem to lack.  Their statements are qualified but they provide the appropriate context for decision making about these medications and the implication is that decision matrix is clearly squarely in the realm of other medical treatments in medicine.

From the standpoint of the media and the associated politics it will also be interesting to see if this article gets coverage relative to the articles that have been extremely critical of psychiatric drugs.  I can say that I have provided the link to the article by Davis, et al on the issue of antidepressant effectiveness to several journalists including the New York Times and it was ignored.  The press clearly only wants to tell the story against antidepressants and psychiatric medications.

Never let it be said that any aspect of psychiatric treatment gets objective coverage in the press.  That problem and the lack of investigation of that problem is so glaring at this point that the press lacks credibility in any discussion of psychiatric treatment.

George Dawson, MD

Leucht S, Hierl S, Kissling W, Dold M, Davis JM. Putting the efficacy of psychiatric and general medicine medication into perspective:review of meta-analyses. Br J Psychiatry. 2012 Feb;200:97-106. PubMed PMID: 22297588

S. Nassir Ghaemi (2009) A Clinician’s Guide to Statistics and Epidemiology in Mental Health: Measuring Truth and Uncertainty.  Cambridge University Press, New York.

Davis JM, Giakas WJ, Qu J, Prasad P, Leucht S. Should we treat depression with drugs or psychological interventions? A reply to Ioannidis. Philos Ethics Humanit Med. 2011 May 10;6:8.

Seemuller F, Moller HJ, Dittmann S, Musil R. Is the efficacy of psychopharmacological drugs comparable to the efficacy of general medicine medication? BMC Med. 2012 Feb 15;10(1):17. Free full text commentary on the main article from another journal    -      download the pdf.

Managed Care 101 – The Utilization Review Hoax

I happened to start practicing psychiatry at a time when managed care was just starting to build momentum. From a political standpoint there was concern in the popular press that healthcare services were being over utilized. There is a famous study by the RAND Corporation looking into whether or not angiography and bypass surgery were being used to frequently to treat cardiovascular disease. There was a concern that medical and surgical procedures in general were being over utilized. This was part of the driving force for a large scale experiment called the Medicare PRO or Peer Review Organizations.

In the late 1980s and throughout much of the 1990s I was a physician reviewer for the Medicare PROs, first in Wisconsin and then in Minnesota. My job was to look at cases selected from all psychiatric hospitalizations in the state and determine whether the total length of time in the hospital was appropriate for the condition and whether or not there were any associated quality problems. There was an extensive list of quality problems that nurse reviewers would identify and forward to me for further assessment. Examples of quality problems ranged from death on a psychiatric unit to abnormal vital signs at the time of discharge to the appropriate monitoring of the therapy like lithium that require close monitoring. All physician reviewers working for this organization had to be carefully screened for conflicts of interest.  I could not review any case if I had any financial interest in the hospital or clinic where the incident occurred.

At about the same time managed care companies were establishing utilization reviewers for their insured members. They had no quality focus or quality markers. Their only focus was whether or not one of their members was entitled to inpatient coverage or a specific course of outpatient therapy. There were no conflict of interest considerations because the reviewers were all paid by the managed care company and therefore their financial interests were aligned with the corporation.

You could consider the two different forms of utilization review to be the great experiments in the provision of medical care in the 1990s. More appropriately the Medicare PROs were probably the experimental side and the managed care utilization reviewers represented a business model that really required no experimentation. It seemed quite obvious that if you could deny care that you would make more money.  What happened to these two models over the next 10 years?

Despite the rigorous screening and structurally defined quality problems used by the Medicare PRO, at one point it was determined that the amount of over utilization found in the state of Minnesota was not enough to justify the cost of the program. After all of the hype in the press about how physicians and hospitals were providing unnecessary care, that was a stunning finding on such a large scale that it should not have been ignored. It essentially meant that from an objective scientific standpoint utilization review is unnecessary. Minnesota stopped its utilization effort and decided to partner on the quality side with health care organizations to improve the treatment of specific conditions.

Utilization review on the managed-care side has not only continued but flourishes despite the fact that there is no objective basis for it and that managed care organizations have complete control over reimbursement to physicians and hospitals and the reimbursement for psychiatric services is the absolute lowest.  The most recent development has been internalizing utilization review directly into the hospital and using care managers to force discharges from hospitals. These care managers often depend on a quasi-scientific set of guidelines or standards that frequently ignore the specific needs of patients

.

Psychiatry has been hit particularly hard by this quasi-quality approach that disproportionately rations care to psychiatric patients. We are currently seeing people with complex disorders like unstable bipolar disorder discharged from psychiatric hospital within a few days because the "crisis" is over and yet they are not able to function by themselves at home. We have allowed managed care organizations to essentially dictate a standard that suggests the only reason that a person should be a psychiatric unit is if they are "suicidal" or a threat to others.  There is broad interpretation of what "suicidal" means and of course the physician reviewer for the insurance company has never personally assessed the patient or their circumstances.  The vast majority of patients who would benefit from quality care in a hospital would not meet either of those criteria and frequently have no other resources.

