I was fortunate enough to hear Kathleen Flenikken on my way home from an informal dinner meeting last Thursday night. In a way I was primed for for it because I had just finished a several hour discussion with another psychiatrist. We ended on a high note - the importance of maintaining your professional inspiration in an era of drudgery and manipulation. It was about an hour drive back home and I was listening to Minnesota Public Radio. Despite being the object of Saturday Night Live satire, public radio offers listeners a unique look into the consciousness of very bright people who you would never hear, see or read in more mainstream media. Ms. Flennikken is no exception.
She was born and raised in Richland, Washington a city built for workers of the Hanford Nuclear Facility. She is currently the Washington State Poet Laureate. On the radio program she described her growning up in Richland as the daughter of a nuclear scientist who encouraged her interest in science. She got a degree in civil engineering and returned to the Hanford Nuclear Site to work for 8 years as a civil engineer and hydrologist. She describes an incident where she became contaminated with nuclear waste and had to be scrubbed free of that material. More importantly she describes the psychological effect that growing up in this nuclear community and then realizing in retrospect that there were problems that people were either not aware of at the time or they were not told about them.
She describes the excitement of living in an "Atomic City" when she was a kid. An atom logo was everywhere including the local theatre marquis. There was an attitude within the town that the scientists, engineers, and administrators that worked there had an understanding of a complicated science. They were cutting edge. That buffered them against the outside opinion that nuclear science and industry were potentially dangerous. Hanford was previously described in the program as a site that had 8 nuclear reactors running to produce plutonium for nuclear weapons and a ninth that was used on a flexible basis for the production of plutonium or fuel for power plants. It is currently the site of an ongoing multibillion dollar clean up ever since it closed in 1986.
Ms. Flenniken describes the emotional aspects of her experience and also describes it very clearly in her poetry. Loyalty to the community was important. Talking about the risks from nuclear work and what might have not been said was fair game for the residents of Richland but she bristled when criticism came from the outside. At times when she was concerned about her frame of reference she used the death of a friend's father from radiation induced illness as a reality check. At one point she makes this remark that I thought was absolutely brilliant and is an important lesson for the times:
"There is this idea out there that there are evil people doing evil things. The truth is much more dangerous. Because it's really very good people...very ethical people making lots of mistakes. There is more a lesson of truth in that than in the idea of some kind of evil doer." (At about the 10:22 mark of the audio file).
That remark hit me like a bolt of lightening. Part of it was the presentation. Ms. Flenniken presents this in a very matter of fact manner. It was delivered like I imagined a civil engineer might discuss the facts. As you get older, it is obvious to most people that conflicts are a lot more complex than you thought they were when you were younger. Apart from the physical demands of the job, military recruits are more psychologically malleable for that reason. In this case, we have a person who survived a dangerous environment, but an environment that was portrayed in a different way to her community. She developed a loyalty to that community to the point that she remains conflicted today about what happened and how she should respond. The problem is captured in her remark.
More generally, I think about a lot of political and professional chaos and how her analysis might apply. From unnecessary wars to stigma against the diagnosis and treatment of mental illness to ineffective advocacy - emotional biases clouding logical analysis of the situation at every step of the way. This program is also a good illustration of the power of the spoken word as opposed to the written word and how eloquent a person can be. Listen to this program and see what you think.
George Dawson, MD, DFAPA
The Story. Poetry From the Atomic City. July 11, 2013.
Saturday, July 13, 2013
Thursday, July 11, 2013
More Talk on Psychiatry and the Affordable Care Act
I guess the magical thinking about how a purely political initiative with absolutely no grounding in science will affect the practice of medicine will never cease. The latest speculation is from the Journal of Clinical Psychiatry and commentary from several prominent psychiatrists (see reference) on "The Effects of the Affordable Care Act (ACA) on the Practice of Psychiatry." I know I have said this before but there is so much wrong with this piece, it is difficult to know where to start.
The centerpiece like most discussions of the Affordable Care Act focuses in integrated care. I criticized the American Psychiatric Association for backing any proposal that relegates psychiatry to a peripheral supervisory position looking at so-called measurements to determine if the clinic population is "healthy" or if they need more treatment (translation = antidepressants). There is weak evidence in this article that this model will be the bonus it promises to be. Care given in the Department of Veteran's Affairs (VA) clinic is given as example of how things might be. A patient seeing multiple specialists may receive care from multiple specialists without personally having to coordinate that care. As a patient at the Mayo Clinic - it has been that way for decades. In fact, if they know you are from out of town they can frequently coordinate that care on the fly so it can all happen the same day! No patient aligned care teams necessary there. Just a good system.
There was a statement about how the ACA could hurt psychiatric care of the seriously mentally ill because the states who previously paid for that care will want to bail out. The discussants point out "although the ACA plans to reimburse certain institutions for emergency inpatient psychiatric care for Medicaid patients, other evidence based practices for treating severe and persistent mental disorders are not usually covered by health insurance." Let me translate that for you. That means there will be even fewer inpatient services. The inpatient care for mental health and severe addictions takes another hit. After three decades of decimation by the managed care industry and that same industry shifting the treatment cost for these severe mental disorders to the state - we are going to pretend that nobody needs these services and continue to downsize. After all, there have been no enlightened managed care CEOs to date who decided that these services were actually important enough to adequately fund. Why would they now that they have the leverage to shift all of the money to the all important Medical Home?
The idea that physicians will be paid by "value rather than volume" had me laughing out loud. I pictured the Medical Home psychiatric consultant poring over the clinic's latest batch of PHQ-9 scores and deciding which patient's antidepressants needed tweaking based on this checklist and the cryptic note of a primary care provider. Will we need more checklists for side effects and unexpected effects on the patient's conscious state? Will we need checklists for neuroleptic malignant syndrome or serotonin syndrome? What about the FDA's recent concern about arrhythmias? Cardiovascular review of systems or electrocardiogram? That will be a lot of paperwork to look over. I wonder what the consultant will be paid for delivering that level of "value". Of course all of the discussants were aware of the fact that most psychiatrists will be employees of some sort or another. Those who have not been assimilated may be in concierge practices or private practice, but good luck interfacing with the ACO.
