More On Homicide Prevention

As the number of mass homicides becomes even more noticeable it is getting some attention in the psychiatric press. This months Psychiatric News has a story that looks at the issue of "explanations" for mass killings. There were a couple of new terms that I was not familiar with such as "rampage violence" or "rampage", "autogenic", or "pseudo-commando" killings.  The perspective in the article was generally public health research or the perspective of forensic psychiatrists. Inconsistencies were apparent such as:

"... Much research has shown that mental illness in the absence of substance abuse does not lead to violence and that most crimes are committed by people who have not been diagnosed with mental illness."

Followed by:

"Even when behavior reaches a level troubling to family or neighbors, getting an affected individual into treatment is difficult, especially in a society that highly values individual liberty..."

Are they referring only to those people who are abusing substances or only those people who become violent as a result of mental illness? My experience is that both categories are important and that is illustrated within the same article that refers to a study of five "pseudo-commando" murders where common traits were noted including the fact that all of the subjects were "suspicious, resentful, narcissistic, and often paranoid".

The overall tone of the article is that we may be too focused on mass homicide because only a small number of people were killed in these incidents compared to the 30 to 40 people per day who die from homicide and that violence prediction may be a futile approach. There is also commentary on why neither the Democrats or Republicans want to comment on this issue. An uncritical statement about the "support for gun ownership" being at an all-time high is included in the same paragraph.  Like most things political in the US, all you have to do is follow the money.

The same issue was covered in the September issue of Psychiatric Times.  Lloyd Sederer, MD takes the position that apathy fueled the lack of a sea change in gun control following the incident when Congresswomen Gifford was shot and several people at that same event were killed.  He includes an apathetic quote from Jack Kerouac and a nonviolent activist quote from Gandhi.  Allen Frances, MD makes the reasonable observation that understanding the psychology of a mass killer will not prevent mass homicide, but proceeds to stretch that into the fact that this is a gun issue:

"We must accept the fact that a small cohort of deranged and disaffected potential mass murderers will always exist undetected in our midst."

and

"The largely unnoticed elephant in the room is how astoundingly easy it is for the killers to buy supercharged firearms and unlimited rounds of ammo.  The ubiquity of powerful weaponry is what takes the US such a dangerous place to live."

He goes on to suggest that there are only two choices in this matter: accept mass murder as a way of life or adopt sane gun policies with the rest of the civilized world.

I don't think that gun laws are the best or only approach.  The idea that "supercharged" firearms are the culprit here or the extension to banning assault weapons as the solution misses the obvious fact that even common widely available firearms - shotguns and handguns are highly lethal.  Anyone armed with those weapons alone would be unstoppable in a mass shooting situation.  Secondly, the effects of stringent firearms laws have mixed results.  The mass shooting in Norway is an example of how tight firearm regulation can be circumvented.  It is well known that there are a massive amount of firearms under private possession in the US, making the effect of firearm legislation even less likely.  There are also the cases of heavily armed citizenry with only a fraction of the gun homicides that we have in the US.  Michael Moore's comparison of the US with Canada in "Bowling for Columbine" comes to mind.

The previous posts on this blog suggest clear reasons why gun ownership is at an all-time high. The problem is that much can be done apart from the gun ownership issue and the solutions are available from psychiatrists who are used to assessing and treating people with mental illness, severe personality disorders, threatening behavior, or history of violent or aggressive behavior. The critical dimension that is not covered is the issue of prevention and the necessity of an open discussion about homicide and how to prevent it. Education about markers that are associated with mass homicide is useful, but the focus needs to be on how to help the person who starts to experience homicidal ideation before they lose control.  That is also consistent with a humanistic approach to the problem.  I have treated many "deranged and disaffected potential mass murderers" who went back to their families and back to work.  We need a culture that is much more savvy about the origins of violence and aggression.  It is too easy to say that this behavior is due to "evil" and maintain attitudes consistent with that approach.  Time to develop research on the prevention of mass homicide, identify the individuals at risk, and offer effective treatment.

