The Chai Man

Back in the 1970s I was in the US Peace Corps in Kenya East Africa.  I worked in an all boys school as a chemistry teacher.  The school was about 100 miles north of Nairobi on a high plateau next to Mt. Kenya.  On the weekends my fellow volunteers and I would drive over to the closest town for a Coke and an inexpensive snack at the White Rhino Hotel.  In those days a Coke or a bottle of beer would cost about a Kenyan Shilling (KES) and a meat pie or a samosa would cost about a Shilling and a half.  One Shilling was about 14 cents American.  Outside the hotel was an apparently homeless man.  He would beg for money often by creating disturbances.  He would obstruct people in the street going to and from the hotel.  He would shout out the word "Chai,  Chai..." repeatedly while spitting down the front of his shirt.  "Chai" is the Kiswahili word for tea.  He would appear agitated and tearful at times.  He was not tolerated very well by hotel security or the local people - people who could speak fluent Kiswahili and the local Kikuyu language.  Some of them would become physically aggressive toward him and cause him to run down the street.  At other times he would show up with a can of dirty water and try to clean auto windshields by wetting down a newspaper and wiping the water all over.  These attempts were always unsolicited and the drivers would become enraged because their windshields were always less clean than when he started.  We eventually referred to him as the Chai Man because nobody ever knew his name.  The Chai man clearly struggled, alienated practically every person I ever watched him interact with, and he got minimal assistance from anyone.  At the time he reminded me of homeless men I would see in my local public library.  It was the only they place they could go in a small town to get a break from the weather.  They would occasionally ask for money, but for the most part avoided people.  When  you are down and out and mentally ill, most people seem to know better than to ask.

By the time my fellow teachers and I made it to our placement north of Nairobi we had contact with hundreds if not thousands of people living on the street as beggars.  Many had physical deformities to the point that they were unable to walk.  Coming into town from the airport was enough contact to convince the most altruistic Peace Corps volunteer (PCV) that they personally did not have nearly enough resources to address the problem.  PCVs had to learn to not look at the people begging on the street and walk quickly by or risk people coming out and grabbing their leg or arm until they were given money.  Like the US, only certain streets and areas allowed for the aggregation of these homeless beggars.  PCVs were not rich by any means but when we got to our eventual destinations, they were usually places where there were no homeless people in sight.  We were rather scruffy ourselves but we could sit in classy places like the New Stanley Hotel and sip on a Coke.

I thought of the Chai Man last night as I listed to a program on "The World" on MPR about a mental health initiative in Kenya (reference 1).  The focus of the program was a young woman Sitawa Wafula started mental health crisis intervention service on her own.  It is a formidable problem.  The program describes how children and adults are "locked up" by their families and may not see the light of day.  Neighbors often do not know that a mentally ill brother or sister exists.  This is reminiscent of Shorter's description of the problem of psychosis in Europe and how it was handled in the early 20th century.   It also happened in my own family in the early 1950s.  In Kenya, there are currently 79 psychiatrists or one for very 500,000 people.  Ms. Wafula gets a number of calls to her crisis intervention service and says that if the problem involves suicidal thinking many people with that problem have had two previous suicide attempts.  The World Health Organization puts Kenya in the top quartile of suicide rates in all countries worldwide.    

I was picked up by a Kenyan physician once when I was hitchhiking back to Nairobi one  day.  I asked him what was available in terms of psychiatric services at the time.  He said there was only one hospital and that the basic medication being prescribed by physicians was chlorpromazine.  At that time, the chlorpromazine generation of antipsychotics were the only ones available and antidepressants were more difficult to prescribe.  Medical care in general was difficult to access.  I would typically get scabies at least one a month.  When I was initially infected I made the mistake of going to a local clinic and standing in line in the hot sun.  I was about number 300 in the line and it moved about 4 or 5 spaces every hour.  I realized that I could hitchhike 100 miles to Nairobi and back and pick up the appropriate treatment from the Peace Corps physician in less time than it took to go to the local clinic.  Eventually I just picked up a large bottle scabicide and applied it whenever I got infected.   At the time Kenya also had one of the fastest growing populations making it more difficult to provide medical and psychiatric care.

About 8 years after I left Africa, I was sitting in a seminar full of fellow psychiatry residents at the University of Wisconsin.  The topic of the day was whether or not the prognosis of schizophrenia was better in what was then called the "the third world" based on some outcome studies available at the time.  Our job was to critique the literature and it was apparent that there were technical differences in studies and in many areas the follow up and methodology was different.  At one point I suggested that exposure to antipsychotic medications may lead to negative outcomes and that raised an eyebrow or two.  I also pointed out that that at least half of the people I was treating had significant alcohol and drug problems and were not interested in quitting.  I doubted that many of the people in these studies had widespread access to street drugs that were known to precipitate psychotic states.  I remembered the Chai Man very well, but knew better than to introduce my anecdotal experience from Kenya.  That axiom about better prognosis in the developing world has since been re-examined (reference 2) and there are clearly more problems with that theory than originally thought.  Like many areas in psychosocial research it may depend more on your political biases before you read the research.  The Scandinavian research on brief psychosis and brief reactive psychosis from about the same time frame certainly suggested similar rates of spontaneous recovery.

These experiences make me smile at couple of levels.  Any time someone "confronts" me with the evidence of prognosis in schizophrenia and the World Health Organization (WHO) studies, I can point out I had a better and more thorough discussion about it with fellow psychiatrists in 1986.  I have also lived in a developing country and saw how people with presumptive mental illnesses were treated.  I have applied that experience and knowledge to clinical practice in this country.

There is the curious parallel of access to psychiatrists in both countries.  How do the citizens who need them the most get access to them?  The public radio story suggests that only people with resources (I take that to mean money) can get access to the limited number of psychiatrists in Kenya.  This country is headed in the same direction largely because rational psychiatrists do not want to be ordered around by insurance companies.  In the case of access for the severely disabled, individual states have different plans but the overall plan has been to ration access and incarcerate rather than hospitalize people with mental illnesses.  In the US, there is generally an order of magnitude greater number of psychiatrists, but that does not translate to more access.  I have talked to too many people who stop seeing a psychiatrist when their insurance stops.  The insurance industry, state governments, and the federal government all have an interest in restricting access to psychiatrists.   If people only see psychiatrists if they have poor insurance coverage and psychiatrists are fleeing insurance - this is a chronic problem that will only get worse.  

In the meantime, I hope that Ms. Wafula continues to be successful in her crisis intervention program and raising awareness that severe mental illness is a public health problem that needs to be addressed.  Families should have more resources and more help.  The WHO program to raise awareness about suicide also seems like a good idea.


George Dawson, MD, DFAPA


References:

1.  Emily Johnson.  Fighting the 'funk:' How one Kenyan battles her mental health problems by helping others.  PRI The World.  March 3, 2015.

2. Cohen A, Patel V, Thara R, Gureje O. Questioning an axiom: better prognosis for schizophrenia in the developing world? Schizophr Bull. 2008 Mar;34(2):229-44. Epub 2007 Sep 28. Review. PubMed PMID: 17905787



Supplementary 1: The map graphic is from the CIA Factbook in the public domain.

Supplementary 2: WHO Infographic on Suicide.