The all important technology card was played and how that should cause us all to swoon. Online or computerized therapy was mentioned. That modality has been available for over 20 years and not a single insurance company or managed care company has implemented it. Any cost benefit analysis favors an inexpensive assessment (PHQ-9 + low intensity primary care visit) and even less expensive medications prescribed as quickly as possible. The unmentioned tragedy of the electronic health record is how much psychiatric assessments have been dumbed down. The loss of information and intelligence due to the electronic health record is absolutely stunning. Phenomenological elements that require a substantial narrative or interpretation by a thinking psychiatrist are totally gone. All that is left is a template of binary elements that are important only for billing and business purposes. I suppose the lawyers might like the fact that you check the "Not suicidal" box before a patient is hurriedly discharged.
Psychiatry without a narrative or a formulation or a rationale is not psychiatry at all. In the end that is what the ACA leaves us with.
George Dawson, MD, DFAPA
Ebert MH, Findling RL, Gelenberg AJ, Kane JM, Nierenberg AA, Tariot PN. The effects of the Affordable Care Act on the practice of psychiatry. J Clin Psychiatry. 2013 Apr;74(4):357-61; quiz 362. doi: 10.4088/JCP.12128co1c. PubMed PMID: 23656840.
The centerpiece like most discussions of the Affordable Care Act focuses in integrated care. I criticized the American Psychiatric Association for backing any proposal that relegates psychiatry to a peripheral supervisory position looking at so-called measurements to determine if the clinic population is "healthy" or if they need more treatment (translation = antidepressants). There is weak evidence in this article that this model will be the bonus it promises to be. Care given in the Department of Veteran's Affairs (VA) clinic is given as example of how things might be. A patient seeing multiple specialists may receive care from multiple specialists without personally having to coordinate that care. As a patient at the Mayo Clinic - it has been that way for decades. In fact, if they know you are from out of town they can frequently coordinate that care on the fly so it can all happen the same day! No patient aligned care teams necessary there. Just a good system.
There was a statement about how the ACA could hurt psychiatric care of the seriously mentally ill because the states who previously paid for that care will want to bail out. The discussants point out "although the ACA plans to reimburse certain institutions for emergency inpatient psychiatric care for Medicaid patients, other evidence based practices for treating severe and persistent mental disorders are not usually covered by health insurance." Let me translate that for you. That means there will be even fewer inpatient services. The inpatient care for mental health and severe addictions takes another hit. After three decades of decimation by the managed care industry and that same industry shifting the treatment cost for these severe mental disorders to the state - we are going to pretend that nobody needs these services and continue to downsize. After all, there have been no enlightened managed care CEOs to date who decided that these services were actually important enough to adequately fund. Why would they now that they have the leverage to shift all of the money to the all important Medical Home?
The idea that physicians will be paid by "value rather than volume" had me laughing out loud. I pictured the Medical Home psychiatric consultant poring over the clinic's latest batch of PHQ-9 scores and deciding which patient's antidepressants needed tweaking based on this checklist and the cryptic note of a primary care provider. Will we need more checklists for side effects and unexpected effects on the patient's conscious state? Will we need checklists for neuroleptic malignant syndrome or serotonin syndrome? What about the FDA's recent concern about arrhythmias? Cardiovascular review of systems or electrocardiogram? That will be a lot of paperwork to look over. I wonder what the consultant will be paid for delivering that level of "value". Of course all of the discussants were aware of the fact that most psychiatrists will be employees of some sort or another. Those who have not been assimilated may be in concierge practices or private practice, but good luck interfacing with the ACO.
The all important technology card was played and how that should cause us all to swoon. Online or computerized therapy was mentioned. That modality has been available for over 20 years and not a single insurance company or managed care company has implemented it. Any cost benefit analysis favors an inexpensive assessment (PHQ-9 + low intensity primary care visit) and even less expensive medications prescribed as quickly as possible. The unmentioned tragedy of the electronic health record is how much psychiatric assessments have been dumbed down. The loss of information and intelligence due to the electronic health record is absolutely stunning. Phenomenological elements that require a substantial narrative or interpretation by a thinking psychiatrist are totally gone. All that is left is a template of binary elements that are important only for billing and business purposes. I suppose the lawyers might like the fact that you check the "Not suicidal" box before a patient is hurriedly discharged.
Psychiatry without a narrative or a formulation or a rationale is not psychiatry at all. In the end that is what the ACA leaves us with.
George Dawson, MD, DFAPA
Ebert MH, Findling RL, Gelenberg AJ, Kane JM, Nierenberg AA, Tariot PN. The effects of the Affordable Care Act on the practice of psychiatry. J Clin Psychiatry. 2013 Apr;74(4):357-61; quiz 362. doi: 10.4088/JCP.12128co1c. PubMed PMID: 23656840.
Tuesday, July 9, 2013
The Lancet's Illogical Digression
The latest editorial in the Lancet has an illogical digression. The brief note starts out by stating that there will soon be a revolution in psychiatry based on a genomics study published in the Lancet. It concludes with a digression to a discussion of about the provision of mental health services across the lifespan with a pejorative connotation:
"The child with ADHD at 7 years could be seen by a child psychiatrist, but at the age of 18 often loses access to mental health services altogether, until he presents with a so-called adult mental health problem. Substance misuse and personality disorders may complicate the picture."
It seems to me that practically all adult psychiatrists would not have any difficulty at all in getting a history of an earlier diagnosis of ADHD and deciding how that would be treated. I wonder if the Lancet's editors would make the same commentary on childhood asthma presenting to an Internal Medicine clinic. Would that be "so-called adult asthma"? The asthma example is instructive because it turns out that what physicians have been calling asthma for decades is more complicated than that. Recent research has adopted the endophenotype/endotype methodology that has been used to study schizophrenia. The reason why adults are seen by adult psychiatrists rather than child psychiatrists is the same reason why people stop seeing their pediatricians as adults. Treating cormorbid substance misuse and personality disorders is just a part of that reason.
