JAMA Psychiatry Suicide Article, Statistics and AI

Suicide Rates - Selected OECD Countries

Suicide is a very important problem for psychiatrists.  Even though it is a rare event, it seems like most of our time is focused on preventing suicide.  There are many days where many high risk patients and patients with chronic suicidal ideation are seen in clinics and hospitals.  Most of them are treated in outpatient settings and very few are treated on an involuntary basis in hospital settings.  Since suicide is diametrically opposed to self preservation it is assumed that any rational person would want to get help with those thoughts and impulses.  Like most things in psychiatric practice it is almost never than simple.  Psychiatrists encounter a wide range of of reasons for suicidal thinking.  At times, the suicidal thinking was not obvious until it was declared after a suicide attempt.  Many people decide to see psychiatrists after a first suicide attempt.  Even at that point it is common to find a person who is disappointed that they did not succeed.  It is more common to find a person greatly relieved that they survived but even then that does not assure the cooperation necessary to prevent another attempt.

The standard of practice for assessing suicidal thinking or ideation and potential risk is risk factor analysis.  This has been the standard of practice for as long as I have practiced over the past 30 years.  To do this analysis, it requires making a diagnosis or a series of diagnoses and looking at associated factors and how the patient describes his/her mental state at the time.  Major psychiatric diagnoses like major depression, schizophrenia, bipolar disorder, panic disorder, borderline personality disorder and chronic substance use disorders all have significant lifetime prevalences of suicide varying from 3 to 15%.  Psychological autopsies of series of suicides find that nearly all of the patients who have suicided in these studies had a significant psychiatric disorder.  There are also studies done from a social science perspective that emphasize the social risk factors for suicide including sex, martial and relationship status, economic factors and loss.

Suicide is a widely misunderstood problem sometimes even for the patients who are experiencing the thoughts.  It is common for example to encounter people with suicidal thinking who say that their only deterrent to suicide is that they don't "have the guts" to do it.  An associated worry might be that it is "too painful."  They feel a need to explain why they cannot carry out an irrational act.  I take this to mean that at some point in time, the suicidal person's conscious state has changed.  They are no longer a rational person and that is why they must explain away the fact that they cannot carry out an irrational act.  Another common observation that speaks to the conscious state is that many people will say "I never understood how a person could be suicidal until I finally felt that way."  That suggests that the altered conscious state is associated with a mood state of depression or many times a mixture of depression, anger, and anxiety resulting in an agitated state that led to the understanding about suicidal thoughts.  A final observation is one of the most stressful parts of psychiatric practice and that is:  "Can I believe this person when they tell me they are not going to kill themselves?"  Much of acute care psychiatry hinges on that ultimate question.  The risk factor analysis is essentially nullified if the patient is in an emergency department and their diagnosis and past suicide attempts are known.  The only thing left to go on are the standard questions about current state of mind, deterrents, safety plans and whether the person seems reliable and says they will not kill themselves.   It is widely known that people kill themselves after leaving emergency departments and hospitals.  People have killed themselves in hospitals while under direct observation.

Many of these assessments become adversarial.  By the time a psychiatrist sees a patient in a hospital, a lot has already happened. In all of the hospitals where I have practiced, crisis teams, paramedics, and the police have assessed the person in the community and brought them in to the hospital.  Very few people were under psychiatric care at the time of that intervention.  Friends and family members of the patient were the people who called the first responders.  The patient is usually there out of some concern for their welfare that they may not be aware of.  The psychiatrist comes around sometime in the next 24 hours and the interaction unfolds.  Very few people seem interested in the fact that they might kill themselves.  Getting out of the hospital may be the priority.  Their approach might be one of non-disclosure or denial: "I really did not say I was suicidal." or "I did not mean it",  or "I was drunk or high at the time".  Even those responses can vary from very unlikely (as in a patient with a serious self inflicted gunshot wound) to unlikely (a patient with delusional depression stopped in the midst or a suicide attempt) to possible (the intoxication history with no suicidal ideation while sober).  The interview dynamic is also quite variable.  A person may be sullen, irritated, and not wanting to discuss much information.  They may express concerns about self incrimination: "I know what I can and cannot say to psychiatrists.  I know if I say the wrong thing you will lock me up and throw away the key."  They may blame their problems on the psychiatrist: "Look - I know you don't care about me.  The only thing you care about is covering your ass.  You are going to do whatever you want to do."  They may be more hostile and sarcastic: "Look if I was really going to kill myself I wouldn't be sitting here talking to you.  I'd be dead.  I wouldn't be talking about it."

All of these statements ignore the fact that the person is sitting in front of the psychiatrist as the result of the actions of several other people including persons affiliated with them and having their best interests at heart.  That situation is so intense and uncomfortable that it prevents physicians from going into psychiatry.  I  have had many physicians tell me they could not go into psychiatry because:  "Guessing about whether or not a person will kill themselves is too stressful."  There are many ways to reduce the guesswork involved but the point I am trying to make here is that all of these behaviors are consistent with the patient having undergone a change in their conscious state.  They are no longer acting like a person interested in self preservation, but they are now a person who is contemplating self destruction and taking active measures to hide that thought pattern.  That is the main reason why psychiatrists can't predict suicide over long periods of time with any degree of certainty.  When a person's conscious state changes that completely, their actions are less predictable even to the point that they may be potentially self destructive and want to cover it up.