George Dawson, MD, DFAPA

Aaron Levin.  Experts again seek explanations for mass killings.  Psychiatric News 2012 (47)17: 1,20.

Lloyd I. Sederer.  The enemy is apathy.  Psychiatric Times 2012 (29)9: 1-2.

Allen Frances.  Mass murderers, madness, and gun control.  Psychiatric Times 2012 (29)9:1-2.

Borderline Personality Disorder - DBT versus GPM

I just got back from a Mayo Clinic CME course "Clinical Management of Borderline Personality Disorder". I went to see John G. Gunderson, MD.  He and I go way back in a peripheral sort of way to the days before the Internet.  About 20 years ago I sent him a letter and he mailed me a copy of his "Diagnostic Interview for Borderlines." That was about three years after Marsha Linehan mailed me a rough copy of her research protocol for Dialectical Behavior Therapy. I like to see and hear from the experts.

The course was excellent and the logical summation of work done in this field for the past two decades. It was accessible and the faculty that included Dr. Gunderson and Brian Palmer, MD were enthusiastic and optimistic about treatment outcomes. Dr. Gunderson pointed out that sampling bias has led to therapeutic nihilism and stigmatization in the past and that more recent outcome studies show very positive results. The basic tenets of therapy that you learn in psychiatry school can go a long way. Therapeutic neutrality, and active interest in with the patient has to say, the therapeutic alliance, and technical skill with specific interventions are common elements in working with patients across all diagnostic categories.  If the diagnosis is accurate psychopharmacology is a secondary intervention.  The primary focus is psychotherapy and case management.

One of the significant points in the presentation was the concept of General Psychiatric Management (GPM) in the treatment of borderline personality disorder. In the years since I received the DBT manual, in many areas that therapy has become the de facto standard of care for borderline personality disorder. There is research evidence that it is effective.  DBT treatment programs seem to have popped up everywhere in the past decade. My experience in inpatient units led me to observe that many of these patients seem to have been misdiagnosed or DBT was being applied to the wrong diagnosis. There are fairly specific selection criteria for DBT, but it seems that anyone with a difficult problem was being put in a DBT program.

Dr. Gundersen referenced an article in the American Journal of Psychiatry comparing GPM versus DBT.  General Psychiatric Management is a variation of what we used to call supportive psychotherapy and it was defined by the researchers as:

"General psychiatric management was implemented as a comprehensive approach to borderline personality disorder, developed and manualized for this trial, consisting of psychodynamic psychotherapy, case management, and pharmacotherapy (P.S. Links, Y. Bergmans, J. Novick, J. LeGris, unpublished 2009 manuscript). The psychotherapeutic model in this approach emphasized the relational aspects of the disorder and focused on disturbed attachment patterns and the enhancement of emotion regulation in relationships. Case management strategies were integrated into weekly individual sessions. No restrictions were placed on ancillary pharmacotherapy in either condition; in general, pharmacotherapy was based on a symptom-targeted approach but prioritized mood lability, impulsivity, and aggressiveness as presented in APA guidelines (16)." (see link below to McMain 2012)"

The study showed that the outcomes of both treatment modalities across several outcome measures (suicidal and non-suicidal self injurious behavior, depression, anger, interpersonal functioning) were comparable.  GPM was delivered as once a week hourly psychotherapy with additional case management and coordination of care.  This is important research because the logical extension of this research is to look at ways to improve functional capacity as well as symptomatology.

Take a look at the references and attend the seminar in the future if you have the chance.

George Dawson, MD, DFAPA

John G. Gunderson and Brian A. Palmer.  Clinical Management of Borderline Personality Disorder.  Mayo Clinic CME, September 14, 2012.

McMain SF, Links PS, Gnam WH, Guimond T, Cardish RJ, Korman L, Streiner DL. A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. Am J Psychiatry. 2009 Dec;166(12):1365-74. Epub 2009 Sep 15.

