The Conscious Experience of Pain

Drawing of Pain Matrix from reference 2 with permission.

One of the main problems with the assessment and treatment of chronic pain is that there are no quantitative or even good qualitative measures of whether pain exists and how much pain is really there.  The current crisis of opioid overprescription began as an initiative to treat pain more aggressively and that started based on the use of a 10 point scale to estimate pain.  There are many problems associated with that approach but the main one is that it is completely based on the patients self report.  Self report is probably not the best measure when prescribing medications with a significant secondary gain component.  Since that scale is used as a basis for potentially high risk therapies - better metrics would be very useful.

That brings me to two papers that I caught a little earlier this year in JAMA Neurology on the Pain Matrix.   The first is a research letter on the pain matrix.  The authors define the pain matrix as the set of brain structure that are activated by nociception or pain perception.  As a general example they describe the general brain structures like the anterior cingulate cortex, thalamus, and insula.  They cite evidence that these activated structures are considered a possible biomarker for drug discovery and legal proceedings.  The paper is designed to test the veracity of this potential biomarker for pain.  Their model was the administer mechanical noxious stimuli to subjects with congenital insensitivity to pain.  These subjects had SCN9A mutations in the sodium channel of sensory neurons that results in loss of pain sensation but preservation of tactile sensation.  For a discussion of the polymorphisms of this gene see reference 3 and the link on Congenital Insensitivity to Pain (CIP) (4). There were two pain free subjects and 4 controls.  All subjects were scanned with a 3-T fMRI.  They were also asked to rate the stimuli on two dimensions - sensation and pain using a 0 (no pain or sensation) to 10 (most intense pain or sensation).

The test subjects and control reported the same responses to sensation in terms of the subjective ratings with mean ratings(standard deviations) of 4.6(0.5) and 4.4(1.2) respectively.  The painful stimulus was not rated as painful by the subjects but at a level of 3.2(1.8) by the controls.  Most importantly there were no differences on fMRI scanning between the groups with similar levels of activation seen in the thalamus, anterior cingulate gyrus, insula, and pain matrix as a whole.

The fMRI results of the pain matrix response in normal controls and patients who are congenitally unable perceive are extremely interesting.  Both groups had similar tactile sensation.  The authors suggest that caution must be used when interpreting the imaging of this pain matrix for studies looking at the treatment of chronic pain.  At another level, they seem like another addition to a long line of neuroimaging studies that do not seem to correlate very well with what they claim to represent.  An accompanying editorial by Geha and Waxman discusses the fact that the pain matrix has been validated in hundreds of studies using different nociceptive input.  They point out that some researchers equate activation of the pain matrix with the conscious perception of pain.  They review some of the evidence against the pain matrix argument.  One group has shown that activation of the pain matrix is multimodal.  They show how context (monotonous versus novel stimuli) and multisensory and multimodal processing is important.  These authors point out that they have shown fMRI activity in the pain matrix in chronic pain patients without any stimulus.  There cite a study that looks at how the pain matrix is activated in the subacute stages of chronic pain (6-12 weeks) and then as it becomes chronic at up to one year it shifts to emotional circuitry in the medial prefrontal cortex.  The authors also describe emotional and reward related decision making by the ventral striatum and medial prefrontal cortex, and how that activity decreases when chronic pain is successfully treated with carbamazepine while other areas of the pain matrix were unchanged.  Plasticity is also cited as being important both at the clinical level with some basic science support showing that hippocampal neurogenesis was necessary to develop chronic pain behavior in rodents.        

This research is extremely interesting at two levels.  The first is a possible route to quantitative assessments of chronic pain.  A lot of that will depend on a lot more data on the resting state of these brain systems and what changes can be consistently measured.  Having lived through the era of quantitative EEGs - I see too many similarities here to not be skeptical.  It is also not possible to do fMRI studies on chronic pain patients - there are just too many.  Like most psychiatric disorders we need a rapid, inexpensive marker that our patient likely has chronic pain and a measure of severity would be useful.  The second level is broadly important and that is figuring out how human consciousness occurs and how the individual conscious states of chronic pain patients differs.  

Until then - I will be paying close attention to the arguments for and against the pain matrix and research papers that use this description.


George Dawson, MD, DFAPA



References:

1:  Salomons TV, Iannetti GD, Liang M, Wood JN. The "Pain Matrix" in Pain-Free Individuals. JAMA Neurol 2016 Jun 1;73(6):755-6. doi: 10.1001/jamaneurol.2016.0653. PubMed PMID: 27111250.

2:   Geha P, Waxman SG. Pain Perception: Multiple Matrices or One? JAMA Neurol 2016 Jun 1;73(6):628-30. doi: 10.1001/jamaneurol.2016.0757. PubMed PMID: 27111104.

3: Tang Z, Chen Z, Tang B, Jiang H. Primary erythromelalgia: a review. Orphanet Journal of Rare Diseases. 2015;10:127. doi:10.1186/s13023-015-0347-1.

4:  Congenital Insensitivity To Pain (CIP).  Genetics Home Reference.  National Library of Medicine.  Link.

Attributions:

1:  From reference 2 above.  The figure is used with permission of the American Medical Association from JAMA Neurology per the above reference.  License Number 3897150095337;  License Date:
Jun 26, 2016

The State Fair.....

Grandstands At Minnesota State Fair

It has been a little over a year since I last expanded my horizons and did something I would never do on my own.  That event was going on an Alaskan cruise.  It seems like I am experiencing less and less control of my life because last night I scratched off another activity I would not typically consider and that is going to the state fair.  Not just any fair but the Minnesota State Fair.  In the runup to the event I have listed to Minnesotans apply corrections for total duration and a fairground stadium to the Texas State Fair, in order to say that Texas is not really the largest state fair - Minnesota is.  I will leave that argument up to the fair experts.  I am more focused on why people go to a fair in the first place and the fair in Minnesota is an extravaganza.

