One of the big media stories today is about David Healy's address to the American Psychiatric Association's Psychiatric Services meeting. Like many of the psychiatrists turned critic his celebrity and notoriety status depend a lot of the amount of controversy that he is associated with and he comments on that in the opening remark. If you carefully read through this article, you will find that the financial conflicts of interest alluded to in the article are largely historical at this point. The elephant in the room for these critics is that practically all antidepressants are generics these days and they are no longer marketed by pharmaceutical companies.
I was an early adopter of maintaining clear boundaries with pharmaceutical companies and for the past 20 years or so - did not see detail salespeople, did not accept food and did not accept any gifts. On the other hand, I have always found pharmaceutical companies to be a rich source of data in addition to the usual FDA approved package insert. As an example, I am looking at a disc sitting on my desk right now entitled "Iloperidone unsolicited slides - for education use only." I gave a lecture on newer atypical anti psychotics several years ago and contacted the scientific divisions of three pharmaceutical companies looking for basic science data on the new drugs and they all supplied me with complete clinical trials data and basic science information on the receptor profiles that I wanted. I will also call them up with possible adverse events and get detailed information about that frequently via fax the same day.
Healy appeared to have made a controversial remark about psychiatrists committing "professional suicide" by their affiliation with pharmaceutical companies. In his previous remarks he make the comment about professional suicide as a preface to the second paragraph below:
"Healy noted further that when data surfaced showing a link between antidepressant use and risk of suicide in children, the APA issued a statement proclaiming that “we believe that antidepressants save lives.”
“What I believe they should have said is that the APA believes that psychiatrists can save lives because it takes expertise to manage the risks of risky pills,” he said; if psychiatrists’ only role were to dole out drugs, then less-trained physician’s assistants could easily replace them, he noted."
I have seen the comment on his blog at least 6 months ago and there should be complete agreement with this statement. Just in the past month I have had to diagnose and address drug induced liver disease, serotonin syndrome, eosinophilia, antidepressant associated hypertension, and spent a considerable larger amount of time making sure that antidepressants could be safely prescribed and that they were not making pre-existing medical problems worse. Recognizing those problems goes beyond the diagnostic process to coming up with a plan to monitor and treat it. A considerable amount of my time is, if not most of my time is spent managing side effects and protecting the health of my patients.
Although Healy takes positions that I would consider to be inaccurate, in this case he is dead on. It is professional suicide to collude with the idea that the treatment of any mental illness resides in a pill. Marketing genius maybe, but certainly not reality. Drugs don't treat and cure depression, psychiatrists do and it goes far beyond selecting a medication. Monitoring the patient for these complications and recognizing rare complications takes time and that time needs to be available - even in visits that are supposed to be focused on "medication management".
George Dawson, MD, DFAPA
Sunday, October 7, 2012
Confusion about Capitation versus Fee-For-Service versus National Health Care
This is from the Shrink Rap blog this morning the consensus is that capitated care is better than fee-for-service care. What is wrong with that picture?
Starting out with the much maligned fee-for-service (FFS) - most medical and psychiatric services are not delivered in that context. You can safely say that FFS, disappeared a long time ago. According to a 2012 Medscape survey of 24,216 physicians across 25 specialties only 4% worked in cash only or concierge style practices. That means that everyone else is subject to varying degrees of insurance company discounting. From my years of providing inpatient care for example, there is a standard DRG payment based on a global discharge or admission diagnosis. For the most common psychosis DRGs the standard payment is $4,500 no matter how long a person is stays in the hospital.
The same thing happens on the outpatient side. I have discussed this more extensively is a previous post. Looking at the commonest outpatient billing code - actual reimbursement for providing services can be as little as $22.45 per visit. In the case where bills are submitted with CPT codes (common to all of medicine) Medicare pays 50% of the usual and customary charge for psychiatry compared with 80% for the rest of Medicine. A lot depends on contracting arrangements since a contract can limit a psychiatrist to billing only a 90862 code and the company can also decide that they disagree that services were provided and either deny payment or demand repayment of a significant amount of money based on a review of the documentation.
The business adaptation to this on the hospital and managed care side (if they own the hospital) is to hire case managers to get patients out of the hospital within 3 or 4 days. Some of these systems have confabulated their own "guidelines" that allow them to do this that are totally independent of any professional standards. So if you are a managed care business and you own the hospital you are winning at two levels - you already shift the risk to the providers and hospitals by the Medicare style DRG payment and you do it a second time by insisting that they go along with the business decision to discharge the patient from the hospital.