McMain SF, Guimond T, Streiner DL, Cardish RJ, Links PS. Dialectical behavior therapy compared with general psychiatric management for borderline personality disorder: clinical outcomes and functioning over a 2-year follow-up. Am J Psychiatry. 2012 Jun;169(6):650-61

Medscape Has Not Stopped Anonymous Postings

I had to put this comment here because my attempt to post it on the Psychiatric Times was unsuccessful.  I tried to put this comment in response to an article by Ronald W. Pies, MD on anonymous posters that are abusive and in some cases threatening.  He discusses situations where psychiatrists who are not anonymous are subjected to these tactics by anonymous posters.  He  goes on to say:

"It was therefore with great satisfaction that I learned of a new (6/27/12) policy on the popular medical Web site, Medscape; ie"we have removed the ability to post comments anonymously in our physician-only discussion forum, Medscape Connect, and in all Medscape blogs."

I am familiar with the discussion area on Medscape for quite a long time.  There are anonymous posters there who are somewhat disagreeable.  There are anonymous posters there who clearly have a lot of time on their hands.  There are posters there whose main goal is to denigrate psychiatry and psychiatrists.  Interestingly posts against psychiatrists and psychiatry have never been censored, no matter how off the wall they are.  One psychiatrist fighting back, made several posts that were pulled.  The abusive anonymous posters there usually fall back on "freedom of speech" as their right to say whatever they want about psychiatry.  As far as I know only a psychiatrist was ever censored in that forum - but in that case an entire series of posts was pulled.

I have always advocated for physicians posting under their own name in any Internet discussion by physicians.  When that does not happen there is always a predictable amount of rhetoric and name calling.  At times the posts on Medscape were at such a level it was difficult to believe that they were made by physicians.  Of all the specialty discussion boards on Medscape, it is probably no surprise that psychiatry was the only specialty under attack.

The problem currently is that despite their advertised policy, posting on Medscape's physician discussion forums really have not changed.  I just looked at the forum and anonymous posting is alive and well.  Bashing psychiatry is alive and well.

Old antipsychiatry habits die hard.

George Dawson, MD, DFAPA

Ronald W. Pies, MD.  Is it time to stop anonymous (and abusive) posting on the Internet?  Psychiatric Times; August 16, 2012.

Why Are There No Detox Units Anymore?

Acute withdrawal from drugs and alcohol can kill you in the worst case scenario and at best can prevent you from initiating the recovery process.  So why are there no detox units anymore or at least very few of them?  You can still end up in a hospital going through detoxification or in a county facility where the priority is more containment of the acutely intoxicated than appropriate medical detoxification.  There are probably a handful of detoxification facilities where you will see physicians with an interest or a specialty in addiction medicine using the best possible standards. Why is the government and why are the managed care systems that run healthcare in the United States not interested in "evidence-based" medical detoxification?

As a person who has seen the system devolve and who has successfully treated a lot of people who needed detoxification this is another deficiency in the system of medical care that is never addressed. Over the course of my career I have seen patients admitted to internal medicine services for detox in the 1980s. When insurance companies and managed care companies started to refuse payment for that level of treatment intensity patients requiring detoxification were then admitted to mental health units.  When mental health units started operating according to the managed care paradigm of no treatment for people with severe addictions, they were either sent home from the emergency department or sent to county detox facilities.  Those county detox facilities were often low in quality and one incident away from being shut down.

I currently teach physicians about the management of opioids and chronic pain in outpatient settings.  I am impressed with the number of addicted patients who are taking opioids for chronic pain.  This population frequently has problems with benzodiazepines.  There is a general awareness that we are in the midst of an opioid epidemic and in many counties across the United States the death rate from accidental drug overdoses exceeds the death rate from traffic fatalities. The question I get in my lecture is frequently how to deal with the addicted pain patient who is clearly not getting any pain relief from chronic opioid therapy and has often escalated the dosage to potentially life-threatening amounts.  In many chronic pain treatment algorithms this is the "discontinue opioids" branch point.   During my most recent lecture I posed the question to these physicians: “Do you have access to a functional detoxification facility?"  Not surprisingly  - nobody did.