Supplementary 3:  I mention the New Stanley Hotel in this post, but sometime after I was there it was blown up by terrorists.  The replacement versions (at least according to Google) continue to be threatened by terrorists, who apparently want to target the tourist business in Kenya.

Use Of "Medical Model" As A Pejorative Term

Hearing “medical model” being used used pejoratively is quite tiresome.  I have heard it used that way for the past thirty years, usually to take a shot at psychiatrists.  I thought I would illustrate how this goes and what I disagree with by responding to a recent article authored by the British Psychological Society on how the system of care for psychotic disorders should be changed.  My interest is not in provoking an argument since I think that these errors are obvious.  The target audience is also relevant here and it is described as “service users, their friends and families, journalists, policymakers, mental health workers and the public.”  As such this is really a political document very similar in nature to the documents generated in the US by SAMHSA or treatment guidelines generated by other special interest groups like managed care companies.  That being the case, I will not spend any time on the technical aspects of psychosis alluded to in this paper.  As a political document it requires active refutation or the suggestions might be adapted as wholesale measures.  I don’t know if British psychiatry is any more successful in doing that than the American counterparts, but judging from what I have read in editorials – I doubt it.  Let me start out with a couple of the authors’ statements about the “medical model”.

"At least in the UK, most mental health services are currently based on the ‘medical model’ – the assumption that experiences such as hearing voices indicate illness and result from some sort of problem with the brain. (p. 103). This idea is also enshrined in mental health law and is the basis for compulsion. In the past many professionals have also believed that people experiencing distressing voices or paranoia are unlikely to recover without treatment (usually medication). This belief has led to a perceived ‘duty of care’ to provide treatment, and a tendency to view someone who does not want the treatment being offered as lacking in insight. As this report has shown, both of these assumptions are unfounded." (p. 103 from Reference 2)

And:

"In the past services have been based on what might be called a ‘paternalistic’ approach – the idea that professionals know best and that their job is to give advice. The ‘patient’s’ role is to obey the advice (‘compliance’). This now needs to change. Rather than giving advice, those of us who work in services should think of ourselves as collaborators with the people we are trying to help." (p. 104 from Reference 2) 

The authors definition of a “medical model” looks at three dimensions.  The first is the assumption that psychotic experiences are due to a brain problem.  That is partially true.  They limit themselves to what they describe as “idiopathic” causes of psychosis and ignore specific psychotic states and etiological factors.  They also exclude medical illnesses that are clearly associated with psychotic symptoms.  That happens to be the area that psychiatrists are trained to recognize and treat.  Trivializing psychiatric diagnosis as a list of symptoms that most clinicians do not refer to anyway is certainly consistent with the authors’ main points of contention, but fortunately that is not reality.  Finally, the diagnostic manual that they criticize has numerous categories that have been researched strictly as psychotic disorders (and anxiety and mood disorders) caused by social etiologies rather than brain problems per se.  Early in my career, I reviewed the predominately Scandinavian literature on brief psychoses or brief reactive psychoses so that I could provide necessary prognostic information to patients and their families.  More clear evidence that significant psychotic symptoms can spontaneously remit without any medical intervention.  That information is a critical part of any medical approach to a spontaneously remitting illness.

Secondly, they go on to say that this also means that “professionals” believe that people are unable to recover without treatment.  I don’t know about other professionals but psychiatrists since the time of Kraepelin have known that people recover without treatment, although in Kraepelin’s day they considered asylum care alone to be treatment.  Like many illnesses people can recover without treatment and the literature on brief psychosis is further evidence.  Psychiatrists have also known that specific types of psychosis (catatonia for example) have very grim prognoses without treatment. Some of the earliest studies showed that malignant catatonia had an 80% mortality rate at the turn of the 19th century.  By the turn of the 20th century the mortality rate approaches 1% or less with modern treatment. So the second part of the definition is clearly wrong.

Finally, the authors use “paternalism” to characterize the role of physicians.  This is a charge that frequently accompanies the so-called medical model often amidst the associated charge of authoritarianism.  It is also incorrect.  Medicine is based on the informed consent model of care.  Any psychiatrist is more aware of this than most other physicians.  Informed consent is based on the idea that the patient is provided with adequate information to make a risk-benefit decision and the patient and physician collaborate on the patient’s decision.  I have these conversations every day and many times a day.   Doing nothing, being referred somewhere else, and being denied the agreed upon care by a managed care company are all additional possibilities.  These conversations can occur with patients who are actively bleeding out on the floor and refuse to allow a trauma surgeon to intervene due to impaired judgment from psychosis.  In that particular situation surgeons are likely to remind anyone involved in the care that they would be assaulting the patient if they intervened and did not have informed consent.  Similar situations occur with people who have various forms of treatable but life threatening illnesses (operable cancer, impending paralysis, uncontrolled diabetes mellitus, etc) who were unable to make decisions in their best interest due to the effects of psychosis.

So - the authors’ definition of a medical model is wrong in 2 ½ of 3 dimensions. That is not a good starting point for a proposal to go beyond the “outmoded medical model”.  It is always good to know what the model really is before declaring it outmoded.  I think a lack of scholarship and experience in these matters in a common characteristic of people who criticize the “medical model” in psychiatry.  Of course it is generally not a scholarly endeavor.  For anyone interested in educating themselves in what a real medical model might look like I would suggest reading Systematic Psychiatric Evaluation (Reference 1) or any other guide to psychiatric evaluation.   Take a look at Appendix A and B for the quick story.   The fact that models like this one are widely emulated by nonphysicians may speak to their utility in understanding and treating psychosis and other mental disorders.

How do the authors do on their characterization of psychosis?   They seem to touch on the high spots. Mention of hallucinations, delusions, and formal thought disorder are all there.  They are obviously heavy on phenomena that would not typically come to the attention of psychiatrists, people who experience hallucinations and delusions or some grey zone phenomena that are not quite psychotic symptoms.  But what about the central feature of psychosis that generally comes to the attention of psychiatrists (the ones within the “medical model”)?  It turns out the authors have little to say about judgment or insight.  They have nothing to say about the conscious state of the individual.  These are the distressing and often life threatening aspects of the illness.  This is the aspect of psychotic illness that causes friends and family to state that they no longer recognize the person due to the disruption of their personality characteristics.  Are we really to believe that psychiatrists are having casual conversations with people intellectually curious and not bothered by hallucinations and delusions? Are we really to believe the affected person may not have experienced a profound change in their conscious state that makes them unrecognizable to their friends and family and unable to work or perform their basic life activities? Are we really to believe that change in conscious state may not possibly represent an acute danger to the person affected or their loved ones? Only people who have not been seriously affected by psychotic states and people who are not responsible for assessing and treating those states can make those statements.  Those people generally do not need to see psychiatrists.

The authors claim that a “lack of insight” can result in a person being detained for mental illness. That does not happen where I practice. I have to document “behavioral evidence” rather than a lack of insight and treatment refusal can also not be used as a basis for detaining someone.  In the USA, there is a strong financial incentive to discharge people from hospitals as soon as possible.  The businesses and governments who manage these facilities welcome treatment refusals.  The patient can be discharged immediately with no follow up demands.  From a business perspective that is "cost-effective care".  If any paternalism exists, it is at a societal level.  Society is the proper arbiter of how its most vulnerable citizens should be treated.  Should they be forced into treatment or allowed to die with their rights on?  Psychiatrists have no choice but to follow society's lead.  If psychiatrists have no vested interest in forced treatment, one of the critical questions is why it exists in the first place?  The obvious answer is that it is a far from perfect approach to help families get their loved ones treated and even then families are routinely disappointed.  Hospitals and courts can still have their own interpretations of these laws that will save them money but not provide necessary treatment.  In the end there is still no medical paternalism.