I am a fully admitted introvert and as one really do not want to be around large and loud masses of people.  So - consider the source of this review.  My entire life is structured around working and getting home and recovering for the next day.  On Friday - the focus is on recovering all weekend for Monday.  Being around people and in awkward social situations is not the pathway to recovery for introverts.  It seriously delays recovery.  In case you are not an introvert, the recovery that needs to occur is a primarily from a heightened sense of tension and anxiety.  In many cases this spills over into autonomic symptoms like accelerated heart rate, tension, feeling flushed and overheated, and a subtle change in breathing patterns.  It also probably affects the perception of situations.  That might explain why both large state fairs that I have attended (Wisconsin and Minnesota) were experienced like Fellini movies.    I expected the same when I walked through the gate and was face-to-face with a young woman wearing a T-shirt that said: "Satan wants you."  But there were more distressing problems than odd T-shirt slogans.

Minneapolis is a large city by any standard, but it is very easy to avoid the city and stay in the suburbs.  On those occasions where I have ventured downtown, I have never observed the crush of people that I have in New York City, Chicago, or Philadelphia.  The Fair is probably the exception to that rule.  Everywhere I went there was a solid stream of humanity 20-30 people wide, often travelling in opposite directions.  There did not seem to be that many destinations but during this week and a half in August the sheer number of people in foot traffic at the fair is probably the highest density of humanity that occurs anywhere in the state.

Food is a related issue.  Gluttony is probably a more appropriate term.  At some point food at the Fair began to take on absurdist qualities.  How many times could the food be deep fried or put on a stick?  At the Fair that seems to be an open question.  In the last several years bacon as a condiment has also been a popular theme with bacon being added to ice cream and donuts.  A friend I was with at the Fair, purchased a drink and a piece of bacon was added as a swizzle stick.  For my own part I had two bites of Australian Fries that are basically deep fried waffle fried potatoes dipped in batter and refried.  The serving size was 4 of these about the size of a medium pancake - covered in either Ranch dressing or liquefied cheese.  I was too conditioned against deep fried food to really enjoy it.  The average Minnesotan tends to view these forays into horrifically bad food with amusement, but at the same time - tons of the stuff are being consumed at a rapid rate and it makes the usual deep fried fast food seem like a health food by comparison.

One of the health parameters that I have not seen discussed anywhere is the air quality at the Fair.  There are so many deep frying and deep frying again establishments in operation all of that aerosolized material has to be vented somewhere.  Many of these establishments had huge roof vents with an obvious non-smoke exhaust.  Aerosolized particles from cooking is a poorly investigated field in medicine but if that was my field of interest I would be attracted to sampling the Fair.  There was more than aerosolized cooking products to deal with.  Cigarette smoke wafted in from both the designated and non-designated smoking areas.  We also now know that humans all have their own unique microbial cloud and emit up to 10⁶  bacterial particles per hour.  That raises the interesting question about whether or not introversion is more than a brain based property and whether at least part of this behavior could be mediated by the immune system.  A fair also has a large number of animals adding more particles to the environment and some of that dust can have immunogenic properties.  I recognize that all of this is speculative and skeptics will ask if there have been any environmentally based illnesses documented in fairgoers.  But my focus is on more than illness or disease.

The most clearcut health problem that I experience at the Fair was ambient sound levels.  In general the sound levels were not a problem.  I did attend a Grandstand Concert given by the Dixie Chicks as part of their DCX World Tour MMXVI.  I could not be construed as a fan of this group and my demographic was underrepresented. 80% of the crowd were women mostly in the age range of 20-45 years old.  Many of them were wearing cowboy boots, probably more cowboy boots than I have ever seen outside of the state of Texas.  Like most concert crowds there was a significant amount of drinking going on and for the first time in a long time - I caught the scent of Mad Dog 20:20.  Some claim to have smelled cannabis, but I did not detect any.  The predominant demographic and their state of intoxication was relevant to the ambient sound levels but first a digression about the actual sound system.

I have no precise knowledge of the grandstand sound systems and could not find any details online.   Apart from portable stacks of speakers and monitors being wheeled about on the stage, it appeared to be two large inverse parabolic arrangement of 20 or more speakers on each side well off the level of the stage.  The opening acts were useful comparisons.  The first act was Smooth Hound Smith a duet that reminded me of a country version of White Stripes except in this case the guitar player was also the drummer.  In terms of sound, the system seemed to be overdriven leading to some distortion and unintelligibility of the lyrics.  The second opening act Vintage Trouble was more of a traditional rhythm and blues ensemble.  Their sound and distortion levels were much less than the first act.  The psychoacoustics may also have been affected by their very dynamic lead singer.  It is risky for an opening act to ask for a lot of audience participation, but he did and was eventually very successful probably through the power of his high energy personality and vocal talent.  By the time the Dixie Chicks took the stage, the sound levels were less distorted but the intelligibility of the lyrics was still a problem.  I was in the nosebleed section far to the left of stage, so I asked people more centrally located if they noticed this problem.  Her observation was that it was a problem and she was glad to see the lyrics projected at one point.

The typical fan in the crowd had no problem at all with the lyrics because they were singing them at full volume.  Imagine sitting in in a sea of 20 year old sopranos singing at full volume and punctuating the songs and transitions with prolonged screams.  The screams were unworldly at times and befitting an audition for a horror movie.  Of course screaming at concerts is nothing new.  It has been there since the early days of rock and roll.  But was this a rock and roll venue?  Are the Dixie Chicks considered to be a rock act?  I don't think so.  There were definite rock elements including an opening recording of Prince and Let's Go Crazy as well as a tribute to Prince complete with his symbol projected on a purple background by the light show.  Judging from the crowd's memorization of complex country lyrics and synchronized movements - Dixie Chicks have produced art with significant meaning to a large segment of the population.  They have sold tens of millions of albums and had no problem at all selling out this venue of 17,000.  One valuable lesson in presentation and marketing is that country acts are presented as rock and rock events these days.  That includes, the amplification, body language, inflection, and associated light show.  The light show associated with this event was first rate including a highly stylized version of a chase scene of the stars inhabiting unlikely vehicles like old Plymouth Valiants and Mercury Montegos at an interlude for an equipment change.  There was also a stream of consciousness display of various prominent politicians flashing across the screen - a possible homage to their previous political controversy when they criticized George W. Bush  about the invasion of Iraq.  