That is also why risk factor analysis is so imperfect.  In the case of the diagnosis, a lot of clinicians are under the impression that if a person satisfies some written criteria for a diagnosis that provides a lot of critical information about the potential for suicide.  Many clinicians seem to miss the point that a patient can have the exact same written criteria for major depression with psychotic features and the same chronic markers on a suicide risk assessment and suddenly be much more likely to attempt suicide.  The only thing that has changed has been the patient's conscious state and their awareness that suicide is an unwanted state.  The evidence that this happens is clinical and ample.  Patients will report back to their psychiatrists that they were in this conscious state and the psychiatrist did or did not miss it.  Either way, there is no clinician in this situation who could make the correct call.  Without any clear markers, there is no way to figure out if this change in conscious state has occurred.  The patient usually recognizes it only in retrospect.

This clinical information on the assessment of suicide is what makes this JAMA Psychiatry article interesting.  In this article the authors attempt to determine predictors of suicide by soldiers in the year following psychiatric hospitalization within the Veteran's Administration hospital system over a 6 year period.  That was a total of 40,820 hospitalizations or 0.9% of the total Army personnel in any 12 month period.  During that time there were a total of 68 deaths by suicide.  That is number is 12% of all US Army suicides.  The authors consider a long list of potential risk factors that are largely demographic in nature to determine concentration of risk of suicide.  That list includes a law enforcement data base that clinicians do not have access to.  Their overall goal was to determine of it was practical identify high risk patients for post hospitalization intervention and whether that might be a cost effective way to prevent suicide.  They were able to identify the highest risk group - the 5% of hospitalizations in which 52.9% of the suicides occurred.  Like many similar studies the authors also comment on  how their "actuarial" methods usually trump clinicians making the same predictions.  I found very limited commentary on that fact that it is generally possible to illustrate what you want with enough variables or as we used to say "a large enough spreadsheet".  In this case they looked at a large number of variables to come up with 421 predictors for further analysis.  I have reviewed hospital records consisting of the printout of the electronic health record where there were scarcely 421 words and it was usually impossible to determine an admission or discharge date.  Any information on even a short term assessment of suicide risk is scant and it frequently says basically that the patient told us he or she was not going to make a suicide attempt.  In some cases a rating scale approach like the Columbia is used.  Clinicians using these scales are often surprised about how few variables change after the initial rating and how the numerical risk does not necessarily reflect an inpatient versus and outpatient population.

As I read through the article, I was also impressed with the amount of alien statistics and fairly esoteric statistical terms.  If JAMA Psychiatry wants to include these methods, I think an example of the calculations and a bibliography of additional reading would be a minimal requirement.  The addition of statistical reviewers' comments or an independent statistical discussion of the pros and cons of these methods would only enhance the quality of the discussion.  One of my concerns is that as the statistical methods get more abstract and vague notions about big data are more accepted, clinical complexity and wisdom are completely diluted down and out.  I saw a headline the other day that Internet sellers know more about your "personality" than your spouse.  It should be fairly obvious from all of the healthcare research done that is based on HEDIS (The Healthcare Effectiveness Data and Information Set) information, that demographic variables and product choices are not the same thing as clinical assessment and treatment.

If the headlines about artificial intelligence replacing doctors ever comes true, it will only happen if the machine can implement the required knowledge.  The performance of computers sifting through text based findings and diagnostic criteria has been know for 20 years (reference 3).   Those data points were generally far superior to demographics.  I owned 2 of those programs and they don't bother to sell them anymore.  In terms of the assessment and treatment of suicide a knowledge base included in the Harvard  Medical School Guide To Suicide Assessment and Intervention might be a step in the right direction.  A lot of that knowledge depends on the skill of a particular clinician and that includes the personality factors of clinicians who continue to do this impossible job day after day.      

Trying to predict suicide and prevent it can't currently be done with an algorithm.  If I see an algorithm I will consider why the high risk people aren't being seen in follow up from the hospital rather than who should get an intervention.   And I would not mind errors on the false positive side.


George Dawson, MD, DFAPA

1:  Kessler RC, Warner CH, Ivany C, Petukhova MV, Rose S, Bromet EJ, Brown M 3rd, Cai T, Colpe LJ, Cox KL, Fullerton CS, Gilman SE, Gruber MJ, Heeringa SG, Lewandowski-Romps L, Li J, Millikan-Bell AM, Naifeh JA, Nock MK, Rosellini AJ, Sampson NA, Schoenbaum M, Stein MB, Wessely S, Zaslavsky AM, Ursano RJ; Army STARRS Collaborators. Predicting Suicides After Psychiatric Hospitalization in US Army Soldiers: The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry. 2015 Jan 1;72(1):49-57. doi: 10.1001/jamapsychiatry.2014.1754. PubMed PMID: 25390793.

2:  Douglas G. Jacobs, editor.  Harvard  Medical School Guide To Suicide Assessment and Intervention.  Jossey-Bass Inc., San Francisco, CA, 1998.

3:  Berner ES, Webster GD, Shugerman AA, Jackson JR, Algina J, Baker AL, Ball EV,Cobbs CG, Dennis VW, Frenkel EP, et al. Performance of four computer-based diagnostic systems. N Engl J Med. 1994 Jun 23;330(25):1792-6. PubMed PMID: 8190157.

Hand Washing

I washed my hands 40 times yesterday and used disinfectant hand cleaner at least 10 times when I did not have immediate access to water and soap.   My hand washing technique was validated by  an infection control nurse who was trained to monitor appropriate hand washing.   I also wiped down the table in my office and the chair about 3 times with disinfectant wipes.  I am careful not to touch my food or my face.  I have an air cleaner running in that office from about 8AM to 6PM that has a UV lamp designed to kill viruses.  Despite all of that I am in day #5 of a flu-like illness (cough, myalgias, fatigue, but no fever).