There are two other sections in this paper that merit commentary – dangerousness and etiologies of psychosis.  After their selective and inaccurate characterization of psychiatric assessment the authors drop this bomb:

"Some psychologists are reaching the conclusion that psychosis is often no more and no less than a natural reaction to traumatic events. For example one recent paper suggested that ‘there is growing evidence that the experiences service users report … are, in many cases, a natural reaction to the abuses they have been subjected to. There is abuse and there are the effects of abuse. There is no additional ‘psychosis’ that needs explaining’." (p 42 from Reference 2)


That is a very interesting observation to psychiatrists who screen all of their new evaluations for trauma history and post-traumatic stress disorder (PTSD).  Instead of a “recent paper” what if I am a psychiatrist seeing 500 new cases per year and I screen everybody I see for psychosis, PTSD, childhood adversity and other forms of psychological trauma.  What if over the space of 4 years and 2,000 new evaluations I observe that about 30% of my patients have significant childhood adversity or psychological trauma, about 5-10% have PTSD related to that trauma and about 5% have psychotic symptoms totally unrelated to previous trauma.  I pose that hypothetical because it would be the common experience of most psychiatrists.  The issue of trauma being a cause for symptoms should also lead to the examinations of previous errors postulating trauma as an etiology for symptoms most notably the Multiple Personality Disorder (MPD) fiasco and the associated phenomenon of Satanic Ritualistic Abuse (SRA).  I would recommend against even using highly qualified statements about this as a possible etiology for psychosis without ample evidence.  Although research bias is a frequent accusation in the area of psychopharmacology research, there is no reason to suspect that favorite theories in psychosocial research are less bias producing.

The authors fall back on the statement about mental illnesses not implying dangerousness.  In the vast majority of cases that is true.  It is also true that the population with the most significant illnesses need to be evaluated for suicidal and aggressive behavior.  Tragedies that occur as a result of impaired judgment and altered conscious states from psychotic disorders are commonplace.  People with these problems can be successfully treated and violence and suicide can be prevented.  It is not enough to suggest that people with mental illnesses may be stigmatized by any connection with violence.  People with psychotic disorders and aggression are among the most stigmatized people in our society.  The solution is not to deny that this problem exists but to identify this as a treatable problem and develop an appropriate public health response.  There is also a very strong bias in the American legal system to punish rather than treat anyone with a psychosis who commits a crime.  Escaping punishment as a result of the not guilty by reason of insanity defense (NGRI) is one of the most consistent urban legends in America.  This defense is hardly ever a success and even then it is likely that the patient involved will spend more time in a forensic prison/hospital than they would have if they were criminally sentenced without the NGRI defense.

The authors are certainly wrong about any “medical model” of psychosis or mental disorders that I am used to seeing.  My medical model is the model of Engel and Chisholm and Lyketsos informed by Kandel and others.  There are very few places it can be practiced in the United States because business interests run the field of psychiatry and medicine.  American managed care companies and governments can certainly reduce psychiatric assessment to a series of checkmarks in the electronic health record and documentation that may be unreadable.

A business model of rationing is not a medical model by any stretch of the imagination.  That business model is also not one that will prove to be receptive to any enlightened model of community care.  The best evidence of that is that the ACT (Assertive Community Treatment) Model invented by Stein, Test and others in 1974.  This model consists of active outreach, crisis intervention and housing, medical and psychiatric care, vocational rehabilitation, and peer counseling with a focus on helping individuals maintain stable housing in the community.  There is no insurance company that I know of that supports this level of care.  The ACT Model is cost shifted to state governments and they strictly ration who gets that level of care.  With regard to Cognitive Behavioral Therapy there is no insurance company that I know of that consistently supports research recommended course of therapy for the conditions that have long standing indications – the anxiety and depressive disorders.  What is the likelihood that it will be supported for the treatment of psychotic disorders and grey zone conditions?

I will hold my remaining remarks on the treatment implications of this paper.  This blog contains extensive commentary on that issue and the real limitations on comprehensive assessment and treatment.

None of those limitations are due to a “medical model.”

George Dawson, MD, DFAPA


References:

1. Margaret S. Chisholm, Constantine G. Lyketsos. Systematic Psychiatric Evaluation. A Step-by Step Guide to Applying The Perspectives of Psychiatry. 2012 The Johns Hopkins University Press. 243 pp.

2. The British Psychological Society. Understanding Psychosis and Schizophrenia. Edited by Anne Cook. Available on the web site of the British Psychological Society.

Abuse Deterrent Opioids - Are They The Solution?

I have a significant interest in opioids, specifically opioid use disorders or addiction to opioids.  We have seen an opioid epidemic in this country largely due to a naïve approach to chronic pain and exposing people unnecessarily to the risk of addiction.  At one level this is a failure of regulators who adopted the idea that chronic noncancer pain is best treated on a mass basis with opioids.  At another level it is a failure of American culture.  Americans are focused on abusable medications and they always have been.  This is not a recent phenomenon.  The reason that addictive drugs are regulated in the first place is that they were widely abused when they could be purchased over the counter from any pharmacy.  Advocates of legalizing drugs almost universally ignore that fact.  It is common to find people hoarding opioid prescriptions, giving them to their neighbors, and taking them for indications other than pain like insomnia, depression, or anxiety.  At the cultural level, opioids are generally regarded as magical pills that will cure whatever ails you.  But there is no such pill.

Physicians are not blameless in this process.  Around the turn of the 19th century, some physicians were maintaining large numbers of people in addiction as part of their medical practice.  At the turn of the 20th century, some physicians advocated “pain as the fifth vital sign” and the widespread practice of recording a patient’s pain rating in routine clinic visits with their vital signs.  In some cases this rating was mischaracterized as an “objective” measure like the other vital signs.  Any physician who is told that the pain rating is a “14” on a scale of 1-10, knows that little objectivity is involved.  The opioid epidemic is often viewed as a problem in physician education or a cognitive deficiency. I doubt that is the problem.  Every physician knows the basics about prescribing opioids by the time they leave medical school.  I can recall working in a clinic of chronic pain patients while I was a medical student in the 1980s.   In that clinic we prescribed hundreds of opioid prescriptions per month.  I also recall that none of those patients was ever asked about addiction or why they still wanted to take the medications even though their pain never seemed to improve.

This problem has also led to significant insights into the real function of the US Food and Drug Administration (FDA).  The FDA web site has three paragraphs on “What we do.”  The first paragraph highlights what I always thought was the main function of the agency:

“FDA is responsible for protecting the public health by assuring the safety, efficacy and security of human and veterinary drugs, biological products, medical devices, our nation’s food supply, cosmetics, and products that emit radiation.”