An interesting technical observation had me thinking about what is lost with the sound system.  It brought to mind  recent story about why Freddie Mercury, the late Queen vocalist is considered one of the all time great rock and roll singers.  A study by acoustic experts point out that his vibrato range was a frequency that exceeded most opera singers.  He was also reported to have a 4 octave range.  Although I am not an audio engineer I am a serious student of high fidelity.  I doubt that a distorted and muddy sound system would allow an appreciation of of those characteristics.  You can check your own emotional response to an a capella rendition by Mercury at this link.  On the other hand - Queen fans could probably have a similarly great time at this venue in a parallel manner to the Dixie Chicks fans.    

Despite not knowing their lyrics, being deafened by their fans, and being put off by the low fidelity of the sound system I was able to relate to their music at a couple of levels.  I am a bluegrass fan.  Bluegrass of the derivations from Will The Circle Be Unbroken.  Some of their music has these origins and at one point they played a bluegrass instrumental on banjo and violin.  They also worked with side musicians who had excellent bluegrass stylings on mandolin, acoustic guitar and electric guitar.

Would I see an act like this at the Fair anytime soon?  Only extraordinary circumstances got me out there this time.  Those circumstances would have to repeat in the future.  If I did go - ear protection would be a must.  I might be tempted to bring along a sound meter and noise cancellation head phones to see if I could block the screaming and hear the act.  I would also opt for seating in the center of the Grandstand and on the same level as the speaker system since high frequencies are directional and that affects both the imaging and clarity of the sound.  



George Dawson, MD, DFAPA


References:


1:   Herbst CT, Hertegard S, Zangger-Borch D, Lindestad PÅ. Freddie Mercury-acoustic analysis of speaking fundamental frequency, vibrato, and subharmonics. Logoped Phoniatr Vocol. 2016 Apr 15:1-10. [Epub ahead of print] PubMed PMID: 27079680. (full text link).

Supplemental:

1.  Yes - I was really there:

A Letter From The Surgeon General

Like most physicians in the United States, I got a letter from US Surgeon General Vivek H. Murthy, MD last week.  The focus of the letter was recruiting the assistance of physicians in solving what he describes as "an urgent health care crisis facing America: the opioid epidemic."  As an addiction psychiatrist about one out of every three new patients that I see is addicted to opioids.  I have been lecturing on this topic for 6 years now, so I have more than a passing interest in what the SG has to say.  I have to say that Dr. Murthy wrote an excellent letter.  I was particularly impressed with his second paragraph describing how the was a combination of good intentions to treat pain and aggressive marketing by pharmaceutical companies and the single most important sentence in the letter:

"Many of us were taught-incorrectly-that opioids are not addictive when prescribed for legitimate pain."

Since I was already out practicing for about a decade at the time, I was spared that initiative.  I never assumed that opioids were not addictive, only that some people were more predisposed to addiction than others and that some had such strong adverse effects that they were very unlikely to become addicted.  But in routine psychiatric practice, even before the epidemic it was common to see patients who demanded increasing amounts of addictive drugs or who were hospitalized for adverse effects.  I had treated numerous people who appeared to have dementia, but were longstanding users of opioids, benzodiazepines, and even older sedative hypnotics.

Dr. Murthy goes on to detail the costs in terms of 2 million people with prescription opioid disorder, increasing heroin use, and increasing numbers of cases of HIV and hepatitis C.  He acknowledges that treating pain with opioids and finding the correct balance between analgesia and addiction will not be easy.  He encourages physicians to take the pledge to turn the tide on the opioid epidemic at www.TurnTheTideRx.org and reading the enclosed pocket card to the CDC Opioid Prescribing Guideline.  He also encourages physicians to approach addiction as a chronic illness rather than a moral failing.  That will probably result in some blowback from the addiction is not a disease crowd.  I hope that it is clear from my previous postings that in popular surveys, most people consider addiction to be a disease.  At the scientific level, I think it makes the most sense.  A lot of the confusion in this area comes from a lack of appreciation about how substance use disorders are stratified.  Volkow came up with a good definition in a New England Journal of Medicine paper earlier this year (1) - separating substance use disorders in general from addiction and defining addiction as severe DSM-5 substance use disorders. (the DSM-5 refrains from using the term addiction).

The enclosed card entitled "Prescribing Opioids For Chronic Pain" touches on a few of the high points.  My section by section critique follows (the entire card is below in the supplementary section for review).  Section 1 focuses on pain ratings using the old 0  to 10 scale where 10 is the "worst pain you can imagine".  The unstated problem with that approach is that it is not quantitative and cannot be taken in isolation.  There are people for example where this rating is completely unreliable.  Section 2 is a consideration of non-opioid therapies.  It lists the usual medication prescribed for chronic pain.  The problem here is that acute pain is often an entry point for addiction.  There are many people getting opioids like oxycodone and hydrocodone for what used to be considered trivial injuries, like an uncomplicated ankle sprain.  The  other acute pain entry point for addiction is post operative pain.  There have been studies that show a significant number of patients are still taking opioids a year after their surgical procedure.  It is common for me to interview very young patients who were given opioids for trivial injuries or surgery who became addicted to these drugs.  Physicians need to be very clear on appropriate pain treatments and not offer choices.  For example,  I was told by a friend that he was in a situation where patients were offered acetaminophen, ibuprofen, oxycodone, or oxymorphone.  This is exactly the wrong way to approach the treatment of pain.  In a culture where many people consider themselves to be drug savvy - the overwhelming choice will always be the most euphoria producing opioid.