As far as the idea that the future of psychiatry is set to change any more than the future of the rest of medicine consider the statement:
"The future of psychiatry looks set to change from the current model, in which ADHD, bipolar disorder, or schizophrenia are considered as totally different illnesses, to a model in which the underlying cause of a spectrum of symptoms determines the treatment."
If that were true, psychiatry would have suddenly catapulted into the most scientifically advanced medical specialty because currently there is no other medical specialty that treats illness based on an underlying genetic cause. The Lancet's attached paragraph on access to services across the lifespan is accurate, but it really has nothing to do with the possible genetic revolution in psychiatric diagnosis. If the services are anywhere near as bad in the UK as they are in the United States (Is public health rationing as bad as rationing done by corporations?) there is a widespread lack of services and disproportionate rationing relative to the rest of medicine.
Until psychiatrists, psychiatric services, and mental illness are destigmatized there is no reason to think that a genetic revolution will mean more access to services.
George Dawson, MD, DFAPA
The Lancet. A revolution in psychiatry. The Lancet - 1 June 2013 ( Vol. 381, Issue 9881, Page 1878 ) DOI: 10.1016/S0140-6736(13)61143-5.
Cross-Disorder Group of the Psychiatric Genomics Consortium. Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysis. The Lancet - 20 April 2013 ( Vol. 381, Issue 9875, Pages 1371-1379 ) DOI: 10.1016/S0140-6736(12)62129-1
Hamshere ML, Stergiakouli E, Langley K, Martin J, Holmans P, Kent L, Owen MJ, Gill M, Thapar A, O'Donovan M, Craddock N. A shared polygenic contribution between childhood ADHD and adult schizophrenia. Br J Psychiatry. 2013 May 23. [Epub ahead of print] PubMed PMID: 23703318.
"The child with ADHD at 7 years could be seen by a child psychiatrist, but at the age of 18 often loses access to mental health services altogether, until he presents with a so-called adult mental health problem. Substance misuse and personality disorders may complicate the picture."
It seems to me that practically all adult psychiatrists would not have any difficulty at all in getting a history of an earlier diagnosis of ADHD and deciding how that would be treated. I wonder if the Lancet's editors would make the same commentary on childhood asthma presenting to an Internal Medicine clinic. Would that be "so-called adult asthma"? The asthma example is instructive because it turns out that what physicians have been calling asthma for decades is more complicated than that. Recent research has adopted the endophenotype/endotype methodology that has been used to study schizophrenia. The reason why adults are seen by adult psychiatrists rather than child psychiatrists is the same reason why people stop seeing their pediatricians as adults. Treating cormorbid substance misuse and personality disorders is just a part of that reason.
As far as the idea that the future of psychiatry is set to change any more than the future of the rest of medicine consider the statement:
"The future of psychiatry looks set to change from the current model, in which ADHD, bipolar disorder, or schizophrenia are considered as totally different illnesses, to a model in which the underlying cause of a spectrum of symptoms determines the treatment."
If that were true, psychiatry would have suddenly catapulted into the most scientifically advanced medical specialty because currently there is no other medical specialty that treats illness based on an underlying genetic cause. The Lancet's attached paragraph on access to services across the lifespan is accurate, but it really has nothing to do with the possible genetic revolution in psychiatric diagnosis. If the services are anywhere near as bad in the UK as they are in the United States (Is public health rationing as bad as rationing done by corporations?) there is a widespread lack of services and disproportionate rationing relative to the rest of medicine.
Until psychiatrists, psychiatric services, and mental illness are destigmatized there is no reason to think that a genetic revolution will mean more access to services.
George Dawson, MD, DFAPA
The Lancet. A revolution in psychiatry. The Lancet - 1 June 2013 ( Vol. 381, Issue 9881, Page 1878 ) DOI: 10.1016/S0140-6736(13)61143-5.
Cross-Disorder Group of the Psychiatric Genomics Consortium. Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysis. The Lancet - 20 April 2013 ( Vol. 381, Issue 9875, Pages 1371-1379 ) DOI: 10.1016/S0140-6736(12)62129-1
Hamshere ML, Stergiakouli E, Langley K, Martin J, Holmans P, Kent L, Owen MJ, Gill M, Thapar A, O'Donovan M, Craddock N. A shared polygenic contribution between childhood ADHD and adult schizophrenia. Br J Psychiatry. 2013 May 23. [Epub ahead of print] PubMed PMID: 23703318.
Larsson H, Rydén E, Boman M, Långström N, Lichtenstein P, Landén M. Risk of bipolar disorder and schizophrenia in relatives of people with attention-deficit hyperactivity disorder. Br J Psychiatry. 2013 May 23. [Epub ahead of print] PubMed PMID: 23703314.
Thursday, July 4, 2013
Preference for Psychotherapy or General Dislike of Medication?
I haven't see the study mentioned in many places yet, but there was a meta-analysis of patient preference for psychological versus pharmacological treatment of psychiatric disorders in the Journal of Clinical Psychiatry. It contained all of the usual buzzwords about evidence based medicine and why this is a hot topic to study because of the possible cost savings and potential for better outcomes if preferences were matched to actual treatments. Interestingly, in the same month a more high tech approach to matching depressed patients with pharmacotherapy versus psychotherapy came out in JAMA Psychiatry where the independent variable was a brain imaging result rather than patient preference.
The authors here looked at a final sample of 34 studies out of 644 studies that were screened. They end up with a chart of effect sizes with confidence intervals for each of the 34 studies. There were a total of 90,483 participants but 78,753 were included in one study. All of the studies are of depression and anxiety. They had tried to include studies on schizophrenia and bipolar disorder and found that they were not published. The authors conclude that their meta-analysis was valid and that there was a consistent preference for psychological treatment in the treatment seeking and non-treatment seeking or recruited patients. From this the authors suggest that patient prefernce should trump other considerations if the efficacy of both treatments are equivalent. They question why medication related treatments have increased and psychological therapies have dimished over the past decade. They suggest that the patients who prefer medication related therapies are non adherent.