I can still recall the denial letters from managed care companies when I was taking care of patients with alcoholism and addiction in an inpatient setting. They had been admitted to my inpatient mental health unit and many were also suicidal. The typical managed care comment was "this patient should be detoxified in a detox unit and not admitted to a mental health unit.”  This is an example of the brilliant concept called "medical necessity" as defined by a managed care company. In the majority of these cases, the patient's county of residence did not have a functional detox unit and there were also clear-cut reasons for them to be on a mental health unit.  County detox facilities do not take people with suicidal thinking or associated medical problems.  I wonder how many letters it took like the ones I received to permanently disrupt the system so that patients with alcoholism and addictions could no longer get standard medical care.

The end result has been no standards for medical detoxification at all. Some patients are sent out of the emergency department with a supply of benzodiazepines or opioids and advised to taper off of these medications on their own. That advice ignores one of the central features of substance abuse disorders and that is uncontrolled use. Without supervision I would speculate that the majority of people who are sent home with medications to do their own detoxification take all that medication in the first day or two and remain at risk for complications.

Appropriate detoxification facilities staffed by physicians who are trained and interested in addictive disorders would go a long way toward restoring quality medical care to people who have a life threatening addictions.  It would restore more humanity to medicine - something that business decisions have removed.  As far as I can tell, people struggling with addictions and alcoholism continue to be neglected by both federal and state governments and the managed care industry.

George Dawson, MD, DFAPA

Happy Labor Day - To All the Docs On The Assembly Line

When I first started working in medicine I was the Medical Director of an outpatient mental health clinic.  We had a staff of 8 psychotherapists, 2 nurses, and 2 case managers.  There were three transcriptionists to type up all of our notes.  Every person I saw had a typed note to document the encounter and all of the charts were paper.  There was no electronic health record.  If a person needed a prescription, I would write one or call the pharmacy and that was the end of it.  The majority of my time was spent speaking directly with patients and I could generally do all of the dictations in about 2 hours per day.

After three years I moved to a hospital setting.  There were three inpatient units with 6 psychiatrists and two transcriptionists.  One of the transcriptionists specialized in paperwork specific to probate court proceedings.  There was an additional pool of transcriptionists available 24/7 on any phone in the hospital for immediate documentation of any clinical encounter.  The admission notes were typed on two or three sheets and inserted in the chart.  Daily progress notes were typed on adhesive paper and pasted into the chart.  After I signed the note, a billing and coding expert came through and submitted a billing fee for the work that had been done.  The same process was in place with pharmacies.  Call them or send them a written prescription and it was taken care of.   Every Sunday I would go to the basement of the hospital in the medical records department and sign all of the areas I had missed to complete the charts.  It was the early 1990s and the administrative burden was certainly there but it was a manageable ritual.

Over the next decade things got much, much worse.  Even in the blur of a retroscope it is hard to say what happened first.  I would guess it was the political theory that health care fraud was the main driver of health care costs and the misguided effort by the federal government to crack down on doctors.  That led to the elimination of the billing and coding experts.  Doctors now had to waste their time in seminars devoted to making them experts in what is an entirely subjective process.  No two coders agree on the correct bill to submit.  How can you teach that lack of objectivity to doctors?  The end result is that the billing and coding people were eliminated or reassigned and doctors took on another job unrelated to medicine.

The next phase was the electronic health record (EHR).  It required that doctors learn the interface (more seminars and training).  Once that was accomplished it was decided that they could also learn to enter their own notes - either really clunky ones using EHR derived phrases or more natural ones with a fairly frequent embarrassing typo using voice recognition programs.  That eliminated the transcriptionists and required much more training. During the transition period I still went in to medical records every Sunday.  I expected to see a staff person there who I had seen every Sunday for 15 years but one Sunday she was gone - a casualty of the EHR.  The end result was doctors with a couple of new jobs and the elimination of both transcriptionists and medical records people.