 Section 3 is a discussion of the treatment plan.  Treatment contracts can be useful here, because most patients need more than a discussion.  They need a document that they can refer to.  It also gives the physician clear anchor points that can be used when discussing a taper or need to discontinue the medication.  Section 4 involves the complicated assessment of harm and misuse.  For most physicians this means the capability to expand their diagnostic capacity from the primary condition and the associated pain disorder to being able to make the diagnosis of addiction.  In some cases there are clear markers (toxicology screens), but in many cases, the patient has developed an addiction as a direct result of the physician's prescription and the line between therapeutic use and addiction is less clear.

The card also provides clear examples of milligram morphine equivalents (MMEs).  This is a term used frequently in the research literature.  When comparing patients on different opioids it is useful to convert whatever opioid they are taking to MMEs.  Mortality and morbidity with opioid prescriptions are generally associated with daily doses greater than 90-100 MME range.  The card points out that this is about 90 mg of hydrocodone or 18 tablets of hydrocodone/acetaminophen 5/300 or 60 mg of oxycodone or 4 tablets of oxycodone sustained release 15 mg.  In patients with addictions it is common to see chronic use of 120-240 mg oxycodone per day.

The card provides advice on starting low and going slow with the dose escalation as well as a suggested taper of 10% per week.  It suggests limited supplies, much more limited for acute pain.  It cautions against prescribing opioids and benzodiazepines concurrently - a practice that remains all too common.  A sentence about how that happens might be useful.  Chronic pain is typically associated with anxiety, depression, and insomnia.  Patients typically are focused on symptomatic relief in all three areas.  That can result not only in benzodiazepine prescriptions but also the prescription of cross tolerant sleep medication like zolpidem or eszopiclone.  Another worse case scenario is the patient using extra opioids for treating these associated symptoms and that is very problematic.  Educating patients about all of these contingencies easily exceeds the time that most primary care physicians have to spend with people.  That may be another reason to have ample documentation available to assist physicians.  There also needs to be a complete discussion of side effects and adverse effects from opioids.

The card transitions into treating an opioid use disorder with medication-assisted treatment like methadone, buprenorphine, or naltrexone.  At this point, I think that the expertise of most primary care physicians has been exceeded and they are looking for referrals to treat the addiction.  I think that the context of care needs to change.  It is very difficult to be in a primary care setting focused on pain as the disorder one week and then transition to addiction care the next.  Most patients will be unable to make that transition in the same clinic.  The idea of offering naloxone for those with high overdose potential on the same card is also confusing.  I could see how it might result in patients being treated for pain and getting prescribed opioids also getting naloxone.  I think that naloxone is more appropriately used with a defined addiction and plan to address the addiction.  The best approach to prevent oversedation and cognitive side effects is close monitoring and gradual dose increases.

All things considered this was a good first effort by the Surgeon General.  I would like to see him become active in changing the cultural attitudes in the US about opioids.  There is a myth that opioids are the magic bullet for pain relief and that is not true especially for chronic pain where the effects are modest and not typically better than non-opioids.  There is a large segment of the American culture that also values getting high and opioids are always discussed from that perspective.  Americans hoard opioid medications and give them away and trade them with other people for various reasons.  When a medication becomes an urban legend like opioids have - it is like the old travelling medicine shows.  Opioids are good for whatever ails you and they make you feel good as a useful side effect.

Countering all of those cultural biases about opioids is a big job - but I am reminded of Surgeon General Koop and his approach to altering American biases about tobacco smoke.                   




George Dawson, MD, DFAPA


References:  

1: Volkow ND, Koob GF, McLellan AT. Neurobiologic Advances from the Brain Disease Model of Addiction. N Engl J Med. 2016 Jan 28;374(4):363-71. doi: 10.1056/NEJMra1511480. Review. PubMed PMID: 26816013. (full text).


Supplementary:

TurnTheTideRx Pocket Card as graphics below.  You can also download the actual card as a pdf at this link:

A Better Analysis Of The Psychiatrist "Shortage"

A paper in Health Affairs on the "psychiatrist shortage" has been getting a lot of press lately (1).  People are acting like the authors' conclusions are definitive rather than highly speculative, but that is a standard approach in the press.  In the article they use American Medical Association (AMA) Physician Masterfiles from 2003 and 2013 to calculate the number of psychiatrists per 100,000 population for those two dates.  They compare it to similar data for neurologists and family physicians.  Between 2003 and 2013 there was a -0.2% change for psychiatrists as opposed to a +35.7% change for neurologists, a 9.5% change for primary care physicians and a 14.2% change for all physicians in this time period.  They also calculated medians for all groups and coefficients to look at workforce distribution.  As expected psychiatrists and neurologists showed some skew of distribution compared with adult primary care physicians.  That could also be seen in the density of psychiatrists by region:  24.47 per 100,000 in New England to 13.33 per 100,000 in the Pacific area.  They show the geographic distributions by highlighting quartiles of distributions on a quartile map of the United States.  The regions highlighted are 300 - Hospital Referral Regions rather than states.

There appears to be a significant typographical error on page 1275: "Our finding that there was almost a 10 percent decline in the population adjusted mean number of psychiatrists per HHR supports the belief that the supply of psychiatrists likely limits patient access to their services".  They are referring to median numbers here and in their abstract where they use the correct term.  The actual number of psychiatrists in 2003 was 37,968 and in 2013 it was 37,889.  The real numbers just don't seem that dramatic.

In the context of these statistics the authors offer a very inconsistent analysis frequently equating the number of psychiatrists with access to services or imposing severe limitations on treatment as illustrated by their statement: "Since the current supply of psychiatrists is not meeting the needs of people with mental illnesses and is not keeping pace with population growth, policy makers and the medical community must consider ways to address the shortage and improve access to mental health care".  This conclusion is quite a stretch considering data that the authors include in the paper.  They use the figure of 9.6 million adults with severe mental illnesses and only 40% of those people receiving care.  That means if the 37,889 psychiatrists they counted had only 250 people with severe mental illness on their caseload - 100% of these patients would be treated.  I propose that psychiatrists only see patients with the severest forms of mental illness and in today's world 250 patients is a very modest caseload.  In the heyday of psychoanalysis, some analysts did not treat many more patients over the course of their career.   At the maximum this suggests a geographical mismatch between patients and psychiatrists rather than a global shortage of psychiatrists.  Is increasing the supply the best approach to this problem?