In their discussion of the limitations of the study they find there was not enough data to compare combination therapy as a choice, they excluded non-published studies and therefore included potential publication bias, and they were not able to address the question about why psychological treatments were preferred over medication based therapies by a factor of 3:1.
These and other important questions have already been answered on this blog, but don't expect to see any publications on this anytime soon. Managed care has taken the very evidence based treatments that these authors emphasize and stood them on their head. I have written many times about the diagnosis of depression using rating scales and the preferred treatment of antidepressants. If you are using a primary care physician follow up code and a PHQ-9 score result to diagnose depression in ten minutes and treat all of these patients with a generic antidepressant ($4/month) - there is no psychotherapy that compares to that low cost.
All psychiatrists who are actively looking for psychotherapists to treat anxiety and depression encounter the problems of a lack of qualified therapists and more specifically a lack of therapist time in managed care systems. Managed care systems especially those that are actively managed to reduce outpatient mental health treatment has reduced available therapy in many systems to 2 or 3 sessions of crisis management and essentially limited or eliminated additional services like psychological testing that some therapists require to do their work. It is no accident that patients seeking psychological therapy can't get it. It is a conscious business decision.
The second problem is the lack of availability to research proven psychotherapies. Any psychiatrist doing patient evaluations will hear the story that therapy sessions are often very non-specific, lack goals, and often result in the patient losing faith in the process and stopping the therapy. Being seen in a psychological therapy is no assurance of a good outcome. Many patients who are provided with excellent research proven therapy are frustrated with the time commitment and stop because of the cost or number of sessions. Psychotherapy may look a lot better on paper than the reality of the relationship with the therapist and the logistics of getting to and paying for the sessions.
What can be done to improve the situation right now? The decision to take a medication for any reason is never a casual one. Taking that medication reliably is even more significant. Non medication alternatives and combination therapies to reduce exposure to medications should be available in every clinic. Instead of screening everyone for a medication on day one, non-medication alternatives should be presented at that time. There are innovative non-medication therapies such as computer delivered psychotherapy for depression, anxiety and obsessive compulsive disorder. No clinic appointments. The therapy is delivered online or by phone any time of the day or night. With the appropriate implementation, these therapies could be offered as first line treatment to massive numbers of patients. The human cost is so low they could essentially be made available across an entire health plan for free. There is no reason why networks of therapy clinics cannot be linked to primary care clinics who see the majority of patients with depression and anxiety. Any medication alternative can be discussed if the psychotherapy or non-medication intervention works.
From a research perspective if only 34 of 644 studies were suitable for inclusion in a meta-analysis, the problem is clearly not being studied very well. I think it is important to ascertain patient preference for psychological, combination, pharmacological and other (eg. lifestyle change) therapies in all registered clinical trials. In clinical practice, it is all part of informed consent for treatment. I think it is the universal experience of physicians that most people prefer to not take medications. The negative treatment of psychiatry and psychiatric medications in the press create an understandable bias against psychiatric medications relative to others as a potential source of the described phenomenon. There is some evidence that the advertising of these medications is different and potentially stigmatizing. We also need better design of clinical trials. If therapies are in fact equivalent, they need to be tested in actual clinical populations where psychiatrists work. That includes severely ill patients with comorbidity, patients who are acutely agitated and suicidal, women and children and adolescents. Much of the discussion of equivalent therapies is based on extrapolation from populations of people who are mildly depressed and in some cases who have enrolled in a number of studies.
This study highlights the current weaknesses in studying how people actually receive psychiatric treatment and how to best approach that from a research perspective. It points out that we need much better research designs and better patient selection in order to answer even basic questions about the treatment process. It should be apparent that a research design that is not adequate to describe clinical practice is not a commentary on clinical practice.
George Dawson, MD, DFAPA
McHugh RK, Whitton SW, Peckham AD, Welge JA, Otto MW. Patient preference of psychological vs pharmacological treatment of psychiatric disorders: a meta-analytic review. J Clin Psychiatry 2013; 74:6: 595-602.
The authors here looked at a final sample of 34 studies out of 644 studies that were screened. They end up with a chart of effect sizes with confidence intervals for each of the 34 studies. There were a total of 90,483 participants but 78,753 were included in one study. All of the studies are of depression and anxiety. They had tried to include studies on schizophrenia and bipolar disorder and found that they were not published. The authors conclude that their meta-analysis was valid and that there was a consistent preference for psychological treatment in the treatment seeking and non-treatment seeking or recruited patients. From this the authors suggest that patient prefernce should trump other considerations if the efficacy of both treatments are equivalent. They question why medication related treatments have increased and psychological therapies have dimished over the past decade. They suggest that the patients who prefer medication related therapies are non adherent.
In their discussion of the limitations of the study they find there was not enough data to compare combination therapy as a choice, they excluded non-published studies and therefore included potential publication bias, and they were not able to address the question about why psychological treatments were preferred over medication based therapies by a factor of 3:1.
These and other important questions have already been answered on this blog, but don't expect to see any publications on this anytime soon. Managed care has taken the very evidence based treatments that these authors emphasize and stood them on their head. I have written many times about the diagnosis of depression using rating scales and the preferred treatment of antidepressants. If you are using a primary care physician follow up code and a PHQ-9 score result to diagnose depression in ten minutes and treat all of these patients with a generic antidepressant ($4/month) - there is no psychotherapy that compares to that low cost.
All psychiatrists who are actively looking for psychotherapists to treat anxiety and depression encounter the problems of a lack of qualified therapists and more specifically a lack of therapist time in managed care systems. Managed care systems especially those that are actively managed to reduce outpatient mental health treatment has reduced available therapy in many systems to 2 or 3 sessions of crisis management and essentially limited or eliminated additional services like psychological testing that some therapists require to do their work. It is no accident that patients seeking psychological therapy can't get it. It is a conscious business decision.