I don't have obsessive compulsive disorder.  I live in Minnesota and it is peak season for the annual influenza epidemic.  I actually take more precautions.  During flu season, I avoid the public.  I used to belong to a gym, but set up my basement so I could do my workout routine at home.  Exercise equipment is a known reservoir of viruses and bacteria.  I have also been in a gym when it sounded more like a hospital ward due to the hacking and coughing.  I avoid movie theaters for the same reason.  I have been doing these same rituals for the past twenty years, initially because I thought I was allergic to influenza vaccine and did not want to catch the flu.  I have been fairly  successful in avoiding the flu, but not so successful in avoiding practically every other respiratory virus.  For twenty three years I worked in an old building that was designed to contain heat rather than clear respiratory viruses.  In that environment, once a virus is introduced there is a predictable epidemic (sometimes within a few days) affecting the entire staff.   Modern employment disincentives (the finite paid time off with no sick time system) keeps all of the ill people working.  They would rather work than lose vacation time.  That keeps the epidemic going.

 Throughout the flu season people at risk are told the same things.  Wash your hands, cough into your sleeve, stay at home if your are ill and get the flu shot.  Unfortunately all of these measures is not enough to prevent infection by airborne viruses.  Face masks help.  A study of college dormitory dwellers showed that hand washing and wearing a mask only offered modest protection against influenza like illness relative to a control group.  They used the term modest, but I would call about a 10% difference in infection rates weak at best.  In their study they looked at three groups of students in college dormitories.  The groups and the attack rates of flu-like illness (FLI) included controls (no intervention) 117/552, face mask only 99/378, and face mask and hand hygiene 92/367.   The authors tried to control as many measures as possible but there are a lot of reasons why experimenting on college students is problematic.  In terms of the basic methods hand washing or use of hand disinfectants is considered to have a small but significant effect on the transmission of respiratory viruses.  The effectiveness of masks depends on the fit of the mask, the physical characteristics of the environment and the virus itself.  One study (4) showed that a tightly sealed N95 respiratory mask would block 94.8% of influenza virus and a poorly fitting mask blocked only 56.6% of the virus.  

The process of creating infectious droplets is an interesting physical process.  There are  current estimates that show normal breathing for 5 minutes creates a few droplets through the process of atomization.  A single strong nasal expiration results in a few hundreds droplets with a few in the 1-2 µm in diameter.  Counting loudly creates a few hundred droplets in the 1-2 µm range.  A single cough produces a few thousand and a single sneeze produces a few hundred thousands to a few million 1-2 µm droplets that can contain viral particles.  There is a a video of what happens to those millions of sneeze generated particle in an airplane.  It might be a good place to wear a mask but that assumes that you have it on before the sneeze.  Atomization can also occur from vomit (10⁷ viral particles per ml) and feces (10¹² viral particles per gram).   Those routes of transmission have been important for SARS and Norwalk Like Viruses.

The most recent estimate of costs due to building influenced communicable respiratory infections was about $10 billion in direct treatment costs and indirect costs of $19 billion in lost productivity and $3 billion in performance losses.  Asthma is significantly affected and possibly caused by airborne respiratory viruses and that is another $18 billion in costs ($10 billion direct and $8 billion indirect).  My interest has been in trying to promote more attention to the problem especially at the environmental levels.  Just altering airflow characteristics or making other changes in the humidity and air temperature can reduce the infectivity rates by as much as 50%.  Apart from the cost, it has an immeasurable effect on employee morale.  It is difficult for anyone to work knowing that at least one month out of the year they will have significant symptoms of a respiratory syndrome.

Why did I post this and in particular on a psychiatry blog?  In my 23 years of inpatient experience, respiratory viruses plagued the staff and the patients we were treating.  Any attempt I made to change that from a non-medical environmental perspective was met with no response.  I think that is the standard response of our culture and most employers.  Mental health settings tend to be located in older buildings and older parts of health care campuses and respiratory viruses is likely a bigger problem.  Health care settings should be leaders in developing environments and infrastructure that is hardened for the airborne respiratory virus problem.  It is imperative as a healthy environment for workers and patients and it provides reserve capacity in the event of a more widespread pandemic.  I have also made some observations about the impact of FLI on psychiatric symptomatology - both improvements and worsening.  There is a increasing literature on the effect of cytokine signaling on brain function and I suspect that is what I was seeing, but more research is needed.    

In the meantime, keep washing your hands.  Keep in mind that this post is only about airborne infections.  Any physician with direct contact with patients needs to wash their hands after seeing a patient and before seeing the next patient.  Most hospitals have a rule that hand washing needs to occur every time a physician enters or leaves a room.   For airborne respiratory viruses, it is not enough but it decreases the risk of respiratory infections to a slight degree.  My guess is that the more highly infectious airborne viruses are much less containable with hand washing and that environmental measures involving airflow, relative humidity, and possibly filtration and UV sterilization is what is required.  Anyone planning new construction should focus on these measures and obtain appropriate heating and air conditioning consultation with an emphasis on reducing respiratory infections.


George Dawson, MD, DFAPA

References:


1:  Aiello AE, Murray GF, Perez V, Coulborn RM, Davis BM, Uddin M, Shay DK,Waterman SH, Monto AS. Mask use, hand hygiene, and seasonal influenza-like illness among young adults: a randomized intervention trial. J Infect Dis. 2010 Feb 15;201(4):491-8. doi: 10.1086/650396. PubMed PMID: 20088690.