Strictly speaking, the examples of discounted fees are technically not capitation. Discounted fees still allow for some elasticity within the system because there is still a fee paid per service event. Capitated systems of care like behavioral health carve outs can be set up to pay a set fee for managing a specific population. For example, a system of care is under contract for providing all services to a specific group of employees for a rate that is negotiated irrespective of actual patient visits.
The best way to understand capitated care is that it is designed to provide insurance companies a significant financial incentive for rationing care. That incentive comes directly out of the total amount of money available for health care spending Psychiatry, mental health, and addiction services were the easiest targets due to insitutionalized stigma, lack of a vocal constituency, and the political ineptness of psychiatrists. It is anybody's guess about how much a managed care company can make for denying or rationing care but some estimates of the margins have been as high as 20-40%.
One thing is for certain. Capitated care is not a comprehensive national health system. It takes hundreds of billions of dollars out of the health care system and diverts it to CEOs and stockholders. Contrary to the political opinion it does not contain the cost of health care inflation. One of the readers of the Shrink Rap blog pointed out that in a national system of health care you might be able to get an expensive medication like aripiprazole but you would have to wait longer. In our current system of capitated care if your managed care company decides - you will not be able to get it at all.
That is probably the best example of the difference.
George Dawson, MD, DFAPA
Starting out with the much maligned fee-for-service (FFS) - most medical and psychiatric services are not delivered in that context. You can safely say that FFS, disappeared a long time ago. According to a 2012 Medscape survey of 24,216 physicians across 25 specialties only 4% worked in cash only or concierge style practices. That means that everyone else is subject to varying degrees of insurance company discounting. From my years of providing inpatient care for example, there is a standard DRG payment based on a global discharge or admission diagnosis. For the most common psychosis DRGs the standard payment is $4,500 no matter how long a person is stays in the hospital.
The same thing happens on the outpatient side. I have discussed this more extensively is a previous post. Looking at the commonest outpatient billing code - actual reimbursement for providing services can be as little as $22.45 per visit. In the case where bills are submitted with CPT codes (common to all of medicine) Medicare pays 50% of the usual and customary charge for psychiatry compared with 80% for the rest of Medicine. A lot depends on contracting arrangements since a contract can limit a psychiatrist to billing only a 90862 code and the company can also decide that they disagree that services were provided and either deny payment or demand repayment of a significant amount of money based on a review of the documentation.
The business adaptation to this on the hospital and managed care side (if they own the hospital) is to hire case managers to get patients out of the hospital within 3 or 4 days. Some of these systems have confabulated their own "guidelines" that allow them to do this that are totally independent of any professional standards. So if you are a managed care business and you own the hospital you are winning at two levels - you already shift the risk to the providers and hospitals by the Medicare style DRG payment and you do it a second time by insisting that they go along with the business decision to discharge the patient from the hospital.
Strictly speaking, the examples of discounted fees are technically not capitation. Discounted fees still allow for some elasticity within the system because there is still a fee paid per service event. Capitated systems of care like behavioral health carve outs can be set up to pay a set fee for managing a specific population. For example, a system of care is under contract for providing all services to a specific group of employees for a rate that is negotiated irrespective of actual patient visits.
The best way to understand capitated care is that it is designed to provide insurance companies a significant financial incentive for rationing care. That incentive comes directly out of the total amount of money available for health care spending Psychiatry, mental health, and addiction services were the easiest targets due to insitutionalized stigma, lack of a vocal constituency, and the political ineptness of psychiatrists. It is anybody's guess about how much a managed care company can make for denying or rationing care but some estimates of the margins have been as high as 20-40%.
One thing is for certain. Capitated care is not a comprehensive national health system. It takes hundreds of billions of dollars out of the health care system and diverts it to CEOs and stockholders. Contrary to the political opinion it does not contain the cost of health care inflation. One of the readers of the Shrink Rap blog pointed out that in a national system of health care you might be able to get an expensive medication like aripiprazole but you would have to wait longer. In our current system of capitated care if your managed care company decides - you will not be able to get it at all.
That is probably the best example of the difference.
George Dawson, MD, DFAPA
Sunday, September 30, 2012
"Doctors don't label"
In a rare statement of clarity amid the usual sensational spin this comment jumped out at me:
"Doctors don't label...Doctors diagnose, take care of, and treat. That's not to say that something cannot be stigmatizing, but 'labeling' kind of gets right into the antipsychiatry component of it." William T. Carpenter, MD - Clinical Psychiatry News September 2012; p 3.
Dr. Carpenter is right and every psychiatrist knows it. Psychiatrists don't label. Psychiatrists diagnose. Psychiatrists are very aware of the limitations of diagnosis given the the sociocultural and medical contexts. The psychiatric orientation is to be helpful to patients and the diagnosis is the focus of that treatment. Furthermore, all psychiatric diagnosis and treatment is supposed to be confidential and there is no group of physicians who has tried to hold the line more against government and insurance companies eroding patient-physician confidentiality than psychiatrists.