In another section of their paper the authors point out that psychiatrists account for only 5% of the mental health workforce; 95% being psychologists, social workers, therapists , and counselors.  They acknowledge that they have no equivalent statistics for those disciplines or nurse practitioners or physician assistants.  Many systems of care these days see a prescriber as a prescriber and selectively hire non-physician prescribers over psychiatrists.  Even without the data it would seem fairly obvious that there has been a proliferation of non physician prescribers over the past decade and no shortage of antipsychotic, antidepressant, stimulant, or benzodiazepine prescriptions.  How can there be a shortage of prescribers in a sea of overprescriptions?

The authors notion that "policy makers and the medical community" are going to provide the solution here is also incorrect on several grounds.  First and foremost - if there is a problem - these are the same people who got us here in the first place.  The authors themselves reference a Graduate Medical Education National Advisory Committee study from 30 years ago predicted the shortage.  Any Medline search looking at "psychiatrist shortage" will also yield papers on this topic dating back to 1979.  In that time frame there have been very modest attempts to expand the workforce in psychiatry.  I made that statement based on expansion of residency slots.  The reality is that there are many International Medical Graduates who are well qualified for residency positions and may have even completed equivalent certifications in their country of origin.  The authors also seem to miss the point that these same "policy makers" have initiated policies to expand non-physician prescribing that has led to decreased staffing by psychiatrists in many settings.  They make the typical mistake that policy makers can't have it both ways and they seem quite intent on reducing rather than expanding the psychiatric workforce.  In the argument the only function a declaration of a psychiatrist shortage limiting mental health treatment is to scapegoat psychiatrists for a problem that may be imaginary but at the minimum is out of their control.  The appeal to policymakers also ignores the fact that policy makers in the US, generally advance pro-business policies that place both physicians and their patients at a distinct disadvantage compared to the business.  I will address some of those points below.

Some additional points not considered by the authors:    

  1.  Inefficiencies in the psychiatric workforce are large - Those inefficiencies are two fold.  First, the practice of psychiatry is notoriously inefficient.  I have done comparisons with both ophthalmology and orthopedic surgery on this blog where comparatively fewer specialists cover an impressive array of serious illnesses.  They do this largely through a much better triage system focused triaging the most serious illnesses.  By comparison, the conditions treated by psychiatrists all receive rationed care and in some cases - the care is completely displaced to a non-medical facility.  In most others there is inadequate infrastructure to address the problem.  The facilities themselves are managed by non-medical administrators who in may cases have caused disruptions in care and severe quality problems.  Care is further fragmented by the fact that managed care companies and governments do not provide realistic reimbursement for the care delivered and incentivize hospitals to provide minimal care.

Second,  managed care and government bureaucrats in their infinite wisdom have made psychiatry even less efficient.  I interject the term "medication management" here as an example and will elaborate below.

2.  The prevailing model of care is antiquated and a throwback to the 1980s - The preferred business and government model of care is the so-called medication management visit also more pejoratively known as the med-check.  It is based on a thoroughly poorly thought out idea that people with severe mental illnesses can be treated with medications for the symptoms of those illnesses.  That model does not work at even the most basic idea that there are social etiologies of symptoms that need to be addressed by social and psychotherapeutic interventions.  There are no medications that treat unemployment, separation and divorce, or the sudden loss of a loved one and yet the entire billing and coding structure for psychiatric visits was based on this model.  Even worse - the productivity scale for employed psychiatrists is still based on this model with a rough correlation between how many people are seen in one day and compensation.

3.   Academic and intellectual approaches to psychiatry are at an all-time low -  An intellectual approach to the field is critical whether considering phenomenology, the conscious state of the individual or all of the medical factors associated with treating the psychiatric disorder.  The environment is also frequently neglected because it is managed by non psychiatrists - at least until there is an incident or violence, aggression, self-injury, or suicide that requires analysis.  The intellectual approach to the field requires study of both the individual and the environment that they are in.  An intellectual approach to psychiatry also requires centers of excellence where people with those problems can go to receive expert care.  Centers of excellence are much less common in psychiatry than other fields.  Over the past 20 years academics and educators in the field have been subjected to the same productivity demands as clinicians.  Academic work of all kinds is devalued in order to increase the number of  patients visits focused on medications.  All incentives in place from the policy makers point toward a continued non-intellectual approach to the field.

4.  Practically all employer based positions are burn-out jobs - Reasonable people will work them for a time and then quit and ask themselves how they got involved in that situation in the first place.  The authors seem to think that better compensation or collaborative care models would increase the participation of psychiatrists in these flawed systems of care where they are "supervised" by unqualified business people.  To me the best insurance against burnout and practicing a higher standard of care is to not accept any payment arrangement that involves your work or professionalism being compromised.

5.  Public health and infrastructure needs are always neglected when it comes to psychiatry and mental health -  The most pressing issue is the dismantling of hospital structures and hospitals with therapeutic environments.  We cannot expect this to be rebuilt with the current paradigm of containment and maximizing profit by discharging people without adequate treatment.  Another way to look at the situation is that we cannot expect intellectually stimulating, state-of-the-art treatment environments when the only admission criteria is business and government defined dangerousness.  We also need therapeutic environments for the psychiatrically disabled rather than psychiatric slums and homelessness.

 The public health measures do not stop there.  America's huge appetite for addictive drugs drives a lot of psychiatric morbidity.  This offers one of the best areas for reducing the incidence of psychiatric problems and the need to see a psychiatrist.  Nobody at the policy level seems to be very interested in this problem.  Perhaps it is a resignation to the political success of the cannabis movement and more recent ideas about psychedelics being therapeutic drugs.  Reducing drug addiction and exposure would not only reduce the incidence of accidental overdoses but it would also reduce the incidence and severity of psychiatric disorders by an additional 30%.  Addictive drugs is just one aspect of prevention that is ignored by policy makers.  I would list violence and homicide prevention as a close second.