2: Verreault D, Moineau S, Duchaine C. Methods for sampling of airborne viruses. Microbiol Mol Biol Rev. 2008 Sep;72(3):413-44. doi: 10.1128/MMBR.00002-08. Review. PubMed PMID: 18772283; PubMed Central PMCID: PMC2546863.

3: Morawska L. Droplet fate in indoor environments, or can we prevent the spread of infection? Indoor Air. 2006 Oct;16(5):335-47. Review. PubMed PMID: 16948710.

4: Noti JD, Lindsley WG, Blachere FM, Cao G, Kashon ML, Thewlis RE, McMillen CM, King WP, Szalajda JV, Beezhold DH. Detection of infectious influenza virus in cough aerosols generated in a simulated patient examination room. Clin Infect Dis. 2012 Jun;54(11):1569-77. doi: 10.1093/cid/cis237. Epub 2012 Mar 29. PubMed PMID: 22460981.

5. ASHRAE (American Society of Heating, Refrigerating, and Air-Conditioning Engineers) ASHRAE Position Document on Airborne Infectious Diseases Approved by ASHRAE Board of Directors January 19, 2014 Expires January 19, 2017.  - This is an interesting approach that looks at how to look at engineering approaches to airborne infectious particles and come up with a better approach.

Supplementary 1:  Various inhalers used over the past year following a probable rhinovirus exacerbation of asthma in January of 2013.  This is a rapid way to meet your annual deductible.

Supplementary 2:  Graphic of pathogens detected per week is from the Minnesota Department of Health web site.

2015 and......

I was going to try to post about alcohol consumption prior to New years Eve, but am still working on that post.  Instead, I found myself reacting to a post on LinkedIn entitled "10 Warning Signs That Your Psychiatrist Is Not A Good Fit" by Amanda Itzkoff, MD.  Look for it on LinkedIN if you are a member and see what you think.  I found it fairly stark and negative.  I found myself immediately typing up my own top ten list on how you know you have found a competent psychiatrist.  That may not fit the usual blogger message that critical statements that apply to only a few is the only reason for commentary.  One of my reasons for writing this blog is that the tremendous number of colleagues who I personally know are all very competent and the list is a composite of what anyone would find walking in to talk with any one of them.  That list follows.

I had thought about posting a list of what I plan to continue to do here in the coming year but decided that was unnecessary.  You can certainly go to any number of blogs to find out what is wrong with psychiatry or psychiatrists.  Much of it is hyperbole.  I hope that you will find what I write here is a realistic antidote to those other sites.

    Top Ten Signs Your Psychiatrist Is Competent

1.  You are understood.

Your psychiatrist makes it very clear to you that he/she understands the problem and all of the mitigating factors by formulating the problem and treatment plan, restating it to you, and giving you useful advice.  That also includes discussing the relationship that you have with the psychiatrist and any concerns that you have about it.  That is one aspect of seeing a psychiatrist that differs from seeing other physicians.  You should be comfortable bringing up any concerns and clarifying any potential misunderstandings.  Your psychiatrist should also be able to answer the basic question about whether you have any diagnosis or problem that requires treatment.  Your psychiatrist should be focused on a discussion of your problems and your best interest should be the focus of treatment.

2.  Your psychiatrist is an expert.

Your psychiatrist has technical expertise in the field and is comfortable discussing new treatments and innovation in the field ranging from psychotherapy to brain science.  That includes an awareness of the current limitations of treatment.

3.  Your psychiatrist knows medicine.

During the initial assessment and beyond, your psychiatrist pays close attention to any other medical problems that you have and how the treatment he/she prescribes might affect those conditions.  That includes being able to diagnose new medical conditions that can lead to psychiatric presentations and ordering the appropriate tests to follow potential complications of any new treatments or how new treatments might impact existing conditions.  That includes a willingness and an ability to talk with the other generalists and specialists providing your medical care.

4.  Your psychiatrist takes enough time.

The assessment and treatment of complicated problems takes time.  Many psychiatrists are in clinics where there are allowed only brief periods of time (10 to 20 minutes) for assessment and treatment.  Many people are satisfied with that amount of time, but if you are not - a different treatment setting may offer more time.  That can be discussed with the current psychiatrist and a referral to psychiatrists practicing in different settings can be obtained.

5.  If medications are involved your psychiatrist thoroughly explains the risks, benefits, and limitations of treatment.

Like most areas of medicine, medical treatments have their limitations.  That includes medications that are not completely effective in alleviating symptoms, side effects, and occasional very serious side effects.  Your psychiatrist should be able to help you negotiate that area and provide you with more detailed information for further study on request.  You should believe that your psychiatrist is taking any concern you have about side effects very seriously.  The discussion of side effects is as important as a discussion of potential therapeutic effects.  Any informed discussion of medical treatment should also include a discussion of non-medical approaches.  Many people are surprised to learn than non-medical approaches are more effective than medications in the treatment of several severe mental health problems.

6.  Your psychiatrist knows about addiction.

A significant number of people being treated by psychiatrists have problems with addiction.  Addiction can cause psychiatric problems and complicate the care of psychiatric problems.  Even if your psychiatrist is not an addiction specialist, he/she should be able to advise you in how to get well and not increase the risk for relapse if you are sober.  Your psychiatrist should also be able to advise you in approaches to your problems if you are not sober.  Chronic pain is also an associated problem and your psychiatrist should be able to make an assessment of your chronic pain problem and how it affects associated mental health and addiction problems.   