The second problem is the lack of availability to research proven psychotherapies. Any psychiatrist doing patient evaluations will hear the story that therapy sessions are often very non-specific, lack goals, and often result in the patient losing faith in the process and stopping the therapy. Being seen in a psychological therapy is no assurance of a good outcome. Many patients who are provided with excellent research proven therapy are frustrated with the time commitment and stop because of the cost or number of sessions. Psychotherapy may look a lot better on paper than the reality of the relationship with the therapist and the logistics of getting to and paying for the sessions.
What can be done to improve the situation right now? The decision to take a medication for any reason is never a casual one. Taking that medication reliably is even more significant. Non medication alternatives and combination therapies to reduce exposure to medications should be available in every clinic. Instead of screening everyone for a medication on day one, non-medication alternatives should be presented at that time. There are innovative non-medication therapies such as computer delivered psychotherapy for depression, anxiety and obsessive compulsive disorder. No clinic appointments. The therapy is delivered online or by phone any time of the day or night. With the appropriate implementation, these therapies could be offered as first line treatment to massive numbers of patients. The human cost is so low they could essentially be made available across an entire health plan for free. There is no reason why networks of therapy clinics cannot be linked to primary care clinics who see the majority of patients with depression and anxiety. Any medication alternative can be discussed if the psychotherapy or non-medication intervention works.
From a research perspective if only 34 of 644 studies were suitable for inclusion in a meta-analysis, the problem is clearly not being studied very well. I think it is important to ascertain patient preference for psychological, combination, pharmacological and other (eg. lifestyle change) therapies in all registered clinical trials. In clinical practice, it is all part of informed consent for treatment. I think it is the universal experience of physicians that most people prefer to not take medications. The negative treatment of psychiatry and psychiatric medications in the press create an understandable bias against psychiatric medications relative to others as a potential source of the described phenomenon. There is some evidence that the advertising of these medications is different and potentially stigmatizing. We also need better design of clinical trials. If therapies are in fact equivalent, they need to be tested in actual clinical populations where psychiatrists work. That includes severely ill patients with comorbidity, patients who are acutely agitated and suicidal, women and children and adolescents. Much of the discussion of equivalent therapies is based on extrapolation from populations of people who are mildly depressed and in some cases who have enrolled in a number of studies.
This study highlights the current weaknesses in studying how people actually receive psychiatric treatment and how to best approach that from a research perspective. It points out that we need much better research designs and better patient selection in order to answer even basic questions about the treatment process. It should be apparent that a research design that is not adequate to describe clinical practice is not a commentary on clinical practice.
George Dawson, MD, DFAPA
McHugh RK, Whitton SW, Peckham AD, Welge JA, Otto MW. Patient preference of psychological vs pharmacological treatment of psychiatric disorders: a meta-analytic review. J Clin Psychiatry 2013; 74:6: 595-602.
Saturday, June 29, 2013
To the Left and the Right of Dr. Frances
Allen Frances continues to erect his wall of criticism of DSM-5. He shows no sign of slowing down even after the DSM-5 was released. He has written a list of 18 problems in the Psychiatric Times that he characterizes as "glaring mistakes in wording and coding." He believes that there were "egregious mistakes on almost every page I read." That is a curious counterpoint to the opinion I heard recently from Jon Grant, MD when he presented the history, process, and details of the development of DSM-5. While Dr. Frances has undeniable DSM-IV experience there is always plenty of room for disagreement. He comments that he has limited time for a detailed read of DSM and I have even less, so I will concentrate on 2 of his 18 points to illustrate what I mean.
Intermittent Explosive Disorder - Dr. Frances main complaint about this diagnosis is that is "lacks the needed exclusions to exclude the other more common causes of violent behavior." The diagnostic criteria actually contains the exclusion:
F. The recurrent aggressive outbursts are not better explained by another mental disorder.....and are not attributable to another medical condition.....or to the physiological effects of a substance.
Specific examples are given and there is also an exclusion for adjustment disorders in children. The actual number of exclusionary diagnoses listed are essentially the same as DSM-IV and the discussion in the differential diagnosis is more extensive (p 612-613). My problem is that I don't think this diagnosis actually exists. That statement comes from over two decades of experience in acute care inpatient psychiatry, community psychiatry, and hospital psychiatry. These are all settings on the front lines of aggressive behavior. When the police encounter aggression and there is any question of an intoxication, medical problem, or mental disorder associated with that behavior - those people are brought in to settings where acute care psychiatrists are involved. In my experience of assessing extreme aggression up to and including homicide I have never seen a single case where the outbursts were not better explained by another mental disorder. I don't agree that the exclusion criteria are any different. I don't believe that this disorder exists. If it does, the prevalence is so low that this acute care psychiatrist has not seen it in thousands of evaluations of aggressive behavior.
Mild Neurocognitive Disorder - Dr. Frances complaint about this diagnosis is "so impossibly vague that it includes me, my wife and most of our friends. It will cause unnecessary worry and a rush to useless and expensive testing."
As I read through these criteria I have a much different perspective. For about 10 years I ran a Geriatric Psychiatry and Memory Disorders Clinic where we did comprehensive assessments of patients with cognitive problems. I worked with a nurse who would collect detailed information on patient's functional and cognitive capacity before they came into the clinic for my assessment. A significant number of those patients had a strictly subjective complaint about their memory or cognition. A large percentage of these patients did not have any insight into the severity of their problem and their typical assessment was: "My memory is no different than any other 60 or 70 year old." Even though we had generally spent about three hours of assessment time with each patient, at the end of my evaluation we often did not have a clear diagnosis. We would stick with that person until we did and often times the outcomes were surprising. We had striking examples of chronic delirious states where the patient was given a diagnosis of dementia based on on neuropsychological testing, and with treatment and reassurance we observed their cognition to clear completely and they were restored to normal cognitive function.