I still operate from the basic assumption that physicians are bright, well intentioned people.  That means they operate best when they have a manageable schedule, are not overworked and sleep deprived, and are allowed time for intellectual pursuits in their field.  You don't go into medicine to put in 8 hours, punch a clock and go home.  Ideally there is intellectual stimulation at work every day.  The intellectual stimulation certainly needs to be there if the psychiatrist has any involvement in teaching psychiatric residents.  It can't be there if physicians are managed like production workers especially when the product they are producing is an inferior one.

And practically every psychiatrist knows that the business-managed work product that they produce is markedly inferior to what they were trained to do and what they are capable of.  That is what fuels the private practice movement - NOT financial remuneration.

How can anyone expect to recruit and retain psychiatrists when their practice environment is actively being destroyed?  Why would anyone be interested in the field?



George Dawson, MD, DFAPA



1: Bishop TF, Seirup JK, Pincus HA, Ross JS. Population Of US Practicing Psychiatrists Declined, 2003-13, Which May Help Explain Poor Access To Mental Health Care. Health Aff (Millwood). 2016 Jul 1;35(7):1271-7. doi: 10.1377/hlthaff.2015.1643. PubMed PMID: 27385244.

Just When You Thought American Healthcare Could Not Get Any Worse.....

I was on a vacation/family reunion last weekend about 150 miles north of the Twin Cities and 120 miles west of the only large northern metro area.  We were in the heart of lake country and about an hour from the closest emergency department (ED).  About 20 people of all ages there  for a few days to get reacquainted after a number of years, enjoy some good traditional foods, and outdoor activities.  Things were going very well until the last day.  Everyone was exiting the lake home to go to a local pizza establishment.  One of the family members missed the last step and fell hard to the pavement, knocking the lens out of his eyeglasses and sustaining a contusion/abrasion over the left supraorbital ridge.   No loss of consciousness.  He did sustain an abrasion on the left hand with some residual wrist pain.  He has some chronic medical problems but is not on anticoagulants.  Another family member is a nurse and applied an ice bag and cleaned a small laceration in the area of the abrasion.  It did not appear to need sutures and it was steri-stripped.

The only other bit of information that is necessary about the injured man is that he is 80 years old.  As a geriatric psychiatrist I ran down the usual considerations of the old approaching the old old - especially anatomic traction on bridging veins and subdurals from that injury.  I did not want to miss any needed brain imaging protocol based on these factors.  I decided to call the local hospital emergency department and run it by the triage nurse.  The call went like this (this is not a transcript).

Hospital:  "Can I help you?"
Me: "Yes - I am currently out at a lake cabin and a family member took a fall and struck his frontal area.  No loss of consciousnesses, headache, visual change, or neurological findings.  I would like to talk to your ED triage person to see whether imaging is indicated."
Hospital:  "Is he from Minnesota?"
Me:  "No he is not."
Hospital:  "We cannot allow you to talk with the ED if he is not from Minnesota.
Me:  "Are you sure about that?"
Hospital:  "Yes very sure."
Me:  "I am a physician - is there any way that I can talk directly physician-to-physician with an ED physician."
Hospital:  "No you can't.  You have to call the number on the back of the insurance card."

That was a precedent setting call for me.  I did not identify myself as a psychiatrist, but I have really never encountered this kind of administrative obstacle to medical care.  I viewed my question as an important one and one that an ED physician would probably know more about than me.  In that context there was something about an out of state resident not getting equal access to medical care.  I am sure it would be easier to get access in France or Germany than it was in Minnesota.  I collected the medical card and made a second call to the nurse triage line listed on the back of the call.  My experience with nurse triage lines is that they at least call the physicians on call and get some semblance of an answer to your question - even on the weekends.

Me:  Explaining the situation again in its entirety and giving all of the relevant insurance information both on and off the card.  The off card data included date of birth and three repeats of a call back number.  It was at that point the triage nurse said:
Triage RN:  "Well I am afraid I can't help you because you have to talk with a nurse who is licensed in the state where your relative resides.  But I will transfer you."
Me:  "OK"
Cricket sounds and bad muzak for about 5 minutes.
Triage RN (back on the line):  "The wait times are too long.  Let me just tell you that as long as he has no headaches, nausea, vomiting, visual changes or neurological symptoms - you can just watch him.  Bring him to the ED if any of those symptoms occur."
Me:  "OK - there is no imaging study given his age?"
Triage RN: "No".

As multiple posts on this blog can attest - I am openly critical of how business and government interests have rationed access to health care.  I had really never imagined obstacles to standard health care based on your state of residence.  I had never encountered a system that refused physician contact with another physician in their system.  I can see the gears turning on how to turn these calls into billable fees, even if it means a steep out-of-pocket payment by the patient.  But even in that case giving me the correct medical information is money in their pocket if it results in a CT scan.  Medical imaging generally covers about one-quarter of the operating budgets of hospitals these days.

For now it appears that after hours physician consultation may be rare and a sequence of calls based on legitimate concern needs to be answerable by a triage nurse's database or a visit to the emergency department.

And you better hope that you are in the right state.



George Dawson, MD, DFAPA




Supplementary (posted on August 23):

Getting back home and doing a little more research shows that both the Emergency Medicine (2) and Internal Medicine (1) literature say that age alone is an indication for a CT scan following a minor TBI.  UpToDate says that age 65 years of age or older is an indication.  The emergency medicine literature uses New Orleans Criteria suggesting an age of > 60 and the Canadian CT Rule suggesting an age of > 65 under CT if any criteria present.  According to these criteria - age alone is an indication for a CT scan.