7.  Your psychiatrist is able to tell you about things that you do not want to hear.

That can cover a broad range of topics from your expectations about medication and psychotherapy, to unrealistic expectations, to boundary problems involving what appear to be straightforward problems like filling out a disability form.  One example would be concerns about a diagnosis of Attention Deficit-Hyperactivity Disorder (ADHD).  A lot of adults seek treatment for this problem and in many cases they are also expecting an approach that leads to enhanced cognition.  A consulting psychiatrist should be able to say that they do not have ADHD and that stimulant medications are not currently indicated for cognitive enhancement.  

8.   Your psychiatrist is concerned about your safety.

One of the characteristics of some mental health problems is that the safety of the person involved is compromised.   Psychiatrists are trained to make these assessments and determine a plan to address the problem.  Many psychiatric disorders result in impaired insight and judgment that is restored once the primary problem is treated.  It is often useful to have a discussion about that in advance.  Some states have a psychiatric advanced directive that is useful to direct your care in the event of an acute episode of illness that affects your judgment.  We live in a litigious society and physicians are often accused of “covering” themselves by making very conservative decisions.  These decisions are most likely driven more by safety concerns than malpractice concerns.  

9.   Your psychiatrist is willing to talk with your family.

You should be certain that your confidentiality is protected at all times per an explicit agreement with your psychiatrist.  That agreement should include emergency contingencies and advise you about the statutes in your state that affect confidentiality.  You should also expect that when you want your psychiatrist to talk with your family that he/she will do that.  For certain aspects of treatment planning such as discharge planning from hospitals and gathering diagnostic information, discussions with family are critical.

10.   Your psychiatrist is mindful of your financial concerns.

Mental health services are the most rationed services in medical care in the US.  That typically results in more out-of-pocket costs for people receiving psychiatric care than other types of medical or surgical care.  Your psychiatrist should be able to discuss the cost aspects of all forms of care.  That includes medication costs and also the cost of ongoing psychotherapy. Cost effective alternatives for both psychotherapy and medical assessment and treatment should be as easily discussed as any other aspect of treatment.  Your psychiatrist is often placed in an impossible situation by the insurance industry.  The insurance industry often makes it seem like your psychiatrist is responsible for decisions that are really the result of insurance industry rationing.  Any concerns you have about the financial basis for decisions should be clarified with your psychiatrist.

Happy New Year!

George Dawson, MD, DFAPA

Snow Shoveling Theory and Plasticity

I drove back from my home town to the Twin Cities area yesterday  In this age of connectedness, there are times when you get a false sense of information.  My wife called her friend who was driving north to Duluth on Hwy 35.  She got the message that there was about 6 inches of snow on the freeway and numerous vehicles in the ditch.  I don't mind driving in the snow.  I used to drive north in the winter in some notoriously unreliable vehicles.   Rear wheel drive and no limited slip differential.   Poor weight distribution was an added bonus.  Some of the worst engineered cars in the world.  Most people my age all still use the brand name Positraction, rather than the generic limited slip differential.  More evidence that pharmaceutical companies don't differ much from other businesses in terms of branding of inserting themselves into the public consciousness.  Like most people, when you get to the point where more safety is affordable you buy it.  I am driving a modern four wheel drive sport utility vehicle (4WD SUV).  I was confidant that 6 inches of snow would only be a problem if there was congestion from large trucks and snow removal vehicles.  I was also confidant that would only happen close to the Twin Cities.  Competency in snow removal seems to vary directly with latitude with northern latitudes being the best.   I thought about that as I drove down Hwy 2 across northern Wisconsin.  The road was clean down to the pavement about 4 hours after white out conditions.

As we turned the corner in Duluth, the grey skies lifted and it turned out to be a bright sunny day but 10 degrees colder than the day before (about 22 ℉).  There was no bad road all the way back to the Twin Cities.  That only happened when we pulled into our neighborhood and there was 6 inches of snow in the driveway.  All of my neighbors driveways were clear and in many cases the pavement was dry and clear.  The physical chemistry of snow is always interesting.  In this case the bottom few millimeters of the snow was liquefied, but the upper 5 inches plus was medium density snow, the kind that is good for cross country skiing.  Clear it off and the liquid evaporates in the direct sunlight, even when it is well below the freezing temperature.  In some cases sublimation occurs and the snow vaporizes directly from the solid state.  But I was focused on additional theories.

People living in northern climes think a lot about moving snow.  We have had some epic snowfalls.  Some of my fantasies coming into this season included getting an enclosed tractor with climate control and the ability to move a massive amount of snow.  The image I have is a condensation of a couple of images.  The first is a cola commercial from many years ago - a set of combines cutting wheat.  All of the operators in their climate controlled cabs drinking Coke (or Pepsi?).  The second is a show about building ice castles in Norway and a small vehicle that was described an an airport runway snowblower that could move a tremendous amount of snow through a chute directly over the operators cab.  Those are my grandiose commercial induced fantasies.  Even a small tractor with a cab set up to move snow is ridiculously expensive and it needs a lot of ongoing maintenance.  I have never been able to locate the manufacturer of the Norwegian snow blower.

The reality is that I have a 15 year old Toro 2 stage snow thrower and about 200 square feet of sidewalk and 1,000 square feet of driveway to clear.  The snow thrower cuts a 24 inch path.  In many ways the strategy is mathematical and practical.  What is the most efficient way to clear away the snow?  Is it just going back and forth and turning the chute on the snow blower on every turn or is it something else?  Since moving into this house I have decided it is a right angled arc starting up the left hand side of the driveway and then turning back (and turning the chute on the snowblower) and heading back in the same direction.  This moves all of the blown snow to the eastern side of the lot, away from the sidewalk and areas where ice might accumulate.  It also results in fewer change in the chute direction that just going back and forth or the length of the driveway.