At about the same time, managed care companies started to ratchet up the pain.  In an inpatient setting you could get one or two "denials" per day.  A denial is the managed care company saying that they refuse to cover the cost of care because the admission was not "medically necessary".  That is managed care rhetoric for "we have decided not to pay you."  These denials are purely arbitrary and have nothing to do with whether a person needs care or not.  The best examples at the time were people with alcoholism or addiction who were suicidal and needed to be detoxed and reassessed.  The standard managed care denial at the time was "This patient should be treated in a detox facility."  The obvious problem was that not every county has a detox facility and those that do will not accept people making suicidal statements.   So the next new job became battling with these companies who were essentially getting free care for their health plan subscribers if you did not jump through all of the hoops necessary to appeal.

Slightly later, managed care decided they could apply the same denial strategy to pharmaceuticals on the basis that cheaper drugs are as good and all drugs in the same class are equivalent.  It turns out that nether of those assumptions is accurate, but in America today business and politics always trumps medical decision making.  This prior authorization process created a blizzard of paperwork that ties up a lot of clinic time.  One study estimated 20 hours per week (across all employees) per physician  on average.  That means if your clinic has 5 doctors in it - 100 hours per week of the total hours worked is used strictly to deal with insurance companies.  It also adds another job to what the doctor already does.

So in the time I have been practicing medicine let's add the number of jobs that have been accreted into the administrative side of medicine for all physicians.  Billing and coding expert + transcriptionist + EHR interface user + voice recognition user + utilization review responder + prior authorization responder totals 6 new jobs in the past two decades, none of which came up in medical school.

With all of that "efficiency" we should expect health care costs to plummet or at least stay the same.  As we all know that has not happened.  The politics and business interests driving this are in the business of making money.  Physician and hospital reimbursement is essentially flat.  One of the easiest ways to make a buck is to have the physicians doing way more administrative tasks and fire the employees that used to do them.  You can also make money by putting up the usual obstacles to doctors doing their jobs of treating patients in hospitals or clinics until they just give up.  I have been so burned out at times that I put a cursory note in the chart to say exactly what I did.  That note did not meet coding requirements so I did not submit a bill.  At some point you just have to stop working.  I know that I am not alone in getting to that point.

So congratulations to all of the docs who are now laboring on this vast assembly line that we now call American medicine.  It is the ultimate product of what Congress, the White House and big business can do.  We can only expect continued "improvements" or "efficiencies" under the new health care law.  It is an assembly line that discourages quality or innovation and that also makes it unique.

Happy Labor Day!

George Dawson, MD, DFAPA

A Neurologist Gets High

Well known neurologist and author Oliver Sacks has written an essay in the New Yorker about his drug experiences in the 1960s.  From about 1963-1967 Dr. Sacks ingested various compounds including cannabis, amphetamines, intravenous morphine, LSD, morning glory seeds, Artane (trihexyphenidyl hydrochloride) and massive doses of chloral hydrate with an accompanying withdrawal state.  He does an excellent job of describing various intoxication and delirium states.  As an example he describes his experience reading a text on migraines from 1873 while taking amphetamine:

"...In a sort of catatonic concentration that in 10 hours I scarcely moved a muscle or wet my lips, I read steadily through "Megrim"....At times I was unsure if I was reading the book or writing it...." p. 47

In my current professional iteration as an addiction psychiatrist these are familiar scenarios.  At some level Sacks realizes that he is lucky to have survived chloral hydrate withdrawal induced delirium tremens and amphetamine-induced tachycardia up to the 200 beats per minute range with an unknown blood pressure.  Vivid visual and auditory hallucinations and a distorted sense of time are described.  There is also the familiar interpersonal dimension that gets activated when a person's life is affected by drug use - concerned colleagues that implore him to seek help and take care of himself.

Dr. Sacks is an intellectual and this is presented in an intellectual context that may not have been very evident at the time of the experimentation.  He describes the sociocultural antecedents of a need for chemical transcendance that has been present throughout human history.  He proceeds to describe some of the relevant historical writings of physicians and other intellectuals.

The usual debate about whether or not there is any utility in taking life threatening amounts of drugs occurs in the text and on the podcast.  Not surprisingly, intellectuals derive insights from their experiences and taking drugs is no exception.  In  the article, the revolution in neurochemistry was one of the preludes to the period of experimentation.  The problems with psychotic symptoms and manic states are well described as well as what states might be the preferred ones.  We learn on the podcast that these experiences have provided insights into possible brain mechanisms and that this might be part of the basis for the author's new book Hallucinations that comes out in the fall.