The fallout from this approach has been tremendous. Psychiatric care in hospital settings is generally viewed as being very poor in quality. Many outpatient psychiatrists I have consulted with have told me that there is essentially no place that their unstable outpatients can be stabilized because they are frequently discharged from hospitals in a few days and the treatment has not been changed. There is little collaboration between inpatient and outpatient psychiatrists because of the need for high turnaround and the time constraints.  The actual inpatient environments are frequently so toxic that people with fairly severe problems don't want to be there.  Managed care is focused primarily on providing high-volume, low quality care by the application of a method that has no basis in reality.

Antidepressants - the limited analysis of a polarized argument

The current President John Oldham and President-elect Jeffrey Lieberman of the American Psychiatric Association came out with this press release today on a 60 Minutes episode characterizing antidepressants as no better than placebo.  They describe this characterization as “irresponsible and dangerous reporting” and “a message that could potentially cause suffering and harm to patients with mood disorders.”

It is good to see the APA finally taking a stand on this issue.  Antidepressants and the psychiatrists who prescribe them have been taking a pounding in the popular press for years.  The main proponent here was also featured in a Newsweek headline story two years ago.  This is a prototypical example of how the media and special interest groups can distort science and facts and politicize the discussion that must be nuanced.  The problem is that you have to know something and be fairly free of bias to participate in a nuanced discussion.  Like most issues pertaining to psychiatry, the issue is always polarized and poorly discussed in the media.

I got involved in this issue as a managing editor of an Internet journal and I solicited a paper from a world renowned epidemiologist to get his current view on antidepressant meta-analyses. In order to present the entire argument I also solicited response from a world renowned psychopharmacologist with broad expertise in this field. Both articles are available online for free and I think if they are both read in total they represent the most accurate picture of antidepressant response.  Both references are listed at the bottom of this page.

Rather than get into the specific details at this point I will say that it was extremely difficult to find a anyone willing to provide a rebuttal to the to the original article by Ioannidis, but anyone who reads that paper by Davis, et al and who follows the antidepressant literature will have a greater appreciation of the effectiveness of these medications.  I hope to post some information on the statistical analysis as well.  At some level people tend to view statistics as a hard mathematical science and there is plenty of room for interpretation.  The use of meta-analysis is a common approach to these problems and a detailed look at the shortcomings of meta-analysis are seldom discussed.  That might explain why one meta-analysis shows minimal effects and another shows that there might be some antidepressants with unique effectiveness (see Cipriani, et al)

A final dimension that is critical in the analysis of any source is potential conflicts of interest.  The only conflict of interest that is typically discussed is the financial interests of authors and pharmaceutical companies in producing positive trials.  That ignores the fact that many of these trials have been very public failures and that post trial surveillance limits the use of some of these compounds.  There are other conflicts of interest to consider when an author is selling a viewpoint and can potentially profit from it – either financially or politically.

The APA could provide a valuable service here in making the documents from the FDA and the EMA widely available for public discussion and analysis.

George Dawson, MD

 “60 Minutes” Segment on Antidepressants "Irresponsible and Dangerous" – APA New release Febrary 22, 2012.

Ioannidis JP. Effectiveness of antidepressants: an evidence myth constructed

from a thousand randomized trials? Philos Ethics Humanit Med. 2008 May 27;3:14.

Davis JM, Giakas WJ, Qu J, Prasad P, Leucht S. Should we treat depression with drugs or psychological interventions? A reply to Ioannidis. Philos Ethics Humanit Med. 2011 May 10;6:8.

Cipriani A, Furukawa TA, Salanti G, Geddes JR, et al.  Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis.  The Lancet - 28 February 2009 ( Vol. 373, Issue 9665, Pages 746-758 ) 

Lessons from Finland on Professional Report Cards

The New York Review of Books this week contains a review by Diane Ravitch entitled “Schools We can Envy”.  In it she reviews “Finnish Lessons: What Can the World Learn from Educational Change in Finland?” by Pasi Sahlberg. 

It turns out that the Finland has one of the highest performing school systems in the world.  That occurs in the context of very high professional standards for teachers and a lack of attention to standardized tests.  From the article:

“Because entry into teaching difficult penetrating is rigorous, teaching is a respected and prestigious profession and Finland. So selective and demanding is the process that virtually every teacher is well-prepared. Sahlberg writes that teachers enter the profession with a sense of moral mission and the only reasons they might leave would be "if they were to lose their professional autonomy" or if "a merit-based compensation policy tied to test scores were imposed".   Meanwhile the United States is now doing to his teachers what Finnish teachers would find professionally reprehensible: judging their worth by the test scores of their students.”

As expected, blaming the teachers is currently popular in the United States but it does not fly in Finland.

And what implications does this have for blaming the doctors? I could easily make the argument that the variance in patient outcomes for a particular physician is probably much less under the control of that physician than the variance in student outcomes for any teacher.

It is time to let the public know that the "report cards" on doctors is another poorly thought out idea from the government and the managed-care cartel and they are probably even less valid than report cards on teachers.  I will provide all of the details in subsequent posts.

George Dawson, MD

Diane Ravitch.  Schools We Can Envy.  New York Review of Books