Mathematics aside - what are the practical aspects?  The first of course is the weather.  Is more snow expected?  Do you really want to concentrate the effort if there is going to be another foot?  In some cases of wet and heavy snow it is imperative.  That layer cannot be allowed to freeze and it is the most difficult to handle with a snow blower.  In this case I was left with about 1/2 inch of translucent slush that I had to scrape up with shovel before it all froze in the colder temperatures.  The second is the surface that you are clearing.  There are some web sites that recommend snowblower sizes based on whether your driveway is finished (asphalt or concrete) or not (gravel).  In my case I have two different surfaces - a concrete driveway and a textured concrete sidewalk.   I can't use the steel shovel on the textured concrete.  I use a plastic shovel very similar to the metal shovel that my father used to shovel coal into a steam engine on the 1950s.  One of my earliest recollection was being placed in the cab of a steam locomotive.  My father was a locomotive fireman at the time and the engine was hand fired.  His job was to keep coal burning to keep the steam pressure up.  He explained to me at the time how the scoop shaped shovel was designed to slide large amounts of coal off of it and into the furnace without wasting any energy.  To clear the sidewalk - I clear one edge and then cut across that using the same motion my father used to shovel coal.  Snow is a lot lighter than coal but it takes me about 50 passes to clear it using this motion.

With every pass, I am careful to extend the stroke out onto the grass by about 2-3 inches.  When my father first taught me to shovel snow, he said this was critical in the event that there was any melting of the snow.  Without that 2-3 inch margin the water pooled on the sidewalk and created ice.  With the margin the water soaked into the grass and no ice was formed.  I have tried to pass that knowledge along to other sidewalk shovelers, but it falls on deaf ears.  Either they don't believe me or they have their own theories of shoveling.

In addition to the theory of clearing snow and carrying it out, I get another thought from about 50 years ago.  I have always been an insomniac and one night back then I was waiting for my father to come home from work.  By then he was a railroad engineer and drove freight and iron ore trains.  It was about midnight.  It was snowing and drifting to a depth of about 3 or 4 feet on the street outside of our home.  He told  me that day before he left that they might need to plow snow off the tracks.  The worst case scenario would be hitting deep snow and blowing it into the diesel engine air intakes on the top of the locomotive.  That would kill the engines and result in a long restarting process that would slow him down.  I kept staring out the window.  The wind was so intense that I could not hear any trains even though we were only about 3 blocks from tracks.  I could finally see him leaning into the wind and snow.  He always wore union style clothes and none of it was really made for winter weather.  He wore a chromer cap with ear flaps that offered limited protection.  He was carrying a leather satchel that he called a "grip" that contained all of his important paperwork.  He was wading through hip deep snow, using the exaggerated hurdler motion that you had to use to travel in deep snow without snowshoes.  I was very happy to see him and even happier when he burst into the kitchen and it smelled like the fresh air version of diesel fuel, Lucky Strikes and leather.

I have a greater appreciation of these events than I used to.  Early on it was easy to grasp the psychodynamic significance, especially when it came to countertransferences toward mechanics and anyone else who might smell of diesel fuel and cigarettes in my office.  There were the associated issues of blue collar rage, exploitation of union workers, and a stronger affiliation with workers rather than management.  These days I can think of it in terms of the brain systems that are represented and the underlying mechanisms that allow for this experience.  I still feel happy when I have that image of my father pushing through deep snow toward home.  It probably accounts to some degree for my affiliation with snow and winter weather.  Every month or so I give a lecture and talk about the time frame, neuroscience and structures that are probably responsible for that experience.

Most of all I remind the students about how these structures allow for unique human experience.  I like to say that if there are 7 billion humans on Earth, there are 7 billion unique conscious states.  I suppose planning and fantasizing about clearing the snow is not that unique in the upper midwest.

But I doubt that any two of us learned to do that in the exact same way.


George Dawson, MD, DFAPA    

          

Psychiatry and Torture

For me - torture has never passed some basic thought experiments.  The first is whether or not there is any information that critical that could be memorized by individuals that would be worth the effort to either conduct torture to get it or resist torture to prevent its disclosure.  Reading Alan Turing's effort  to crack German cryptography  in World War II comes to mind.  Those messages had to do with the deployment of German submarines.  In that case there was a elaborate code that could only be decrypted by a team of geniuses and a computer they invented.  That was 70 years ago.  Is it likely that information in the computer age would be easier and more efficient to hide outside of human memory?  It certainly seems like it to me.  In the case of relationships, wouldn't surveillance be a much more reliable source of information?   The second is the mindset of the person being tortured.  If I knew the information was redundant, carried by multiple sources,  or subject to fail safe why would I not tell any captor what they want to know?  Third, if my captors either did not believe me or decided to proceed for other reasons, why would I not tell them exactly what they want to know or make up any story they wanted to hear to get them to stop?  The cinematic stereotype of resisting any disclosure at all costs while undergoing various forms of torture seems totally irrational to me.  All of these considerations taken to their conclusion would produce information that was accurate but possibly rejected because it was easily obtained or information that was inaccurate but accepted because it was made up under duress.  Either way it seems like a very poor source of information.