I see the diagnosis of Mild Neurocognitive Disorder as a portal to that level of care. Based on the list of 10 brain diseases and other medical conditions listed as specifiers the authors of this criteria clearly had that intent. It is clear to me that any clinic with a high standard of care for patients with cognitive disorders like my clinic had can use this diagnosis both as part of the continuum to more Major Neurocognitive Disorders associated with progressive neurodegenerative dementias and to provide high quality assessments for patients with concerns about any cognitive changes. Keep in mind that the typical managed care model would use a crude screening test and possibly refer for other psychological testing. There might not be a physician in the loop who can make the necessary assessments and diagnoses. Current research in this area also points to the need to identify patients as early as possible, especially as treatments become available.
On these two points I guess I am to the right of Dr. Frances on Intermittent Explosive Disorder and to the left on Mild Neurocognitive Disorder. But I think the entire argument misses the mark if we think about the issue of psychiatric diagnosis and where the DSM fits in. Any DSM cannot be used like a phone book to classify hundreds of different presentations to a Memory Disorder and Geriatric Psychiatry Clinic. The unique conscious states of those individuals and their relative levels of impairment can only be determined by a comprehensive evaluation by a physician who is knowledgeable in all of the possible brain diseases that are suggested as etiologies. Apart from the obvious increase in complexity for anything that is determined by a central nervous system, getting a diagnosis of Mild Neurocognitive Disorder is no different than getting a diagnosis of "Neck pain" or "Ankle pain" from a primary care physician. And yes - those primary care diagnoses are very common.
The idea that there are precise criteria that can be written down and applied to make definitive diagnoses is a common misconception of the DSM and other diagnostic schemes. To emphasize that point, I will end with a quote from Harold Merskey, FRCP, FRCPsych:
"Medical classification lacks the rigor either of the telephone directory or the periodic table."
That is all medical classification and not just the DSM-5. A good starting point toward realizing the truth in this quote is to stop looking at the DSM-5 like it is a phone book. You don't get a psychiatric diagnosis from the DSM-5.
You get a psychiatric diagnosis from a psychiatrist.
George Dawson, MD, DFAPA
Merskey H. The taxonomy of pain. Med Clin North Am. 2007 Jan;91(1):13-20, vii. PubMed PMID: 17164101
Intermittent Explosive Disorder - Dr. Frances main complaint about this diagnosis is that is "lacks the needed exclusions to exclude the other more common causes of violent behavior." The diagnostic criteria actually contains the exclusion:
F. The recurrent aggressive outbursts are not better explained by another mental disorder.....and are not attributable to another medical condition.....or to the physiological effects of a substance.
Specific examples are given and there is also an exclusion for adjustment disorders in children. The actual number of exclusionary diagnoses listed are essentially the same as DSM-IV and the discussion in the differential diagnosis is more extensive (p 612-613). My problem is that I don't think this diagnosis actually exists. That statement comes from over two decades of experience in acute care inpatient psychiatry, community psychiatry, and hospital psychiatry. These are all settings on the front lines of aggressive behavior. When the police encounter aggression and there is any question of an intoxication, medical problem, or mental disorder associated with that behavior - those people are brought in to settings where acute care psychiatrists are involved. In my experience of assessing extreme aggression up to and including homicide I have never seen a single case where the outbursts were not better explained by another mental disorder. I don't agree that the exclusion criteria are any different. I don't believe that this disorder exists. If it does, the prevalence is so low that this acute care psychiatrist has not seen it in thousands of evaluations of aggressive behavior.
Mild Neurocognitive Disorder - Dr. Frances complaint about this diagnosis is "so impossibly vague that it includes me, my wife and most of our friends. It will cause unnecessary worry and a rush to useless and expensive testing."
As I read through these criteria I have a much different perspective. For about 10 years I ran a Geriatric Psychiatry and Memory Disorders Clinic where we did comprehensive assessments of patients with cognitive problems. I worked with a nurse who would collect detailed information on patient's functional and cognitive capacity before they came into the clinic for my assessment. A significant number of those patients had a strictly subjective complaint about their memory or cognition. A large percentage of these patients did not have any insight into the severity of their problem and their typical assessment was: "My memory is no different than any other 60 or 70 year old." Even though we had generally spent about three hours of assessment time with each patient, at the end of my evaluation we often did not have a clear diagnosis. We would stick with that person until we did and often times the outcomes were surprising. We had striking examples of chronic delirious states where the patient was given a diagnosis of dementia based on on neuropsychological testing, and with treatment and reassurance we observed their cognition to clear completely and they were restored to normal cognitive function.
I see the diagnosis of Mild Neurocognitive Disorder as a portal to that level of care. Based on the list of 10 brain diseases and other medical conditions listed as specifiers the authors of this criteria clearly had that intent. It is clear to me that any clinic with a high standard of care for patients with cognitive disorders like my clinic had can use this diagnosis both as part of the continuum to more Major Neurocognitive Disorders associated with progressive neurodegenerative dementias and to provide high quality assessments for patients with concerns about any cognitive changes. Keep in mind that the typical managed care model would use a crude screening test and possibly refer for other psychological testing. There might not be a physician in the loop who can make the necessary assessments and diagnoses. Current research in this area also points to the need to identify patients as early as possible, especially as treatments become available.
On these two points I guess I am to the right of Dr. Frances on Intermittent Explosive Disorder and to the left on Mild Neurocognitive Disorder. But I think the entire argument misses the mark if we think about the issue of psychiatric diagnosis and where the DSM fits in. Any DSM cannot be used like a phone book to classify hundreds of different presentations to a Memory Disorder and Geriatric Psychiatry Clinic. The unique conscious states of those individuals and their relative levels of impairment can only be determined by a comprehensive evaluation by a physician who is knowledgeable in all of the possible brain diseases that are suggested as etiologies. Apart from the obvious increase in complexity for anything that is determined by a central nervous system, getting a diagnosis of Mild Neurocognitive Disorder is no different than getting a diagnosis of "Neck pain" or "Ankle pain" from a primary care physician. And yes - those primary care diagnoses are very common.
The idea that there are precise criteria that can be written down and applied to make definitive diagnoses is a common misconception of the DSM and other diagnostic schemes. To emphasize that point, I will end with a quote from Harold Merskey, FRCP, FRCPsych:
"Medical classification lacks the rigor either of the telephone directory or the periodic table."