1:  Randolf W. Evans.  Concussion and mild traumatic brain injury. In: UpToDate, Aminoff MJ, Moreira ME (Eds), UpToDate, Waltham, MA (Accessed on August 22, 2016). - see graphic 50743.

2:  Haydel M. Management of mild traumatic brain injury in the emergency department. Emerg Med Pract. 2012 Sep;14(9):1-24. Epub 2012 Jul 20. Review. PubMed PMID: 23101569. (full text online).


Attribution:

That's me walking on a dock in Lake Country.

Indexing Versus Diagnosis - A Non-trivial Difference?

There was an interesting article written by Kenneth S. Kendler, MD in this month's American Journal of Psychiatry.  It addresses a phrase that I have seen in typed evaluations that causes me to cringe: "The patient does/does not meet criteria for major depression."  I was asked why that phrase bothered me so much and I basically pointed out that I don't care whether a person "meets criteria" for a specific DSM criteria - the overall assessment was more important to me.  Kendler describes the difference in terms of phenomenology - are there other aspects of depression that merit further description than what is in the DSM?  That seems true to me as well as, the time domain of symptoms development and how some of the critical symptoms may have developed.  On a developmental basis - sleep, anxiety, and depression all may have different time frame and given the length of time that the DSM approach has been around - there has been very little discussion of some of the key convergences and divergences.  Is primary insomnia beginning in middle school associated with depression in the twenties - the same problem as no insomnia in childhood and depression in the twenties.

To study the issue Kendler looks at 19 textbooks and 18 symptoms domains described in each of those textbooks.  He has specific criteria for textbook selection that resulted in 19 texts from 5 countries published between 1899 to 1956.  He included full criteria published by Wendell Muncie in 1939 and Aubrey Lewis in 1934 as being particularly instructive.  He looks at the number of authors describing a particular symptoms and additional descriptors of the symptoms they found in depressive states.  Just looking at neurovegetative states, the results are interesting.  The atypical depressive symptoms of hypersomnia and increased appetite and weight gain were essentially absent. Fourteen authors described sleep problems as initial insomnia or non restorative sleep.  Three authors described early morning awakening.  Poor appetite was listed by 10 authors and weight loss by 9 authors.  Anhedonia was listed by seven authors.  Kendler provides a detailed analysis of the remaining symptoms and how many of the authors consider these symptoms to be representative of depression.

One of the most instructive aspects of the paper was a direct comparison with DSM5 criteria across 18 symptoms, whether they are covered in the DSM and to what extent.  The symptoms not covered included volition/motivation, speech, other physical symptoms, anxiety, and depersonalization/derealization.  Experienced clinicians commonly encounter depressed people with all of these symptoms in everyday practice.  As an example, some of the most severely depressed people that I have treated were somatically focused to one degree or another on a continuum to the point of somatic delusions.  Adhering to DSM5 criteria would leave out the most important feature of their illness.  A more complete description of these symptoms allows for a better demarcation of the line between depression and psychotic depression - a critical line for developing a treatment plan.  Another critical aspect is the relationship between anxiety and depression.  The DSM tends to sacrifice a broader phenomenological approach for narrow, easily determined diagnostic markers.  Instead of describing the anxiety associated with depression, depressed patients often end up with additional diagnoses of anxiety disorders and in the DSM field trials it appears that anxiety and depression morph into on another and the criteria appear to have low diagnostic reliability in that context.

The broader concept from Kendler's philosophical perspective is whether meeting criteria is that same thing as having the disorder.  From a phenomenological perspective it is certainly possible to produce detailed analysis of patients that do not resemble one another in many regards.  Considering the fact that depression is always mapped onto unique conscious states that should not be too surprising.  Kendler's idea is that the DSM5 criteria do a "reasonable but incomplete job of assessing the prominent symptoms and signs of depression in the western post Kraepelinian tradition  ".  The idea of indexing cases of depression from what is not depression is relevant here.  I think that he should have been a little more specific in his criticism.  I don't think they do a reasonable job when they are not part of a psychiatric assessment by a psychiatrist who has enough time to do a good job.  Taking the DSM5 criteria and converting them into a checklist and applying that to the masses comes to mind.  This is probably the most absurd conclusion to the indexing concept, surpassed only by telling those who are screened that "you meet criteria for depression and that meets our health plan criteria to start citalopram".

 Kendler points out the consequences of reifying diagnostic criteria to the point that they become distinct disorders in the absence of any quantitative markers.  Andreassen made similar arguments about DSM technology and the death of an interest in psychopathology in a previous paper (2).  Both authors seem to miss the mark in terms of what is really missed here.  The diagnostic nosology has shifted from a relative simple mind based paradigm to one that purports to pick up extreme conditions at the fringe of human behavior.  The accuracy of those diagnoses is less as the described disorders get more common.  Human consciousness appears to be the critical variable here and there remain very few commentators on this issue.  Psychiatric disorders become very complex once the psychiatrist goes far beyond symptom lists and even personality disorders and what is commonly considered personality traits to recognizing that the person in front of you is a truly unique conscious state associated with a unique neurobiological state.

              

George Dawson, MD DFAPA



References:

1: Kendler KS. The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria. Am J Psychiatry. 2016 Aug 1;173(8):771-80. doi: 10.1176/appi.ajp.2016.15121509. Epub 2016 May 3. PubMed PMID: 27138588.

2: Andreasen NC. DSM and the death of phenomenology in America: an example of unintended consequences. Schizophr Bull. 2007 Jan;33(1):108-12. Epub 2006 Dec 7. PubMed PMID: 17158191; PubMed Central PMCID: PMC2632284. (full text)


Attribution:

Quote at top is from reference 1 by Dr. Kendler.

Open Psychiatric Units Mean Fewer Suicides and Elopements ?!!