A significant part of this article about the content of a letter from the Society for Humanistic Psychology (Division 32 of the American Psychological Association). Read the letter and draw your own conclusions. The points of contention listed in the letter have been exposed in several other media contexts. As I read through the letter there are several problems:
"This document was composed in recognition of, and with sensitivity to, the longstanding and congenial relationship between American psychologists and our psychiatrist colleagues."
I don't think that this is an accurate statement. When I started out in psychiatry and was in my third year of residency the American Psychological Association decided to get more aggressive politically and their target was basically American psychiatry. I won't rehash all of that ugliness but simply point out that things were far from congenial and in many areas remain problematic. Much of those political efforts were based on the idea that organized psychiatry had an inordinate amount of control over the treatment of mental illness. Any observer - biased or unbiased should recognize that psychiatrists and physicians in general have been marginalized and the American Psychiatric Association is politically ineffective and weak. Of course any other group of mental health providers is in the same boat.
"Given lack of consensus as to the “primary” causes of mental distress, this proposed change may result in the labeling of sociopolitical deviance as mental disorder."
This is a comment on the new DSM5 definition of a mental illness, specifically that the new definition does not explicitly say that deviant behavior and conflicts with society are not mental disorders. The current version states that these conflicts need to be the result of dysfunction within the individual. It is hard for me to see a situation where this is relevant to the practice of psychiatry. Is there really a case where I am going to diagnose a person in this situation with a mental disorder? Definitely not and the reason is that I have been confronted with the situation many times before and pointed out that the conflict was not the product of a mental illness. The authors here have focused primarily on a lower threshold for diagnosis and how they are not confident about the clinical decision making skills of practitioners - but do not comment on the threshold part of the definition.
"Increasing the number of people who qualify for a diagnosis may lead to excessive medicalization and stigmatization of transitive, even normative distress."
The risk of "medicalization" needs to be considered for a moment. What is "medicalization"? The implication of this letter at a practical level is that it involves an excessive use of medications. Suspending the poor quality of many of those studies for a moment, what is the real driver of medication use in today's practice environment? The minority of people taking any kind of psychiatric medication see psychiatrists. The managed care industry and the government are clearly the driving force. Current "evidence based" approaches are linked directly to medication use. A checklist diagnosis and rating scale approach has been used to rapidly treat patients with antidepressants in primary care settings. That approach alone has easily outpaced any DSM5 modifications. Direct to consumer drug advertising compounds the issue of getting as many people on medications as possible. You don't even have to read the DSM5 to see that medicalization has little to do with medical doctors. In fact, managed care companies would clearly like to replace as many doctors as possible with "prescribers" who can fill prescriptions according to these protocols. The pharmaceutical and managed care industries are far more interested in distilling psychiatric treatment down to a pill or a capsule than psychiatrists are.
The associated idea that psychiatrists may be the initiators of this medicalization or at least collude with it ignores psychiatric innovation that does not involve the prescription of medications. On this blog alone, I have posted excellent examples of work done by Greist and Gunderson on innovative and highly successful non medication approaches to significant problems. Dr. Greist's ideas have been presented to a wide audience that includes pharmaceutical companies. His ideas about how to make effective psychotherapy widely available have been successfully applied in other countries. Ignoring psychiatric innovation outside of psychopharmacology is a curious phenomena, but it definitely makes it easier to see psychiatrists as the "medicalizers". I am sure that both Greist and Gunderson would not see medications as the primary treatment for anxiety disorders or borderline personality disorder.
Once again, the focus on problems in the DSM5 leading to medicalization and stigmatization is clearly overemphasized. There is no group of people more aware of the limitations of the current diagnostic system than psychiatrists. There is no group of people better equipped to compensate for these deficiencies. There is no group of people more aware of the stigma of mental illness and addiction. Psychiatrists have a unique perspective in observing first hand how health care systems institutionalize stigma and use it to reduce the resources dedicated to treat these problems. There should be no doubt that the DSM5 is being produced in what is considered the best interest of the American Psychiatric Association. There should also be no doubt that the critiques of the process have their own interests and their opinions should be evaluated in that context.
George Dawson, MD, DFAPA
"Doctors don't label...Doctors diagnose, take care of, and treat. That's not to say that something cannot be stigmatizing, but 'labeling' kind of gets right into the antipsychiatry component of it." William T. Carpenter, MD - Clinical Psychiatry News September 2012; p 3.