That seems like a straightforward definition.  In practice it is more complicated.  The best example I can think of to illustrate that is the FDA approval of the sustained release, high-dose hydrocodone product Norco.  The FDA’s own scientific committee overwhelmingly recommended against approving this product in the midst of an opioid epidemic.  They were overruled and the product was approved based solely on the manufacturer meeting regulatory requirements.  Despite concern about getting medications to market fast enough it seems like there are few obstacle to opioid preparations that are basically old medications repacked in a new form.

The financial considerations in this field are significant.  Several years ago speculation was that any successful abuse-deterrent opioid formulation would be a billion dollar a year drug for that manufacturer.  That is highlighted by the number of recent approvals for these drugs noted in the table below.

The current market for abuse-deterrent opioids is estimated to be about $7 billion.  The global pain market is estimated to be worth about $50 billion growing at a rate of 10% annually.  From the table above it is apparent that this is basically a patent extension market.  All of the main ingredients in these medications are generic opioids that are very inexpensive on their own.  By putting them in a special formulation or combining them with opioid antagonists (naltrexone or naloxone) the manufacturers claim they are producing a medication that is less likely to be abused. Whether or not that ultimately happens is anybody’s guess.  I tried to pull up one of the more notable prodrug use web sites and have not seen those compounds and so far no suggestion on how to defeat the abuse deterrence.  There are historical precedents.   Abusable drugs generally follow a predictable course of oral use to smoking or insufflation (snorting) to intravenous use.  Breaking up that chain of events is one strategy that may lead to less severe drug use, but the fact remains that the original oral formulation is still a potent medication that can lead to addiction.  The original case in point was the reformulation of Oxycontin in 2013.  The original capsule could be breached and the contents snorted, smoked, or injected.  The reformulation put the oxycodone in a hydrogel making it less available for snorting, smoking or injecting.  The detailed package insert still says that this formulation and the original formulation place the user at risk for addiction.

What can be learned about the proliferation of abuse deterrent formulations?  There is a strong incentive both in terms of market size and low production costs.  All of the medications in the table are very inexpensive generics that are reformulated with an inexpensive antagonist or a different pill matrix.  The main safeguard is the FDA in terms of the total number of these medications on the market.  The FDA has the potential to decrease the incidence of opioid use disorders.  There is no evidence that is their strategy because they are approving medications over the objections of their own Scientific Committee.  In some cases they discuss post marketing surveillance as being a measure of whether the abuse deterrent medication is working.  Neither of those strategies would seem to be very likely to me.  It is well known that reports of signifiant medication related events are probably very low relative to the actual incidence of these events.  I have previously advocated for a pharmacosurveillance/data-mining solution that would produce results before the expected complications of opioid dependence and unintentional overdoses.  The FDA’s current approach seems to be that further education of physicians will solve the problem.  This is not a problem of physician education.

As the formulations of opioids continue to propagate, there needs to be an awareness that the FDA is not attempting to contain the number of new opioid products released and that a preventive approach is necessary and is more likely to save lives than waiting for people to report complications or waiting for the Drug Enforcement Agency to make arrests.  It is also time to consider what can be done at the level of American culture and focusing on some basic misperceptions that result in the overvaluation of opioids.  The idea that opioids can alleviate chronic pain, that they are the best treatment for chronic pain and that everyone can take them safely are primary among them.

There also needs to be a better understanding of opioid use disorders.  Recent stories in the popular press make it seem like addictions are easy problems to get over.  Just make a decision to stop and most people are able to.  Tell the old story about returning Vietnam vets and how easy it was for most of them to stop using heroin.  These are not the people who are seen in acute care settings or who are treated for drug overdoses.  Many of those people will say that they knew they were using a lot of the drug, that they were not thinking about suicide but they did not care if they lived or died because: "All I wanted to do was get high."

That is a powerful incentive for defeating abuse deterrent pills.



George Dawson, MD, DFAPA   


Supplementary 1: What is an New Drug Application (NDA)? This is the formal application to the FDA where the sponsor (usually a pharmaceutical company) proposes that a new drug be approved for sale and marketing in the United States. For detailed information from the FDA web site follow this link.   

  

Birdman

I was inspired to see Birdman from my Facebook feed after seeing this descriptor: "Birdman WTF?" Up until that point it was just another heavily hyped Hollywood movie.  The hype in this case was the usual promotional stuff combined with the tension of whether or not Micheal Keaton would be selected as best actor in a leading role.  I had seen most of his previous stuff and there were glimmers of my idea of greatness as an actor but always a lot of personality.  My choices were to see it at a theatre or try to stream it.  The only available streaming option was a place I had never used before that required the purchase of their coded streaming device and payment on their Internet site.  After taking care of the technical details, I was ready to roll with little time to spare.  I would see the final scene about an hour before the best picture was announced on the Academy Awards on Sunday night.   The full title of the film is  Birdman or The Unexpected Virtue of Ignorance.

Spoiler alert at this point.  Although it is difficult to give away the ending because it is largely interpretive, I am going to discuss all of the key details that will clearly alienate and anger a few.  So don't read this if you have to see a pristine and not previously described film.  I don't see any way around it.    The opening scene sets the tone for the film and the tone taps into what are typically considered the negative emotions - anxiety, anger, depression, and disgust.  Unlike most films there is nothing to protect you from this level of discomfort.  Riggan Thomson (Michael Keaton) is in a dingy room, seated in a lotus position but suspended in the air about 3 feet off the floor.  He questions himself about how he could have possibly ended up in this situation.  A voice answers him and about a minute later he gets an incoming call on his laptop computer.  The call is from his daughter and as the camera pans to the computer, the viewer realizes from all of the light bulbs around his mirror that this is a dressing room for an actor.  He steps out of the lotus and walks to his dressing table to answer the call.

I knew from the outset that I was going to like this film.  Unless this was an actual superhero film, the scene demonstrates the stream of consciousness of this character.  What he may be consciously aware of and what he is not consciously aware of.  We get some insights into his conflicts and defenses.  It is common to hear a discussion about alter ego or clash of egos as though these are all clear separate entities.  I prefer this presentation to the actor looking at the camera and telling the audience what is happening.

The plot develops fairly rapidly from there and the viewer pieces together the facts that Riggan was a previous star of three superhero movies.  He is divorced and still in an emotional relationship with his ex-wife Sylvia.  He is opening a play on Broadway and is under a lot of pressure financially and professionally to succeed.  He is more clearly defined in the relationships with the rest of the cast, his ex-wife, his daughter, and a hostile critic who at one points assures him that her review is going to close his play after opening night.  He and his daughter Sam (Emma Stone) have a relationship that is hostile at times.  We learn that Sam has a substance use problem and has completed treatment when Riggan confronts her about smoking marijuana.  She lashes out with a diatribe that suggests his struggle to remain relevant is meaningless and he should just accept that fact like the rest of humanity.  Riggan has several additional confrontations with that dilemma over the course of the film with his fellow actor Mike Shiner (Ed Norton) and theatre critic Tabitha Dickson (Lindsay Duncan).  The confrontations with Mike seem to highlight the fact that he is a rising star and Riggan is a has-been.  In the case of Ms. Dickson she brings in the bias that Riggan is just a movie star and that is not the same level of art as a Broadway actor.  The final confrontation with the critic leads to the emotional upheaval that results in the penultimate scene.    