There is a headline making the rounds in the media about whether or not locked psychiatric units are useful in preventing suicides and "absconding" behavior in inpatient psychiatric units.  Absconding is running away before the formal discharge and in the US it is referred to as elopement.  The media handling of this article is a bit less scholarly than you might expect from the average psychiatrist reading this article.  Even media circulating to psychiatrists sends out the headlines from a news service:  "Locked psychiatric wards may mean more suicide or escape attempts." Since I have spent the majority of my career on locked psychiatric units and consider myself an expert in this area - reading the article and looking at its deficiencies comes naturally to me.

The article looks at a coalition of 22 German psychiatric hospitals and their affiliated psychiatric services.  Sixteen of the hospitals had at least one locked psychiatric unit over the course of the study.  Four hospitals had no locked wards over the course of the study.  One of the hospitals started out with no locked wards but "had to introduce locked wards for legal reasons" in November 2000. organized under a central agency that looks at quality assurance and quality management.  Twenty one of the hospitals participated in data analysis by a central quality assurance/management agency the Dokumentationsverbund Psychiatrie (DVP).  The study period ran from January 1, 1998 to December 31, 2012.  This was  an entirely retrospective analysis based on anonymized data.  During the study period there were 271,128 admissions to locked wards and 78,446 admissions to open wards.

Primary outcome variable was completed suicide and secondary outcome variables were suicide attempts during treatment, elopement without return, and elopement with return.  Some of the characteristics of the populations were described and they appear to have diagnoses similar to what might be found on inpatient units in the US with major difference - some of the primary diagnoses listed would likely not be admitted - like somatoform disorder or personality disorder as a primary diagnosis, but the study says very little about admission criteria.  On American inpatients psychiatric units pure substance use disorders are actively discriminated against, by insurers and government agencies that govern hospitalizations and in the German sample. they constitute 18-25% of the primary diagnoses.  The authors do a statistical comparison between the locked ward and open ward groups across the outcome variables.               

There are two logical flaws with the study and the researchers comment on one.

The first is generalizability of the data.  The authors seem to recognize this in their use of OECD data and the rates of psychiatric bed utilization in Germany (2.8 per 1,000 population) versus the UK (0.5 per 1,000) and the US (0.3 per 1,000)  suggesting that there is greater acuity in the populations with fewer beds and that there is a greater proportion of acutely ill patients.  The other parameter that is critical in American inpatient psychiatry is the number of aggressive and homicidal patients.  At large metropolitan hospitals units comprised almost entirely of highly aggressive patients are not unusual.  Other patients are generally considered too vulnerable to be admitted to these units.

Aggressive behavior can create near riot conditions on units like this and an unlocked door would create numerous situations leading to violent confrontations with staff.  The striking part about this comparison to the German system was that this paper left out all mention of aggression, violence and homicide suggesting that these patients were not being admitted to these hospitals.  The only line containing these words in the entire paper was in one of the references.  That makes this study impossible to compare with any set of metropolitan psychiatric units in the US.  There is the associated question of what the Germans do with their aggressive patients?  Are they sent to forensic hospitals or specialized units?  It would be very unlikely to not encounter thousands of highly aggressive patients in any American sample this large even at a time when the largest psychiatric hospitals in the country are county jails.

The second is that the implicit notion about a randomized controlled trial.  For the reason I previously mentioned it is not likely to be ethical, amenable to human subjects approval or therefore doable.  The authors suggest that being under a mandate to treat all patients in a certain geographic area reduces selection bias.  That is difficult to accept if potential for aggression and overt aggressive behavior is not an admission criteria and if it not compared between the locked and unlocked units.      

That said, what can American psychiatric units learn from the German experience?  The first and most important is that unlocked units are possible.  I worked at a facility that typically had 4 psychiatric units and when we started one unit was open.  It was a transitional unit where people were sent after their acute disorder, agitation, aggressive behavior. and suicide risk was treated but they were not quite ready for discharge.  The management of psychiatric units by business managers eventually dictated that these partially stabilized people should just be discharged - frequently when there had been an almost imperceptible improvement.  This was all based on the fallacious "dangerousness" argument by managed care companies.  They decided about 20-25 years ago that the only reason anyone should be hospitalized on an inpatient psychiatric unit was if they were dangerous to themselves or others.  That also led to locked hospital wards, if not by implication by explicit managed care feedback as in: "If the patient does not need to be on a locked unit - they don't need to be in the hospital and therefore we are denying payment for this admission."  Have these managed care tactics dumbed down inpatient treatment and adversely affected the atmosphere of these units?  Of course it has.  It has created a palpable corrections-like atmosphere in many units.  The only reason people are there is to figure a way to get out.  This reinforces the thought that the people there really don't have any problems in the first place they are just being discriminated against.  So the first lesson from Germany is to restore the running of hospitals to psychiatrists and not business managers.

The second issue is infrastructure and length of stay (LOS).  Most EU countries have significantly more psychiatric beds available to their populations.  The most likely reason is that they are not rationed (nearly out of existence) by managed care companies or the government like they have been in the US.   Lengths of stay are also significantly greater.  The interesting dimensions for comparison would be the functional status of patient at discharge as well as the therapeutic milieu in comparing German to American units.  That would require a more sophisticated research approach but it might bring some science to inpatient psychiatric care.  It would also be interesting to know if the German hospitals have state of the art specialized programs for specific conditions and whether their environment is designed to emphasize the therapeutic rather than containment aspects.

There is also the opportunity to look at the administrative aspects of these units more specifically the impact of a business management approach to a more clinical or at least less of a short term profit approach.

We have all witnessed what healthcare businesses can do to inpatient care in the US - and it is never good. 

George Dawson, MD, DFAPA

References:

1: Huber CG, Schneeberger AR, Kowalinski E, Fröhlich D, von Felten S, Walter M, Zinkler M, Beine K, Heinz A, Borgwardt S, Lang UE. Suicide risk and absconding in psychiatric hospitals with and without open door policies: a 15 year, observational study. Lancet Psychiatry. 2016 Jul 28. pii: S2215-0366(16)30168-7. doi: 10.1016/S2215-0366(16)30168-7. [Epub ahead of print] PubMed PMID: 27477886.