That is all medical classification and not just the DSM-5. A good starting point toward realizing the truth in this quote is to stop looking at the DSM-5 like it is a phone book. You don't get a psychiatric diagnosis from the DSM-5.
You get a psychiatric diagnosis from a psychiatrist.
George Dawson, MD, DFAPA
Merskey H. The taxonomy of pain. Med Clin North Am. 2007 Jan;91(1):13-20, vii. PubMed PMID: 17164101
Tuesday, June 25, 2013
The Real Problem With Managed Care Research
You know the kind of research I am talking about. The research that shows that managed care is more cost effective and higher quality than fee for service. This stuff has been out there since the 1990s. Is there really research like that out there or is it little more than a political exercise? We have more than a few clues thanks to recent analysis of a Health Affairs article by Kip Sullivan. The article is titled: "The ‘Alternative Quality Contract,’ Based On A Global Budget, Lowered Medical Spending And Improved Quality" Sullivan points out that the title of this article is misleading because it suggests that the managed care intervention here "lowered medical spending and improved quality" in the title, but in the body of the work the authors state:
"Our findings do not imply that overall spending fell for Blue Cross Blue Shield of Massachusetts in 2009-2010."
and a paragraph later:
"This result makes it likely that total Blue Cross Blue Shield payments to groups in 2010 exceeded medical savings achieved by the group that year."
Sullivan's analysis here is dead-on, especially the idea that "medical savings" can be parsed from overall savings when there is suddenly a large managed care infrastructure. From some of the places where I have worked, this means bringing in a raft of middle managers who provide no service and generate no income to "manage' the people who are actually providing the care. In some settings that could mean a "manager" for every 5 - 10 physicians. If your goal is to cut reimbursement to the providers by just paying them less or sending them fewer referrals while adding a costly overhead of a number of managers who think they can translate their ideas about business into better clinical care - that seems like a recipe for higher costs, record physician dissatisfaction, and disregard for professional quality based guidelines. Sullivan points out that this specific problem in managed care research has been around since the 1990's
The "higher quality" issue is as interesting. I encourage anyone interested to download the paper because it is only free until Sunday June 30. As you read it, take a look at the table labeled "Exhibit 4". It is a table of quality care measures across both the control groups and the intervention groups. Although many of the variables are easily defined a couple of issues appear to be clear. Many seem to be process variables. In other words, just keeping track of variables and making sure that you are ticking them off gives you more credit. This is standard procedure in a managed care environment with more case managers. They can literally be assigned to remind physicians or ward teams to do tasks on a time frame that gives them credit for the process variable. More administrative manpower should equate to a larger percentage of process variables.
I note that within the quality variables there are two that apply to psychiatry - Depression: Short Term Rx and Depression: Long Term Rx. There are no significant differences across that study period at the P<0.05 level. This is interesting at a couple of levels. First, if this is actually the number of depressed people treated the change after the managed care intervention is not significant. Secondly, what measures are used to make this determination. Are these actually depressed people or are they patients scoring above a certain cutoff on a PHQ-9 rating scale? Third, is the change in percentage of patients treated a legitimate quality marker? Aren't we more interested in retention in treatment and actual treatment of individual patients treated into remission rather than a cross sectional look at the percentage of patients treated?
The scientific concerns about this paper are numerous. Like all research (and I mean all research) there are political implications. The defined intervention here of the Alternate Quality Contract, is basically a primary care physician as gatekeeper model that consumers rejected over a decade ago. At that point in time, managed care organizations realized that they would need to compete on the basis of providing direct access to specialty care without primary care referrals. The adaption of the MCOs was to hire their own specialists and build speciality clinics. The article describes this as basically the "patient centered medical home" (p 1886). I wonder if the average consumer realizes that the medical home is really a primary care gatekeeper system from the past?
I can't help stressing the importance of article like this one and all research that purports to save money with larger administrative structures that are there in a large part to supervise physicians rather than create administrative efficiencies. There is no better example than the non-existent mental health system for what this kind of rationing and administrative excess can create. Diverting money from the direct provision of clinical care into complicated forms of administrative overhead needs to be measured accurately in all of these studies.
George Dawson, MD, DFAPA
"Our findings do not imply that overall spending fell for Blue Cross Blue Shield of Massachusetts in 2009-2010."
and a paragraph later:
"This result makes it likely that total Blue Cross Blue Shield payments to groups in 2010 exceeded medical savings achieved by the group that year."
Sullivan's analysis here is dead-on, especially the idea that "medical savings" can be parsed from overall savings when there is suddenly a large managed care infrastructure. From some of the places where I have worked, this means bringing in a raft of middle managers who provide no service and generate no income to "manage' the people who are actually providing the care. In some settings that could mean a "manager" for every 5 - 10 physicians. If your goal is to cut reimbursement to the providers by just paying them less or sending them fewer referrals while adding a costly overhead of a number of managers who think they can translate their ideas about business into better clinical care - that seems like a recipe for higher costs, record physician dissatisfaction, and disregard for professional quality based guidelines. Sullivan points out that this specific problem in managed care research has been around since the 1990's
The "higher quality" issue is as interesting. I encourage anyone interested to download the paper because it is only free until Sunday June 30. As you read it, take a look at the table labeled "Exhibit 4". It is a table of quality care measures across both the control groups and the intervention groups. Although many of the variables are easily defined a couple of issues appear to be clear. Many seem to be process variables. In other words, just keeping track of variables and making sure that you are ticking them off gives you more credit. This is standard procedure in a managed care environment with more case managers. They can literally be assigned to remind physicians or ward teams to do tasks on a time frame that gives them credit for the process variable. More administrative manpower should equate to a larger percentage of process variables.