Throughout the film, we hear the dialogue between Riggan and a grandiose and self-centered Birdman.  At times we see the Birdman character in full costume.  In scenes where Riggan is angry he uses telekinesis to throw common objects against the wall and in one scene essentially trashes a room. In another scene he flies effortlessly above the New York traffic for several miles until returning to the front of the theater.  The camera stays on Riggan wherever he is in the scene and the presence and absence of the other actors depends on his trajectory.

What can be made of all of these supernatural occurrences in a movie that is not about a superhero?   I saw these events as narcissistic defenses against his growing vulnerability and an ultimate horror of aging - meaninglessness.  What better way to fight back than to be able to crush your enemies or provide immediate proof of your potency?  What better proof than to fly effortlessly above them?  Who hasn't had those familiar fantasies of unlimited wealth, power, or ability?  The ultimate way to deny dependence on the highly flawed opinions of others is to become an island unto yourself.  There is nobody left to marginalize you if you are living at that level.  As I was typing this, I also had the thought that blogging may be a lower level defense against this same existential crisis.  Is blogging an attempt to type your way out of meaninglessness and anonymity?  If it is - what are you prepared to do to appear to be unique?  What does it mean when there are tens of millions of bloggers out there generating parallel streams of information and minimal productive dialogue?  This kind of crisis can be explored at multiple levels.

Some of the folks in my Facebook feed ask the question: "Does the film glamorize suicide?"  I don't think so.  Suicide is after all part of the final act of the play that Riggan is trying to present.  There is enough ambiguity about the choice of the weapon and what actually happened to question the issue of suicide at all.  It is very difficult to survive the suggested suicide attempt even if the weapon was shooting blanks.  Most suicidal people pointing guns at themselves are highly ambivalent.  In survivors the gun often "just went off" rather than being fired on a volitional basis.  In the narrative with Riggan in the hospital, the description of what he is alleged to have done also seems unlikely when he peels off the bandages and inspects the damage in the mirror.  Even considering that scene as a suicide attempt, the critical question becomes, is it the prelude to another suicide attempt or something else?  The attitude of the film critic and the theatre goers seems to have turned around completely on the basis of the suicide attempt.  They are praising the play and Riggan's business partner Jake (Zach Galifianakis) suggests that the play will be running a long time in multiple venues.  He is suddenly and unexpectedly - a Broadway success.

Riggan's last act seems to be the most confusing.  He is in the hospital room where he is being cared for following the suicide attempt.  After he takes off the bandages, the walks to the window and stands on the ledge.  He jumps.  Sam comes into the room and goes to the window.  She naturally looks down and does not react, but then looks up into the sky and smiles.  Riggan is clearly not dead at this point.  His daughter is finally able to see that he is able to soar, in fact he always was able to - not as the result of conscious planned activity, but the combination of his collective unconscious and the less than ideal relationships he made in the Broadway debut.  In doing this Riggan demonstrates that he can engage the universal struggle through life and come out the other side unscathed and even temporarily transcendent.  In the scene where he says: "I can't do it anymore",  I have lost count of the number of times I said the very same thing to myself contemplating some unsolvable crisis at work.  I was ready to walk away and in one case I did walk away.  In those situations where there is no clear path forward there is a lot to be said for throwing yourself into the breech and seeing what happens, hence the alternate title.  It turns out that the illusion of certainty is not enough to live on - at least for some of us.

That's my interpretation and I'm sticking to it.  I did not read any detailed reviews before writing mine.  I did not go back and try to read a copy of the script, so this in entirely from memory and therefore I may have missed a lot and hopefully not embellished much.  The beauty of art is that many interpretations are possible and that the experience of the viewer is very important.

I found myself closely identified with Riggan Thomson in this film because his struggles are my struggles and I am just as ignorant.  I happened across some scathing comments on sites where I tried to stream the video.   With a film of this nature, I do not find that surprising.  In my experience there will be people who can identify with Riggan's struggles at every step of the way and many others who can not.  There will be people who are very aware of their daydreams, fantasies and defenses and others who are not.  A lot of people go through life experiencing it as a linear exercise in conscious decision making where all of life's major decisions are conscious choices and others do not.

These are some of the dimensions that may make this an enjoyable film.


George Dawson, MD, DFAPA

What Can The APA Learn From UpToDate?

By way of introduction UpToDate is a highly successful online internal medicine text.  It has associated features such as handouts for patients on medications, procedures, and medical conditions.  It also has an online drug interaction feature that allows a limited set of preferences on the part of the physician.  CME credits are available for reading online.  The text covers a broad range of diseases and conditions.  I have asked them for more specific data on the extent of their coverage and total number of pages, but they refused to give it to me citing that it was proprietary information.  I noticed that they currently say that they have 77,000 pages updated by 5100 physicians.

I have been a subscriber to this service for a number of years and the subscription rate is currently about $500/year.  To illustrate how important that number is I need to compare UpToDate to what it replaced.  Ever since graduation from medical school I purchased a new internal medicine textbook about every 4 - 5 years.  I was also a 20+ year subscriber the the Medical Clinics of North America.  I considered it all a part of keeping up on general medicine while practicing psychiatry.  The cost of a typical medicine text like the last one I purchased Textbook of Internal Medicine (William N. Kelley, MD, ed) was somewhere in the $200+ range.  Searching Amazon it looks like my text is out of print by the two comprehensive texts are available for $224 (Harrison's) and $151 (Goldman-Cecil).  Doing the math shows that for $200 you can get a serviceable text that might last you for 5 years (it goes without saying that you always have to do additional reading) and at the end of the day - you still have text in your hand and a valuable reference.  That same 5 year period as a subscriber to UpToDate will provide you with online access of updated data and at the end of that time unless you renew - it is all gone.  Granted it is handy to have this available online if you are working in a hospital setting on different units and the CME feature is very nice - but the cost is about $2500 or twelve and a half times as much as a text every 5 years.

The premium cost in UpToDate relative to a medicine text probably has many things driving it.  The advent of the hospitalist in combination with the electronic health record are probably two of the most significant factors.  If you have internists working 10 hour days 7 days on and 7 days off across large hospitals suddenly there is not time to go to libraries and do research.  All of the information needs to be available as they are essentially word processing documents in the EHR at computer terminals.  In case you haven't tried it, it is also much easier to electronically search a textbook than to heft its considerable weight and keeping flipping flimsy pages back and forth from the index.  Many large groups now provide UpToDate online to their hospitalists and medical specialists in order to keep them working right at those word processing terminals.  These same hospitalists consulting on my inpatient psychiatric unit introduced me to UpToDate when it first came out.

How does all of this this apply to the currently dated and I am guessing infrequently used American Psychiatric Association (APA) Practice Guidelines?  Just looking at the dates of these guidelines shows that applying my approach to internal medicine by purchasing a new text every 4 or 5 years, would have left me more up to date with a psychiatry text than the current APA Practice Guidelines.  What about content in UpToDate?  There are 13 chapters on the major psychiatric disorders that psychiatrists treat.  There are several subheadings under the major headings.  For example, under the heading Anxiety Disorders there are chapters on acute procedure anxiety, acute stress disorder, agoraphobia, combat operational stress,  comorbid anxiety and depression, co-occurring substance use disorder and anxiety, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, and social anxiety disorder.  There are separate chapters on the pharmacotherapy and psychotherapy of these disorders including fairly esoteric approaches to treatment like deep brain stimulation for obsessive-compulsive disorder.   The sections are all detailed and frequently updated.  Not only that but the recommendations section is essentially written as treatment guidelines.  As an example from that section (1):

"We recommend that patients with obsessive-compulsive disorder (OCD) be treated with cognitive-behavioral therapy (CBT), a selective serotonin reuptake inhibitor (SSRI) medication, or both (Grade 1A)."