Dr. Carpenter is right and every psychiatrist knows it. Psychiatrists don't label. Psychiatrists diagnose. Psychiatrists are very aware of the limitations of diagnosis given the the sociocultural and medical contexts. The psychiatric orientation is to be helpful to patients and the diagnosis is the focus of that treatment. Furthermore, all psychiatric diagnosis and treatment is supposed to be confidential and there is no group of physicians who has tried to hold the line more against government and insurance companies eroding patient-physician confidentiality than psychiatrists.
A significant part of this article about the content of a letter from the Society for Humanistic Psychology (Division 32 of the American Psychological Association). Read the letter and draw your own conclusions. The points of contention listed in the letter have been exposed in several other media contexts. As I read through the letter there are several problems:
"This document was composed in recognition of, and with sensitivity to, the longstanding and congenial relationship between American psychologists and our psychiatrist colleagues."
I don't think that this is an accurate statement. When I started out in psychiatry and was in my third year of residency the American Psychological Association decided to get more aggressive politically and their target was basically American psychiatry. I won't rehash all of that ugliness but simply point out that things were far from congenial and in many areas remain problematic. Much of those political efforts were based on the idea that organized psychiatry had an inordinate amount of control over the treatment of mental illness. Any observer - biased or unbiased should recognize that psychiatrists and physicians in general have been marginalized and the American Psychiatric Association is politically ineffective and weak. Of course any other group of mental health providers is in the same boat.
"Given lack of consensus as to the “primary” causes of mental distress, this proposed change may result in the labeling of sociopolitical deviance as mental disorder."
This is a comment on the new DSM5 definition of a mental illness, specifically that the new definition does not explicitly say that deviant behavior and conflicts with society are not mental disorders. The current version states that these conflicts need to be the result of dysfunction within the individual. It is hard for me to see a situation where this is relevant to the practice of psychiatry. Is there really a case where I am going to diagnose a person in this situation with a mental disorder? Definitely not and the reason is that I have been confronted with the situation many times before and pointed out that the conflict was not the product of a mental illness. The authors here have focused primarily on a lower threshold for diagnosis and how they are not confident about the clinical decision making skills of practitioners - but do not comment on the threshold part of the definition.
"Increasing the number of people who qualify for a diagnosis may lead to excessive medicalization and stigmatization of transitive, even normative distress."
The risk of "medicalization" needs to be considered for a moment. What is "medicalization"? The implication of this letter at a practical level is that it involves an excessive use of medications. Suspending the poor quality of many of those studies for a moment, what is the real driver of medication use in today's practice environment? The minority of people taking any kind of psychiatric medication see psychiatrists. The managed care industry and the government are clearly the driving force. Current "evidence based" approaches are linked directly to medication use. A checklist diagnosis and rating scale approach has been used to rapidly treat patients with antidepressants in primary care settings. That approach alone has easily outpaced any DSM5 modifications. Direct to consumer drug advertising compounds the issue of getting as many people on medications as possible. You don't even have to read the DSM5 to see that medicalization has little to do with medical doctors. In fact, managed care companies would clearly like to replace as many doctors as possible with "prescribers" who can fill prescriptions according to these protocols. The pharmaceutical and managed care industries are far more interested in distilling psychiatric treatment down to a pill or a capsule than psychiatrists are.
The associated idea that psychiatrists may be the initiators of this medicalization or at least collude with it ignores psychiatric innovation that does not involve the prescription of medications. On this blog alone, I have posted excellent examples of work done by Greist and Gunderson on innovative and highly successful non medication approaches to significant problems. Dr. Greist's ideas have been presented to a wide audience that includes pharmaceutical companies. His ideas about how to make effective psychotherapy widely available have been successfully applied in other countries. Ignoring psychiatric innovation outside of psychopharmacology is a curious phenomena, but it definitely makes it easier to see psychiatrists as the "medicalizers". I am sure that both Greist and Gunderson would not see medications as the primary treatment for anxiety disorders or borderline personality disorder.
Once again, the focus on problems in the DSM5 leading to medicalization and stigmatization is clearly overemphasized. There is no group of people more aware of the limitations of the current diagnostic system than psychiatrists. There is no group of people better equipped to compensate for these deficiencies. There is no group of people more aware of the stigma of mental illness and addiction. Psychiatrists have a unique perspective in observing first hand how health care systems institutionalize stigma and use it to reduce the resources dedicated to treat these problems. There should be no doubt that the DSM5 is being produced in what is considered the best interest of the American Psychiatric Association. There should also be no doubt that the critiques of the process have their own interests and their opinions should be evaluated in that context.