Dr. Sacks describes himself as an observer and explorer of psychotic symptoms and how that seems to be protective when he is tripping.  What is missing here compared to the people I have talked with is a highly subjective response that increases the risk for drug use.  I typically hear about intense euphoria, high energy, and increased competence in physical, intellectual and social spheres.  Not having that response may be protective and may allow one to avoid the risks of ongoing chemical use.  In some cases there may just be a compulsion to recreate the drug induced state.  The essay may have been a lot more complicated or written by someone else if those descriptions were there.

George Dawson, MD, DFAPA

Oliver Sacks.  Altered States - Self experiments in chemistry.  The New Yorker, August 27, 2012: 40-47.

Oliver Sacks.  Podcast: The New Yorker Out Loud.

Lance Armstrong and parallels with physician discipline

I read the headlines in the paper today "Armstrong stripped of seven Tour titles."  I had just read his personal position on Facebook.  For those who have not followed this issue, the US Anti Doping Agency (USADA) has been trying to say that Armstrong violated doping regulations by using banned substances despite a significant amount of objective evidence in his favor.  The objective evidence in his favor was to such a degree that the Department of Justice dropped a 2 year investigation of him.  The USADA is not a branch of law enforcement branch but it does have the power to ban athletes, ban them for life, and apparently remove any awards that they have won in a retrospective manner even though they were under intense scrutiny at the time.  In my reading the USADA also apparently believes that their test results are infallible which makes their spin on those results even more confusing.  As Armstrong points out - during competition he had to submit for testing 24/7 at at no time did the USADA say that he had a positive test result or pull him from competition.  I am not going to review the pros and cons of the decision - only to say that at this point it has been politicized and a stunning amount of objective evidence has been ignored.  My interest in the process is how it resembles similar processes that are conducted against physicians.

The "disruptive physician" concept seems to have been the driving force behind a lot of these initiatives.   Disruptive physicians to me would be physicians who have not violated the medical practice statutes in their states.  They would be basically physicians that somebody doesn't like because of their behavior or personality.  The Joint Commission has a position statement:

"Intimidating and disruptive behaviors including overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks were quietly exhibiting uncooperative attitudes during routine activities. Intimidating and disruptive behaviors are often manifested by healthcare professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages, condescending language or voice intonation, and impatience with questions or it overt and passive behaviors undermine team effectiveness and can compromise the safety of patients. All intimidating and disruptive behaviors are unprofessional and should not be tolerated."

They go on to cite research suggesting that these behaviors are widespread as high as 40% in some settings. The research is survey research and there are no concerns about its potential quality or biases. My concern and working in a number of medical settings for the past 30 years is that I have witnessed it exactly once. An attending physician personally verbally attacked me several times after he learned I was going to be a psychiatrist at least until I outguessed him on the correct diagnosis of acute abdominal pain.  I think that behavior would clearly qualify.

On the other hand, I have become aware of many physicians being disciplined and even losing their jobs over trivial situations in the workplace. Apparently the threshold for a complaint against a physician is that the complainant feels as if they were "disrespected".  In today's healthcare environment that complaint plus a personal dislike from a department chairman is enough to get you fired or at least live a miserable existence until you decide to quit.  That is true irrespective of the number of people who would testify on your behalf, service to the department, patient satisfaction ratings,  ratings by residents and medical students, and other professional accomplishments.  If you are a physician these days all it takes is the subjective opinion from someone who does not know you or your personal motivation or reasons for doing things to file a complaint and potentially destroy your career. Even if you are not fired outright, there could be a lingering process of accumulating demerits and reviews by other physicians who are not sympathetic to your plight before you are ultimately let go.

At least Lance Armstrong can say that a ton of objective evidence was ignored in order to make this decision. The decision against a physician can be based on a single subjective complaint irrespective of how reliable or credible the complainant is and what sort of evidence exists.

That is all it takes to be a disruptive physician.

George Dawson, MD. DFAPA