Their definition of  Grade 1A Recommendation is:

"A Grade 1A recommendation is a strong recommendation, and applies to most patients in most circumstances without reservation. Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present."

This is the general outline of the psychiatric disorders section in UpToDate.  From the sections I have read their literature review and section updates are all within the last 1-2 months and some of the sections are written by top experts in the field.  The detail is well above what an internist or family physician would need but I would not say it is less than what most psychiatrists need.  It gives practical advice on what is known about the treatment of psychiatric disorders and it is condensed down to about 4 - 12 bullet points at the end of each section.  Solid recommendations are made on management where possible and the recommendation is also graded as to whether or not there is good research to back it up.

What is the importance of these developments for psychiatrists, organized psychiatry, and medicine in general?  I think there are a number of important points.  First, psychiatry is represented in a text that is read by internists and family physicians to a greater extent and in more detail than ever in the past.  This is good for several reasons.  It provides some guidance to primary care physicians in considering the treatment of patients with complicated psychiatric problems at time when there may be fewer psychiatrists covering their patients.  It provides them with technical details that are needed to provide care.  It makes it easier for them to assume the care of patients who have be correctly diagnosed but can no longer be followed by a psychiatrist.  Overall it is good for the idea that psychiatry is a mainstream speciality in the field of medicine.  Second, it brings up the critical question of why the APA has a web page with the APA Practice Guidelines listed at all?  Most are hopelessly out of date.  They have little public visibility.  There have been some opinions that the time for practice guidelines by professional organizations are a thing of the past.  After all, managed care organizations and governments write the guidelines now don't they?  A secondary question is what is the purpose of a professional organization?  In my most read post on this blog, I suggest that it is to propose and disperse state-of-the-art treatments to its membership ("There is a responsibility to establish professional standards for patients referred to psychiatrists for the assessment and treatment....").  Certainly there was a recent opportunity.  An expensive effort bringing together top experts in all fields from around the world was done to compile the DSM-5.  The public was clearly confused about this project when the press and several critics equated the DSM-5 to treatment rather than diagnosis and misread the DSM-5 as being something more than it really is - a guidebook to the International Classification of Diseases.  I have seen experts from that collaboration speak at two conferences now and they happen to also be experts in the treatments of these conditions.  Would it have been wise to update the treatment guidelines in the manner of UpToDate rather than leaving the effort at the level of the DSM-5?  I think that it probably would have.

I brought this issue up recently and was told by people at decision making levels in the APA that they are rethinking the Practice Guidelines from a cost effectiveness standpoint.  My thinking on this is very clear.  If the APA does not want to represent the membership as a union dedicated to advancing the rights and interests of the members from that perspective then it really needs to present itself as a professional organization.  APA members certainly don't enjoy the benefits typically seen when businesses or unions lobby Congress.  If anything psychiatry and medicine has been in an unchecked downward spiral of overregulation and exploitation from businesses for about 30 years now.  The argument is typically made that we are a professional organization and focus on professional education and accountability.  Practice guidelines demonstrate that you have the expertise and wisdom to make that claim.  The APA can no longer say that.  There are more succinct treatment recommendations written by experts and more frequently updated in an online text that targets nonpsychiatrists.

I will be the first to suggest that  this is bad for the profession for a number of reasons and further evidence that the APA is doing very little to advance the profession and the plight of its members.  The current guidelines should be removed (at least the dated ones) and the organization needs to think about a streamlined process to construct new ones or get out of the practice guideline field.  



George Dawson, MD, DFAPA    

References:

1:  Simpson HB, Stein MB, Hermann R.  Pharmacotherapy for obsessive-compulsive disorder.  In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on February 21, 2015.)


        

A Return To Asylums Will Not Stop The Rationing

An article was published in the JAMA recently where three ethicists argue for the return of asylum care.  It has become an expected flash point for the antipsychiatry movement as well as some psychiatrists who still think that the word asylum has some meaning.  I thought I would add a more realistic opinion and solution.  I refer readers to the original article or many that I have written here about the reduction in bed capacity in long term psychiatric care.  The reductions are indisputable and well documented.  I am more interested in elucidating the mechanisms behind this reduction and the lack of effective care in the remaining community hospital beds.  The authors allude to the underlying dynamics as captured in the sentence "For the past 60 years or more, social, political, and economic forces coalesced to move severely mentally ill patients out of mental hospitals."  They discuss the well known euphemism for incarcerating psychiatric patients or "transinstitutionalization" and rotating the chronically mentally ill in and out of emergency departments.

The authors even go so far as pointing out the bloated estimated inpatient costs for care in Michigan at $260,000/year/patient and Washington, DC at $328,000/year/patient.   For comparison they include a state of the art facility the Worcester Recovery Center and Hospital that has 320 beds at a cost of $60 million per year or or $187,500/bed/year.  It is difficult to figure out why what may arguably be the best public hospital in the United States has the lowest cost of care for what may be more comprehensive services.  But that is part of the problem.  Most of these institutions are managed by human services agencies through the states and the real fiscal status is always difficult to ascertain.  State and business accounting frequently provides calculations for bed or per patient rates that seem to include unrealistic estimates of overhead costs (often for subpar facilities).  The administration of many of these facilities also seems to depend on restricting psychiatric care at several levels.  In many cases the managed care concept of "medication management" or a "med check" mentality is applied, often with the overall plan of replacing psychiatrists with "prescribers".  Any notion of quality is trumped by a managed care notion of "cost-effectiveness" that typically includes removing psychiatrists from management positions and delegating policy and management at the institutional level to people with no training in psychiatry.

The authors accurately describe the problems of severe mental illnesses.  People have very complex neuropsychiatric disorders and will either not be getting well soon or will never recover enough functioning to do well in any community setting.  They were some of the first victims of "medical necessity" criteria.  I was a Peer Review Organization (PRO) reviewer for Medicare hospitalizations in the states of Minnesota and Wisconsin in the 1980s and 1990s.  For at least part of that time I was sent boxes of medical records from state hospitals for review.  If I looked the the records and decided the patient should continue to be hospitalized, I would get a call from the Medical Director of the PRO suggesting that I should consider the medical necessity criteria.  In the case of long term care, that meant that the patient was "stable" meaning that I would not expect them to change significantly with additional treatment.  If I could say that, the hospital was notified that the patient did not meet criteria for continued long term hospitalization and they needed to be discharged.  In fact, it was very likely that although they were not changing at a rapid enough pace, they would still present formidable problems for community placement.  It may be impossible to discharge them.  In many cases discharge resulted in almost immediate readmission to an acute care hospital and the cycle emergency department to brief hospital admission to homelessness to jail or readmission occurred.  At least until the person was sent back to the state hospital.