George Dawson, MD, DFAPA
Wednesday, September 26, 2012
Why antidepressants are not addictive
I recently noticed that a blogger posted his
theory on the addictive properties of antidepressants. He pointed out that
people get "psychologically addicted" and that using the term
"addiction" for physical addiction seemed too restrictive. His supporting evidence is a newspaper article about how Glaxo Smith Kline
dropped its claim on a patient information pamphlet for paroxetine saying that
the drug was "not addictive". David
Healy is quoted as saying "If there is withdrawal, then there is physical
dependence. There will be some people who will never be able to halt this
drug, there will be some for whom halting will not be awfully difficult and
some for whom it is a real issue". The article goes on to say that although
SSRIs are not like opiates they are "more comparable to the
benzodiazepines such as diazepam, which is now prescribed only with great
caution because of withdrawal problems".
Working in the addiction field this entire line of thinking
is rhetorical. There is significant psychiatric comorbidity in people with
addictions with anywhere from 40-75% having co-occurring disorders. Most of
those co-occurring disorders are anxiety disorders and depression and they are well
known triggers for relapse as well as initiating drug and alcohol use in the
first place. Contrary to public denial, addictive disorders have huge
liabilities in terms of morbidity and they are often lethal illnesses. My goal is to reduce the risk of relapse by
treating the co-occurring disorder while the person is being treated for
addiction. SSRI medications are one of the mainstays of treating anxiety and
depression these days. They are effective medications. I would not be
prescribing them if they caused "psychological addiction". Furthermore,
many treatment programs for addiction teach the concept of cross addiction and
nobody studying that concept would want to take an SSRI if it caused any kind
of addiction.
A better starting point would be to look at more
comprehensive definition
of what an addiction is. That starting point would be the October 2011
definition issued by the American Society of Addiction Medicine. Paragraph 2 of the short definition will
suffice and reading those four lines should make it very clear that the use of
antidepressant medications does not lead to addiction. The real hallmark of
addictions is uncontrolled use and there is no evidence that modern antidepressants
are used in an uncontrolled manner. Additional
evidence is that antidepressants have absolutely no street value and therefore
are in the majority of 34 million chemical compounds listed in Chem Abstracts
of which only about 322 are addicting.
If your doctor has recommended that you take an
antidepressant medication certainly be aware of the fact that there may be
discontinuation symptoms. Discontinuation symptoms are not an addiction. Needing to take an antidepressant for a
chronic mood or anxiety disorder is not an addiction. Contrary to Dr. Healy's opinion there are a number of nonpsychiatric medications can be discontinued and cause severe discontinuation symptoms. The term "physical dependence" suggests an addiction or the inappropriate use of a potentially addicting drug where in fact that is not the case with antidepressants. Comparing antidepressants to other clearly addictive
compounds like benzodiazepines or opioids is not an accurate comparison across
any dimension. I agree that any person considering an antidepressant drug needs to be aware of the fact that mild to
moderate symptoms can respond to psychotherapy as well as medication. ANY medication can lead to rare but very serious
complications. Any person considering treatment with medications needs to be working with a physician who is skilled in the use of these medications and who can address any potential side effects. My personal experience in
treating people who have severe anxiety and depression is that they reach a
point that anyone with a severe chronic illness reaches in making a decision
about medication. That point generally involves asking themselves: "What
else am I going to do?".
As physicians we can never minimize the importance of that
question.
Response to Dr. Willenbring
I wrote this response to Mark Willenbring's post on his blog. I reposted it here because the links do not work in the reply section of his blog in case anyone is interested in the references:
------------------------------------------------------------------------------------------------------------
I generally agree with what you are saying. I think the no fault aspect of the illness is
very difficult for many to grasp - most importantly the policy makers and
health plan administrators. I think it
is captured very well in the latest ASAM definition. I think that Sellman’s Top Ten list and the
responses to it are also instructive especially item 7 “Come back when you are
motivated” is no longer an acceptable therapeutic response’ is part of your
message.
From a systems standpoint, the lack of a full array of
services to treat addiction is striking.
Over the course of my career I have seen detox services essentially
moved to mental health units and then to the street. I wrote a post about this several weeks ago
that was read by current detox staff who agreed with it. It is hard to believe that in many if not
most cases people with addictions are sent home from the ED, sent home with a
handful of benzodiazepines, or sent to a facility with no medical coverage for
a complex detox process. I think the
test of any health care system is whether a primary care doc can ask themselves
if they have a safe detox procedure for any of their regular patients who are addicted
to opioids and benzodiazepines and needs surgery.
Medical systems in general have a very poor attitude toward
people with addictions. I think that
these healthcare systems and their personnel are much more likely to take a
moralistic attitude toward addicts and not treat them well. I have seen that theme repeated across
multiple care settings. Many rationed
care settings disproportionately reduce resources necessary to treat addiction. I think it is safe to say that most
cardiology patients with suspicious chest pain get a $10,000 evaluation and
reassurance or appropriate treatment.