The Senate Report on the CIA interrogation and detention methods came out a few days ago and there is the expected media enhanced political furor.  The entire document is 499 pages long.  It is also redacted to remove details that could not be declassified.  I decided to take a look at it because I saw one of Atul Gawande's tweets decrying the involvement of the medical profession that he described as "doctors, psychologists, and others sworn to aid human beings......".  That struck a chord with me because I was aware of this issue and how the American Psychiatric Association reacted to it in 2005.  Then president Steven Sharfstein, MD took the initiative in making it explicit that it is unethical for psychiatrists to participate at any level in torture, enhanced interrogation or even deceptive interview practice.  There was some lag in a similar response from organized psychology but eventually both organizations came out with a joint statement on the issue.

Psychiatry and the CIA have crossed paths on occasion most notably on the notion of being able to profile political leaders.  The original ethical conflict with CIA psychiatrists was the Goldwater Rule (see reference 3). That rule states that it is not ethical to diagnose a person (usually a public figure) without actually interviewing that person and disclosing the information with their consent.  It came about as a result of the 1964 Presidential election.  The candidates were Barry Goldwater and Lyndon Johnson.  One of the more infamous attack ads in political history suggested that Senator Goldwater would put the US at higher risk for involvement in a nuclear war.  A survey of psychiatrists suggest that he was unfit for the office.   That same article points out that even today despite the rule, there appear to be no shortage of psychiatrists willing to offer their opinions about people they have never personally examined.    

I decided to take a course on profiling political figures by one of the original psychiatrists who worked on these methods -  Jerrold Post, MD.  The course was offered at the Door County Summer Institute in August 2003.  He provided a disclaimer at the outset that "psychological interpretation" based on childhood experiences was a scientific fact that could be applied to the analysis of the personality of political leaders.  Over the next 4 days he reviewed personality and its development in political leaders, how personality is a factor in political decisions and decision making in hundreds of different compromised and uncompromised political leaders.   The final day was devoted to a look at terrorism.  He made the argument that terrorists were psychological normal meaning that they had no major psychiatric diagnoses.  He suggested that that there were predominant personality types attracted to terrorism including aggressive sociopaths and angry paranoids and that a common externalizing defense could be observed in both groups.  He discussed theories about personality types that might comprise terrorist groups.  The issue of the Goldwater Rule seemed irrelevant.  Dr. Post presented profiles that were based on actual historical data about the lives of political leaders rather than the self report that typically forms the basis of most psychiatric evaluations.  It was after all his job and he and his cohort of colleagues specializing in the psychology of political leaders developed methods for this work.  It culminated in a text of how this analysis proceeds (see references).  The text provided a fuller appreciation of the limits of this kind of analysis than the PowerPoints:  

"Understanding and predicting the behavior of smart, highly functioning individuals, who are acutely aware of their circumstances and what might be needed to surmount them,  make it a very tricky undertaking.  It is possible that, in spite of their own psychological inclinations, such persons, if not alone, then certainly with the help of many advisers, whose only occupational purpose is to help leaders pursue their own personal and political self-interest."  (p.  300).

Translation: the psychological profiling done by psychiatrists and psychologists with decades of experience is less of a sure thing than the television profilers that you can see on a nightly basis.   At that point I decided that the analysis of the psychology of political figures by the CIA was really not the same as somebody on the local news speculating about the next mass shooter.  In many ways this analysis has much more relevant data than any typical psychiatric evaluation.

The ethics of the psychological profiling of politicians seemed resolved.  What about interrogations and coercion.  It turned out that there was a course the next year  called "A Law Enforcement Approach To Behavior Analysis" taught by Dale Mueller, a 30 year veteran with the FBI.  The course covered crime scene analysis, terrorist personality types and interview strategies, hostage and crisis negotiations,  interviews for deceptive verbal behavior, and interrogation techniques that answer the question: "What does law enforcement do to get a confession?"  That course was an eye opener in terms of the differences between interrogation and a clinical interview.  He described interrogation techniques and the reliability of various observations that suggested a person my be lying.  He described the optimal environments and mindset of the professional conducting the interrogation.  He emphasized good preparation and a non-threatening manner.  Interrogations are not without stress for the person being interrogated because at some point the strategy may become a direct confrontation like:  "Because of A, B, and C you are lying."  The interrogator may stand directly over the the person being interrogated for additional effect.  Some famous interrogations were reviewed and a tape of an interview was shown.  It was a product tampering case.  The suspect had social and possibly psychiatric problems.  The main focus of the interview was to convince her to admit to the crime and she did.  Specific interrogation techniques were discussed for different terrorist personality types.  Interrogation is an alien interaction with people for a clinical psychiatrist like me.  Psychiatrists are clearly not trained in these techniques and generally do not have much interest in who is guilty of crimes or not.  During the actual interrogation of a person who appeared vulnerable, I would probably have veered off to discuss  those problems and solutions rather than focusing on a conviction.  Interrogation seems to be the sole purview of law enforcement and nothing that a psychiatrist would do.

The issue with psychiatrist employees in the CIA or any other organization - even at the contract level is the ever present conflict-of-interest between professional standards and the interest of the organization signing the pay check.  In many cases that is a changing point of reference and it is not always clear.  I have consulted with expert witnesses for example who felt that at some point they were massaged into a position that they really did not want to testify to by the attorney who hired them.  Physicians can clearly be manipulated into doing whatever other entities want them to do and that is why it is imperative that professional organizations take a stand that is unequivocal, based on professional standards and faster than any other response.  In this case, organized psychiatry - specifically former APA President Sharfstein was at the forefront.  I applauded his position then and I applaud it now.  There is always some criticism that this just involved jumping on the bandwagon with everyone else but the public opinion result at the time was far from certain.  After the opinion was public, there was hardly any acknowledgement that anybody cared.  That opinion came out 8 years before the current Senate document.