In her opinion piece, Dr. Montross suggests that these patients have been abandoned in the name of autonomy or  treating people in the so-called "least restrictive alternative."  That seems at odds with frequent sustained incarcerations for minor and in some cases trivial offenses.  What is really going on here and why do people continue to ignore it?  I have analyzed the problem many times and it is apparently so institutionalized at this point that nobody sees it as a problem anymore. The problem that I continue to point it out is managed care and all of the rationing mechanisms that they employ.  The very first one in the paragraph above is the so-called medical necessity criteria.  Any managed care company physician reviewer can deny care based on their own proprietary guidelines or a purely arbitrary and subjective interpretations of those guidelines.  Managed care companies can harass physicians with mountains of unnecessary paperwork and deny payment or demand payment back based on more subjective interpretations.  Even more problematic, states have incorporated some of these same management techniques and almost uniformly have completely abandoned quality in favor of "cost-effective" care which is quite frankly - care on the cheap.

The end result of all of this cost cutting, rationing, and insurance company profiteering at the expense of patients with mental illness or substance use problems is extremely poor quality care.  One of the authors suggests longer inpatient treatment may be the solution.  Right now practically every psychiatric hospital does their best to get patients discharged in 5 days or less.  Outpatient psychiatrists see patients who have not been stabilized after a 5 day admission.  That is business as usual in acute care psychiatric hospitals.  If that discharged patient makes it to an out patient clinic, they are seen for 10 - 15 minutes in a medication management visit (another fabrication of the managed care industry and the US government) and if they are lucky they discuss the medication and whether it is effective for symptoms or causing side effects.  The problem is that there are important areas in the patients life - like their cognition and social behavior, that are never discussed or evaluated in any productive way.  Very few patients with severe mental disorders receive any kind of psychotherapy despite the evidence it is useful to them.

Putting all of these problems back into the asylum will have predictable results.  The medication management mentality is basically now inside the walls of an institution. There is no enlightened, research driven treatment that addresses all of the problems that the person has.  The asylum is typically administered by a bureaucrat, bound by the same arbitrary budgeting that comes down from the Governor's office.  Across the board spending cuts by a certain percentage and no adjustments when the cash flow is positive.  Money "saved" on asylum care transferred to the state's general fund and used to build roads or whatever was stated in campaign promises.  Suddenly the asylum is an overcrowded bottleneck due to cost shifting by every county in the state who does not want provide services for serious mental illnesses.

The alternative?  How about doing things the right way for once.  We seem to have people who recognize that mental illnesses are not going away, that the current care is atrocious and inhumane, and that it is time to do something about it.  Estimates for the number of people in each state with severe mental illnesses are out there.  Consistent reasonable funding is necessary.  That includes the state, but also it is time to not allow managed care companies to dodge these costs and transfer them to the tax payers.  Finally, it it time to eliminate stakeholder meetings and develop systems of care for the people who it matters the most to - patients, families, psychiatrists, and the other mental health and medical professionals involved in providing this level of care.

Without those conversations, an asylum is just a poorly managed building.    




George Dawson, MD, DFAPA



References:

1: Sisti DA, Segal AG, Emanuel EJ. Improving long-term psychiatric care: bringback the asylum. JAMA. 2015 Jan 20;313(3):243-4. doi: 10.1001/jama.2014.16088.  PubMed PMID: 25602990.

2:  Christine Montross.  The Modern Asylum.  New York Times February 18, 2015.

"Junk" Neuroscience?

A recent comment on my observation that normal function of human memory could explain what he considered to be obvious lies prompted a reading suggestion.  The author suggested that I should read a book called "Junk Neuroscience" by Satel. The only book I could find with a similar title was  Brainwashed: The Seductive Appeal of Mindless Neuroscience.   I am reluctant to spend good money on a polemics when I can get as much polemic as I want by reading it for free on the internet.  It turns out I am familiar with the author's work from a Frontiers in Psychiatry series that I reviewed last year before presenting a CME course lecture on the neurobiology of addiction.  There are currently 19 papers collected there including Satel and Lilienfeld's.  It is somewhat ironic that the entire series is based on a what I would see as assumptions that have a faulty historical, medical and certainly neurobiological premise and that is:

"For much of the 20th Century, theories of addictive behavior and motivation were polarized between two models. The first model viewed addiction as a moral failure for which addicts are rightly held responsible and judged accordingly. The second model, in contrast, viewed addiction as a specific brain disease caused by neurobiological adaptations occurring in response to chronic drug or alcohol use, and over which addicts have no choice or control....."

The first few lines captures the main problem with debates about any topic but it is particularly pernicious when it comes to addiction and neuroscience.  It leads to a number of false observations that seem to be cropping up in the popular press at an increased frequency.  The observation that most addictions spontaneously remit is taken as evidence that they do not require treatment or that neurobiological factors do not need to be considered.  There is the idea that you can be a "heavy drinker" without being an alcoholic suggesting that "heavy drinking" is protective against the factors leading excessive mortality and morbidity in alcoholism.  Those same arguments lead back to the idea that addiction is either a choice or a bad habit.  Both are gross oversimplifications of how complex decision-making is affected in addictions.  One of the main diagnostic systems for addiction from the American Society of Addiction Medicine (ASAM) describes addiction as:  "Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry".  It does not however suggest that addicts "have no choice or control".  In fact, much treatment of addiction depends on a 12-step recovery model that is designed to help learn new controls, improve social affiliation, and re-engineer living environments to remove triggers for relapse.  The learning, affiliation, cravings and relapse triggers all have neurobiological substrates.  Against that backdrop there are 19 papers offered and Satel and Lilienfeld's is one of them.

I happen to be fortunate enough to work at a residential center that specializes in treating addictions.  In addition to the clinical work I present a number of lectures to graduate students, physicians, and residents.  The residents are in primary care and psychiatry.  The two slides that follow are right out of my PowerPoint on the neurobiology of addiction.  The Theories of Addiction slide is intended as a rapid survey of addiction theories.  I put it out there as a warm up and free associate to the theories on the slide.  As an an example, I will look at the nutritional deficiency theory of alcohol or look at alcohol being considered a medicine by itself and how that correlates with per capita alcohol consumption in the US.  I can build on that point by looking at the cultural factors that affect per capita alcohol consumption int he US and the UK.  I might ask groups of physicians if Self Medication is a legitimate theory of addiction.  Practically all physicians have heard: "Listen doc, if you can't do something about my (pain, depression, anxiety, insomnia) - I know what I can do to make it go away for a few hours."  Everybody in the room also knows that in the long run, none of those symptoms/syndromes/disorders can be treated and in fact many become considerably worse as a result of the drug or alcohol use.  Even the example of availability proneness that I typically use only partially accounts for addiction.

Any approach to neurobiology has to account for pathways to recovery as well as pathways to addiction.  In treatment centers most of those pathways are based on learning interventions.  I digress to talk about the how learning occurs both in the addiction process and in the recovery process.  I start out with Kandel's example from his classic New England Journal of Medicine article on plasticity.  His original example talks about two people in a room during a psychotherapy session, and the brain changes that occur in both as a result of that session.  Both people leave the room and their brains have been changed by the discussion.  Experience dependent changes in the brain.  That brief introduction brings me to the four considerations of the neurobiology lecture.  They are listed in the second slide below.  