Most patients with addictions do not even get a $300 evaluation. They may actually see a physician who provides
them with medications that fuel their addiction. Institutionalized stigma plays a big role in
that. There are no billboards in the
Twin Cities advertising state-of-the-art addiction treatment. There are many advertisements for heart
centers.
I am less pessimistic about the effects of 12-step recovery
and time in a residential setting whether it is a high end recovery facility or
a state hospital. I think if you are in
a setting where there is no active treatment or sober environment you are
probably wasting your time. I have seen
people who were declared hopeless recover with time away from alcohol and drugs
on the order of months. Vaillant’s study
of severe alcoholism is a great example of the different paths to recovery and
there are many. His subsequent analysis
of how AA might work suggests that affiliation rather than blaming may be the
most curative element. AA is difficult
to study but I think that the message is positive and embodied in #3 of the Twelve Traditions. Up to that point the founders were looking at
the issue of exclusion but decided against it because alcoholism was a life
threatening disease and they could turn nobody away.
Sunday, September 23, 2012
What replaces DSM5? Whither RDoC?
"However, in antedating contemporary neuroscience research the current diagnostic system is not informed by recent breakthroughs in genetics; and molecular, cellular, and systems neuroscience. Indeed it would have been surprising if the clusters of complex behaviors identified clinically were to map on a one-to-one basis onto specific genes or neurobiological systems." NIMH 2011.
With the thorough politicization of the DSM5 and the dichotomous debates in the media it is surprising that nobody talked about what is in the works to replace it at the largest government funded think tank - The National Institute of Mental Health (NIMH). The proposed solutions in the media were generally to do nothing or to let a wide variety of professionals have input into criteria that have essentially been static for the past 30 years. There was very little comment about how the DSM5 is not a very good framework for incorporating recent scientific discoveries from brain imaging, molecular biology and genomics in addition to the typical subjective descriptions of each disorder. That is where NIMH's Research Domain Criteria (RDoC) come in.
Looking at the "Draft Research Domain Criteria Matrix" - it is hard to envision a standard 60 (or usually 30) minute clinical interview as a starting point for diagnosis or treatment. For example, with an initial episode of psychosis, there will probably be a lot more work done trying to identify cognitive endophenotypes or other transitional phenotypes within the current subjectively derived domains. A very conservative estimate suggests that this alone will take take least one hour of testing. There will probably need to be a lot of time and effort expended on determining when a person is testable. An RDoC diagnosis will be both time and resource intensive. It won't be a template or a checklist.
I am sure that the antipsychiatry/myth of mental illness crowd and some of the thinly veiled variants of this philosophy will be disappointed. After all, this is a diagnostic approach that directly assails one of the most typical arguments from them: "There is no "test" for mental illness." When the RDoC comes to fruition there will not just be one test. There will be many tests.
Like most things psychiatric, the biggest threat to the realization of a more comprehensive diagnostic system for our most complex illnesses is not the obvious detractors. It is the current political culture that applies junk science to the management of the health care system. It remains an incredible fact that political ideology and not medical science dictates medical treatment in this country. The current political consensus is that psychiatric care (like medical care) can be managed for both cost and quality by companies who can profit by rationing care. The care they ration the most is for the treatment of mental illnesses and addictions.
Will an Accountable Care Organization (ACO) in the future spend what it necessary to thoroughly evaluate an initial episode of psychosis if it takes as many or more resources than Cardiology currently uses to assess heart disease? The answer to that lies in whether the stigma against mental illness and addictions in health care and governing organizations can be overcome. Despite all of the lip service - it is that stigma that supports the current system of care that is predominately brief hospitalizations orchestrated by case managers and 15 minute "medication management" approaches to the treatment of mental illness.
You can't implement an RDoC in that environment.
George Dawson, MD, DFAPA
With the thorough politicization of the DSM5 and the dichotomous debates in the media it is surprising that nobody talked about what is in the works to replace it at the largest government funded think tank - The National Institute of Mental Health (NIMH). The proposed solutions in the media were generally to do nothing or to let a wide variety of professionals have input into criteria that have essentially been static for the past 30 years. There was very little comment about how the DSM5 is not a very good framework for incorporating recent scientific discoveries from brain imaging, molecular biology and genomics in addition to the typical subjective descriptions of each disorder. That is where NIMH's Research Domain Criteria (RDoC) come in.