I note that within the quality variables there are two that apply to psychiatry - Depression: Short Term Rx and Depression: Long Term Rx. There are no significant differences across that study period at the P<0.05 level. This is interesting at a couple of levels. First, if this is actually the number of depressed people treated the change after the managed care intervention is not significant. Secondly, what measures are used to make this determination. Are these actually depressed people or are they patients scoring above a certain cutoff on a PHQ-9 rating scale? Third, is the change in percentage of patients treated a legitimate quality marker? Aren't we more interested in retention in treatment and actual treatment of individual patients treated into remission rather than a cross sectional look at the percentage of patients treated?
The scientific concerns about this paper are numerous. Like all research (and I mean all research) there are political implications. The defined intervention here of the Alternate Quality Contract, is basically a primary care physician as gatekeeper model that consumers rejected over a decade ago. At that point in time, managed care organizations realized that they would need to compete on the basis of providing direct access to specialty care without primary care referrals. The adaption of the MCOs was to hire their own specialists and build speciality clinics. The article describes this as basically the "patient centered medical home" (p 1886). I wonder if the average consumer realizes that the medical home is really a primary care gatekeeper system from the past?
I can't help stressing the importance of article like this one and all research that purports to save money with larger administrative structures that are there in a large part to supervise physicians rather than create administrative efficiencies. There is no better example than the non-existent mental health system for what this kind of rationing and administrative excess can create. Diverting money from the direct provision of clinical care into complicated forms of administrative overhead needs to be measured accurately in all of these studies.
George Dawson, MD, DFAPA
Tuesday, June 18, 2013
DSM-5 and Primary Care
In the pre-DSM-5 hysteria, I posted the observation that primary care physicians were not "avid readers" of the DSM and therefore the idea that they would be likely to be influenced by it was erroneous. Of course I was responding to the propaganda that the DSM-5 was basically a tool for psychiatric hegemony and that upstanding physicians everywhere would be mere pawns of organized psychiatry. Tens of millions of people would be overmedicated. There would be total chaos while Big Pharma, the APA, and psychiatrists everywhere lined their pockets with the proceeds of inappropriate prescribing. In that atmosphere some considered my statement controversial.
From this week's American Medical News:
"....Perry A. Pugno, MD, MPH, vice president for education for the American Academy of Family Physicians, is not surprised that he hasn't heard about DSM-5 from the organization's members.
'From a pragmatic perspective, we don't use (the manual) very much,' he said. 'Most of the things we see we already know the diagnostic criteria for them.' " (page 12, AMEDNEWS, June 17, 2013).
Remember I also said that psychiatrists are not memorizing the DSM-5 either, for a similar reason.
As I think about what happened in the press before the release of DSM-5, mass hysteria is not a bad phrase. Mass psychogenic illness is probably more politically correct these days but some experts consider an anxious form and a somatic form. There are numerous examples of each and some references suggest that it is compounded by the presence of social media. At any rate, the dynamic is very similar to the critical DSM-5 frenzy prior to the release. In both cases, it can start as a rumor or speculative theory. If that speculation sounds plausible to a larger group it is accepted and built upon. At some point the response to the speculation is critical. Will some experts step in and confirm the original speculation or introduce their own shocking hypotheses? The reaction of the authorities takes it to the next level. Will they seem to take the problem seriously. Media coverage makes things worse. Will additional systems be activated to broaden the response? Momentum builds and before you know it the anxiety or somatic symptoms are linked with a totally implausible hypothesis. Some reviews suggest that treatment involves separating the affected individuals and keeping them out of the limelight for a while until the symptoms fade away. As a psychiatrist who has treated many cases of conversion disorders with neurological symptoms using psychotherapy, I can't imagine competing with several "experts" in the media all having their own theories about the problem. My guess is that my therapy would be either neutralized or severely protracted.
A lot of these things happened in the run up to the DSM-5. So I am using mass hysteria here as a metaphor and not a "diagnosis". I thought I should clarify that because I fully expect that somebody would accuse me of that and go on to suggest that I am a control agent for somebody (?)
It is also not a diagnosis because it is not in DSM-5 or DSM-IV for that matter.
Hopefully cooler heads will prevail in the next big public controversy about psychiatry. But I doubt it.
George Dawson, MD, DFAPA
From this week's American Medical News:
"....Perry A. Pugno, MD, MPH, vice president for education for the American Academy of Family Physicians, is not surprised that he hasn't heard about DSM-5 from the organization's members.
'From a pragmatic perspective, we don't use (the manual) very much,' he said. 'Most of the things we see we already know the diagnostic criteria for them.' " (page 12, AMEDNEWS, June 17, 2013).
Remember I also said that psychiatrists are not memorizing the DSM-5 either, for a similar reason.
As I think about what happened in the press before the release of DSM-5, mass hysteria is not a bad phrase. Mass psychogenic illness is probably more politically correct these days but some experts consider an anxious form and a somatic form. There are numerous examples of each and some references suggest that it is compounded by the presence of social media. At any rate, the dynamic is very similar to the critical DSM-5 frenzy prior to the release. In both cases, it can start as a rumor or speculative theory. If that speculation sounds plausible to a larger group it is accepted and built upon. At some point the response to the speculation is critical. Will some experts step in and confirm the original speculation or introduce their own shocking hypotheses? The reaction of the authorities takes it to the next level. Will they seem to take the problem seriously. Media coverage makes things worse. Will additional systems be activated to broaden the response? Momentum builds and before you know it the anxiety or somatic symptoms are linked with a totally implausible hypothesis. Some reviews suggest that treatment involves separating the affected individuals and keeping them out of the limelight for a while until the symptoms fade away. As a psychiatrist who has treated many cases of conversion disorders with neurological symptoms using psychotherapy, I can't imagine competing with several "experts" in the media all having their own theories about the problem. My guess is that my therapy would be either neutralized or severely protracted.
A lot of these things happened in the run up to the DSM-5. So I am using mass hysteria here as a metaphor and not a "diagnosis". I thought I should clarify that because I fully expect that somebody would accuse me of that and go on to suggest that I am a control agent for somebody (?)
It is also not a diagnosis because it is not in DSM-5 or DSM-IV for that matter.
Hopefully cooler heads will prevail in the next big public controversy about psychiatry. But I doubt it.
George Dawson, MD, DFAPA
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