I think that these are all fairly basic starting points for a lectures on neurobiology and proceed to talk about a number of systems and structures that are thought to be important from a neurobiological standpoint.  I bring in the concept that nobody knows how it all works together by a brief discussion of Chalmers hard problem or the fact that we don't know how anyone's unique conscious state comes about and what that implies.  I am evolving to a new lecture that looks at complex decision making and its roots in the neuroanatomical structures that I discuss in this lecture.  Studying this field is what I consider to be fun.  It brings together a number of concepts from my previous scientific studies.  I would probably be focused on this if I was practicing clinical psychiatry or retired.  I will be the first to admit that I am not a trained neuroscientist, but I have been trained in science and worked in scientific research.

That brings me to Satel and Lilienfeld's paper.  I don't know either author.  If you read the paper it is definitely well written and it has 121 references.  There is a bolded statement before the text begins saying that this paper is excerpted from the book Brainwashed: The Seductive Appeal of Mindless Neuroscience.  As far as I know that is the book that would apparently straighten out my views about neuroscience.  The author's begin with: "The brain-disease model implies erroneously that the brain is necessarily the most important and useful level of analysis for understanding and treating addiction." and build rapidly to a second: "In short, the brain-disease model obscures the dimension of choice in addiction, the capacity to respond to incentives, and also the essential fact people use drugs for reasons (as consistent with a self-medication hypothesis)."

Working at an addiction treatment center and talking with thousands of people in my career with severe addictions leads me to have an explosion of associations whenever I see broad generalizations about the problem.  I don't know that the concept of disease means that an affected organ system is necessarily "the most important and useful level of analysis."  There seem to me to be many diseases where that is not true.  On the issue of "reasons to take drugs" it is seldom as rational as the author's suggest.  A classic example is one that I frequently use when lecturing about the current opioid epidemic.  A significant portion of the population is prone to get a hypomanic euphorigenic effect from taking opioids.  For nonpsychiatrists, that mean the person becomes extremely euphoric, energetic, productive, and socially outgoing.  On the initial night or two, they may engage in work or creative activities at a rate that surprises them.  Many will say: "I thought I had become the person I always wanted to be."  Carefully interviewing that person several months later will get the description that they developed a tolerance to that effect.  Now they were taking the opioid "just to stay well" or prevent withdrawal symptoms.  Koob has described this cycle as  "a chronic relapsing syndrome that moves from an impulse control disorder involving positive reinforcement to a compulsive disorder involving negative reinforcement."  Consistent with this definition is that the drug has both positive (euphoria) and negative (prevents withdrawal) reinforcing effects.  The reason to take the drug is an addiction or the specific match of drug effects on a specific nervous system.  Even in a case when addictive drugs are taken for other reasons (there is a long list) it often is due to the fact that the drug is perceived as having magical qualities or as a rationalization for continuing the addiction.

I could make similar arguments for all of the main points in this paper that I have laid out in the following table.  The authors provide ample details examples to support their contentions.  Part of the problem is that the concept of disease is complex.  When you try to dissect it the problems become apparent.  The other problem is that if this is a disease, it is a disease of complex decision making and very few people focus on that.  

What after all is considered a disease?  Any reader can come up with conditions that they consider diseases for many of the ten points above.  That is easiest for the points involving the clearest comparisons with disease (1, 2, 6, 10).  In other cases (4), their point seems to be somewhat arbitrary.  With any chronic illnesses it is usually possible to function with limited incapacity due to the illness until the late stages.   In some cases the critique has more to do with the unique capacity of the organ than anything else.  For example in point (3), emergent properties that are less obvious can be considered a property an any electrical tissue.  Cardiac tissue can produce electrical patterns of decreasing complexity as a heart ages or is affected by disease.  The brain can produce a very similar pattern (see Supplementary 1).  The only difference is that heart tissue is unable to produce a conscious state.  Two of the points (5, 9) minimize the role of a systems involved in complex decision-making.  This is no trivial matter because it is associated with addictive behaviors that lead most people to classify alcohol and drug use disorders as diseases.  Common examples include people who are unable to stop using drugs and alcohol despite life threatening illnesses, repeated pleas from family members, or repeated problems with relationships, employment or the law.  Deaths due to addiction are common and they impact on a large population.  You are much more likely to see a condition as a disease if you know it has killed somebody.  Point (7) is a curious argument.  In the past several years, I have attended seminars showing for example that in some trials of buprenorphine maintenance for opioid use disorders that the addition of counseling adds nothing to the outcome beyond the medication.   I don't personally believe that, but I am used to seeing people with severe addiction who cannot stop until they are taken out of their using environment.  In every residential treatment center that I am aware of, the main focus is on "personal agency" whether that is 12-step recovery (Alcoholics Anonymous, Narcotics Anonymous) or other methods for psychological change.  As part of that process there is often a focus on neurobiology not as an excuse but as an explanation for how people can become somebody that they never thought they could become and how that process can be reversed.  The other reason for a focus on neurobiology is medication assisted treatment and a discussion of how those medications might work as part of both informed consent and interest on the part of the patients.

I wonder if the best characterization of what is going on here has more to do with philosophy than neuroscience.  As I previously pointed out in a critique of a philosopher's attack on psychiatry - a straw man approach was used.  He suggested that something was true about the field and then proceeded with his attack as if it was true.  When confronted with that single fact and asked about any evidence to support the contention - the people supporting that contention drew an apparent blank.  To this day as far as I know there is no rational way to argue that the APA has an implicit position in the DSM-5 that teaches people how to live their lives.  Even as I write it on the page it is absurd and yet that was the form of the argument.   The current paper is much more sophisticated than that.   It points out the limitations of the disease concept and how that can be used rhetorically but then proceeds to eschew what they refer to as a "neurocentric view" of addiction.  I don't think that argument carries the day largely because there is very little evidence that the people who know neuroscience have the adverse effects that the authors suggest.  There is plenty of evidence that the neuroscientist-clinicians are focused on multiple levels of care.  I have a lot more to say about what is a disease and diseases of complex decision-making but I am going to stop here.  Look for those topics to be addressed in individual posts in the future.  In the meantime, read about the neuroscience of addiction.  The field has added more to brain neuroscience than just about any other discipline in the past three decades.  

I think an additional explanation of my intent in the reply is necessary.  I use the term "political" a lot when referring to editorials, rhetoric, and other polemics.  People who should know better seem to respond to a lot of these articles as though they are either the "truth" or the "facts" that happen to support their viewpoint.  I like my science very dry.  I ascribe to Pigliucci's observation that science is a process and if there is a truth it only occurs at the end of a very long process or a series of approximations.

Seeing it any other way shuts down that process and we are left with something that is ideologically based and no longer science.

George Dawson, MD, DFAPA

1: Satel S, Lilienfeld SO. Addiction and the brain-disease fallacy. Front Psychiatry. 2014 Mar 3;4:141. doi: 10.3389/fpsyt.2013.00141. eCollection 2013.   Review. PubMed PMID: 24624096


Supplementary 1:

I attached these graphics to illustrate that electrically active tissue can have emergent properties that are really unknown by either looking at the tissue or doing other kinds of biological analyses.  That is true for both the brain and the heart.  I don't have the heart graphs but could probably find them.  They are identical.  I do have the graphs of brain activity from a patient with Alzheimer's Disease and a normal control patient.  Recordings are from a single parietal electrode in the delta frequency and show the degree of variability over the same time interval.

Single Electrode EEG - Control

Single Electrode EEG - Alzheimer's Disease