Looking at the "Draft Research Domain Criteria Matrix" - it is hard to envision a standard 60 (or usually 30) minute clinical interview as a starting point for diagnosis or treatment. For example, with an initial episode of psychosis, there will probably be a lot more work done trying to identify cognitive endophenotypes or other transitional phenotypes within the current subjectively derived domains. A very conservative estimate suggests that this alone will take take least one hour of testing. There will probably need to be a lot of time and effort expended on determining when a person is testable. An RDoC diagnosis will be both time and resource intensive. It won't be a template or a checklist.
I am sure that the antipsychiatry/myth of mental illness crowd and some of the thinly veiled variants of this philosophy will be disappointed. After all, this is a diagnostic approach that directly assails one of the most typical arguments from them: "There is no "test" for mental illness." When the RDoC comes to fruition there will not just be one test. There will be many tests.
Like most things psychiatric, the biggest threat to the realization of a more comprehensive diagnostic system for our most complex illnesses is not the obvious detractors. It is the current political culture that applies junk science to the management of the health care system. It remains an incredible fact that political ideology and not medical science dictates medical treatment in this country. The current political consensus is that psychiatric care (like medical care) can be managed for both cost and quality by companies who can profit by rationing care. The care they ration the most is for the treatment of mental illnesses and addictions.
Will an Accountable Care Organization (ACO) in the future spend what it necessary to thoroughly evaluate an initial episode of psychosis if it takes as many or more resources than Cardiology currently uses to assess heart disease? The answer to that lies in whether the stigma against mental illness and addictions in health care and governing organizations can be overcome. Despite all of the lip service - it is that stigma that supports the current system of care that is predominately brief hospitalizations orchestrated by case managers and 15 minute "medication management" approaches to the treatment of mental illness.
You can't implement an RDoC in that environment.
George Dawson, MD, DFAPA
Saturday, September 22, 2012
Concentration of Effort, Academics, and Managed Care
I follow the Nephron Power blog because I have maintained a life long interest in Nephrology or at least since I found out what it was in Medical School. The conventional wisdom at the time was "Oh you're going into psychiatry - take as many medicine electives as possible because you will never have the chance to do medicine again." If there are any medical students reading this - I ended up doing another 22 years of following renal function, treating people who were delirious and in renal failure, treating manic patients who were in renal failure waiting for a kidney transplant, and consulting with Nephrologists. I can say without a doubt that the Nephrologists who I worked with are some of the brightest, most thoughtful and hardest working people I have ever known.
I still consider the Renal Service where I worked in medical school to be the model for academic medicine and how to teach medical students and residents. It was located in two adjacent hospitals and headed up by a cranky old guy. I say "old" realizing that he was probably about the same age that I am right now and he had the appearance of being cranky like a lot of old guys can get. You could tell he was very bright, very interested and not above giving the medical students a hard time. He made sure that on all of the consults we had conducted the appropriate "liquid biopsy" by performing our own urinalyses on patients we were seeing.
We rounded three times a day seeing all of the hospitalized patients in the morning, clinic patients in the afternoon, and hospital consults in the evening and at night. My last action as a medical student was staffing two Renal Medicine consults at about 8PM the night before I graduated. The other team members included another two attendings, two fellows, three Internal Medicine residents, and another medical student. The physical layout of the service was two hospital wings and a very busy clinic with a separate day for a Hypertension clinic. The hospital service was in the same hospital as the transplant team and we would also care for patients with transplant complications.
The atmosphere on this service was electric. Everyone was on time, interested, bright, academic and effective. To this day - I consider this team from the 1980s to be the prototype for what a teaching service in a Medical School should be and in many ways how serious medicine should be provided. When I left the hospital that night after the last two consults staffings of my medical student career I can remember thinking - should I have gone into medicine and become a nephrologist? My fantasy in psychiatry became to recreate this model or at least parts of it in psychiatry.
Flash forward 26 years. Most people would be fairly surprised to find out that you can come close to my fantasy in very few psychiatric units. The patient flow into and out of many psychiatric units generally does not depend on academic considerations like providing the best medical and psychiatric care to patients. In most cases patient flow does not depend on the judgment of psychiatrists. My ability to care for patients with the most severe illnesses did not come about because there is an elite cadre of psychiatrists who are academically interested and have the necessary resources to provide that level of care. It came about because the system where I worked needed a place to put these folks and I happened to be a psychiatrist who was interested in all of their problems.
I got very close to recreating at least the inpatient side of my old Renal Medicine service, but these days there are just too many administrative problems along the way. It is impossible to take a learned approach to medicine and psychiatry with administrators breathing down your neck about an absurdly short length of stay. It is a clash of paradigms and as far as I can tell the administrators have won. You cannot possibly address complex problems when someone is telling you that the only reason a patients should be in the hospital is that they are "suicidal" or "homicidal" - both very loosely defined business terms for getting the patient out in time to capture about a 20% profit on the DRG payment. Let's suspend the reality that this person is just too ill to function or that their illness has created an impossible situation at home or they are not able to care for their new medical diagnoses until they have recovered their cognition to some extent.
If you are really interested in a rigorous approach to tough problems these days you will run afoul of a huge managed care infrastructure that is there to process patients in and out of hospitals based almost entirely on business decisions. That makes life a lot less interesting for physicians and a lot more frustrating for patients. Patients coming out of the managed care environment have an almost universal experience that they were hardly seen in the hospital and when they were, there was not a lot of interest in solving their problems. They end up saying what they think people want to hear in order to be released and after they have been discharged realize that nothing has changed.
In the final analysis these are contrasting models but nobody pays much attention to the contrast. An academic full spectrum of care model versus a severely rationed model where care is based on an administrators notion of "dangerousness". Clinicians aware of the full spectrum of illness, grappling with all of the nuances and offering the necessary care versus a doctor sitting in an office prescribing pills as fast as they can.
That is what we are talking about and in that context - I will take the Renal Service any day.
George Dawson, MD, DFAPA
I still consider the Renal Service where I worked in medical school to be the model for academic medicine and how to teach medical students and residents. It was located in two adjacent hospitals and headed up by a cranky old guy. I say "old" realizing that he was probably about the same age that I am right now and he had the appearance of being cranky like a lot of old guys can get. You could tell he was very bright, very interested and not above giving the medical students a hard time. He made sure that on all of the consults we had conducted the appropriate "liquid biopsy" by performing our own urinalyses on patients we were seeing.
We rounded three times a day seeing all of the hospitalized patients in the morning, clinic patients in the afternoon, and hospital consults in the evening and at night. My last action as a medical student was staffing two Renal Medicine consults at about 8PM the night before I graduated. The other team members included another two attendings, two fellows, three Internal Medicine residents, and another medical student. The physical layout of the service was two hospital wings and a very busy clinic with a separate day for a Hypertension clinic. The hospital service was in the same hospital as the transplant team and we would also care for patients with transplant complications.
The atmosphere on this service was electric. Everyone was on time, interested, bright, academic and effective. To this day - I consider this team from the 1980s to be the prototype for what a teaching service in a Medical School should be and in many ways how serious medicine should be provided. When I left the hospital that night after the last two consults staffings of my medical student career I can remember thinking - should I have gone into medicine and become a nephrologist? My fantasy in psychiatry became to recreate this model or at least parts of it in psychiatry.
Flash forward 26 years. Most people would be fairly surprised to find out that you can come close to my fantasy in very few psychiatric units. The patient flow into and out of many psychiatric units generally does not depend on academic considerations like providing the best medical and psychiatric care to patients. In most cases patient flow does not depend on the judgment of psychiatrists. My ability to care for patients with the most severe illnesses did not come about because there is an elite cadre of psychiatrists who are academically interested and have the necessary resources to provide that level of care. It came about because the system where I worked needed a place to put these folks and I happened to be a psychiatrist who was interested in all of their problems.
I got very close to recreating at least the inpatient side of my old Renal Medicine service, but these days there are just too many administrative problems along the way. It is impossible to take a learned approach to medicine and psychiatry with administrators breathing down your neck about an absurdly short length of stay. It is a clash of paradigms and as far as I can tell the administrators have won. You cannot possibly address complex problems when someone is telling you that the only reason a patients should be in the hospital is that they are "suicidal" or "homicidal" - both very loosely defined business terms for getting the patient out in time to capture about a 20% profit on the DRG payment. Let's suspend the reality that this person is just too ill to function or that their illness has created an impossible situation at home or they are not able to care for their new medical diagnoses until they have recovered their cognition to some extent.
If you are really interested in a rigorous approach to tough problems these days you will run afoul of a huge managed care infrastructure that is there to process patients in and out of hospitals based almost entirely on business decisions. That makes life a lot less interesting for physicians and a lot more frustrating for patients. Patients coming out of the managed care environment have an almost universal experience that they were hardly seen in the hospital and when they were, there was not a lot of interest in solving their problems. They end up saying what they think people want to hear in order to be released and after they have been discharged realize that nothing has changed.
In the final analysis these are contrasting models but nobody pays much attention to the contrast. An academic full spectrum of care model versus a severely rationed model where care is based on an administrators notion of "dangerousness". Clinicians aware of the full spectrum of illness, grappling with all of the nuances and offering the necessary care versus a doctor sitting in an office prescribing pills as fast as they can.
That is what we are talking about and in that context - I will take the Renal Service any day.
George Dawson, MD, DFAPA
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