Searching the document reveals exactly 1 reference to psychiatry/psychiatrist, 56 references to psychologist/psychology, 58 references to medical officer, and 5 references to physician/physician assistant.  The most specific references include this section in the summary about contract psychologists who "devised" the enhanced interrogation techniques.

The political rhetoric is always interesting:

1.  Does torture produce results?  After reviewing the evidence I don't think there is any evidence that it does.  In fact, it is daunting to think about the millions or billions of people who have been tortured at one point or another in human history with this goal in mind.  In retrospect much of the contested information was trivial and meaningless in the course of human history.  I don't recall any major battle or war where the outcome was determined on information produced by torture.  I think there is a stronger argument that terrorism or what used to be called guerilla warfare produces more results than torture.  And let's not forget that a contractor with the National Security Agency probably released more secret data that all of the people tortured since the dawn of time.  And all of that data was accurate.

2.  Does torture inflame the enemy and lead to more adverse consequences for the torturers?  I heard an interesting discussion of this issue on Fareed Zacaria's Sunday morning show on CNN.  The discussant was an Arab from the Middle East and it was clear that his sympathies did not align with the US.  When asked about the impact of this document on public opinion, he said that he did not think it would have much of an impact because of a baseline issue.  Most people had such a low opinion of the United States that they would expect something like this to happen.  There was after all the Abu Ghraib prison incident in 2003.

3.  Are there qualitative differences in torture?  Certainly these techniques were bad but they pale in comparison to the atrocities described in the middle east and the atrocities inflicted by some of these combatants on their own countrymen.  As one of the consulting psychologists pointed out about 48 hours after the report was leaked there is also the question of what is worse a slap in the face during an interrogation or "sending in a Hellfire missile that kills grandma and the kids."  (ABC news Thursday AM show)

4.  How is the release of this document relevant to the concept of American democracy and American life?  Interestingly one of the critics on the Sunday morning show gave the opinion that self disclosures like this report does seem to distinguish American democracy from other political systems and raises the general awareness  that this is true.

5.  How can I make the most of this story?  Certainly media outlets and bloggers are motivated to whip this story up to attract viewers to their sites.  I saw a very funny comedy sketch by a stand up comedian who ranted against "Cheeto eating bloggers.." who were destroying his comedy act by posting politically incorrect experimental pieces that he was trying out in his routine as though he was serious.  The blogosphere likes to see itself as more innovative and more pious than the press but conflicts of interest remain.  It has gone from a corporate conflict of interest to conflict of interest at an individual level.  At many levels bloggers are more strident, argumentative, and hyperbolic.  It is not too surprising that they attract a like-minded following.  That being said, there have been few psychiatric bloggers that seem to have picked up on the torture issue.  It was an active area of discussion on the APA Listserv with several psychiatrists taking the role of human rights advocates.

Professionals often find it difficult to resist government interventions.  I have criticized the lack of an adequate response from organized psychiatry and organized medicine to any number of government interventions.  In other cases, they have come through with an exceptional response.  On the torture issue, Dr. Sharfstein took an unequivocal position on torture.  I was involved in a discussion of the issue at the time and there was speculation that there would be political pressure from "CIA psychiatrists".   There is always the question of whether a small special interest group within an organization can affect its policy.  In this case, the clinical focus of the membership, the maxim to do not harm and the modern conceptualization of the physician-patient relationship.  In the end there was no commentary that I am aware of from CIA psychiatrists.  I am not sure that there are any CIA psychiatrists.  I applied to be a CIA psychiatrist at about 15 years ago and the focus of the position was on interviewing potential employees rather than terrorists.

I think it is important to clarify any role that psychiatrists were involved in these activities.  They are not trained in interrogation techniques and I think that most psychiatrists would balk at the techniques.  On the other hand, it is clear that programs can be developed within government agencies that have little to do with clinical training and may clash with patient centered ethics.  It is also true that psychiatrists or physicians can abandon their usual clinical roles and use their knowledge for other purposes.  I am very skeptical of the science behind any of these techniques.   That sounds like an absurd statement on the face of it, but keep in mind the references to the program being based on a "learned helplessness model".  That is a scientific model that has been used to study depression.  Any review of that model would show that using it to develop an interrogation program is quite a stretch.  Actual human research would not pass the scrutiny of any Human Subjects Review Committee that I am aware of and it certainly is not associated with any standard of care.  The acceptance of these ideas indicates that there is really nobody in the CIA capable of scientifically reviewing a program like this or they just did not care.  As to the ultimate question of psychiatric involvement, I have a more definitive source on order (reference 5) and will report any differences here.  There is also an online database (reference 6) but it does not have much granularity but some of the linked reports contain a some details that I have not seen anywhere else (reference 7).


George Dawson, MD, DFAPA



References:

1.  Senate Select Committee on Intelligence.  Committee Study of the Central Intelligence Agency's Detention and Interrogation Program.  Foreword by Senate Select Committee on Intelligence Chairman Dianne Feinstein.  Findings and Conclusions.  Executive Summary.  Approved December 13,2012.  Updated For Release April 3, 2014.  Declassification Revisions December 3, 2014.

2.  APA Official Actions.  Position Statement on Psychiatric Participation in Interrogation* of Detainees.  Approved by the Board of Trustees, May 2006.  Approved by the Assembly, May 2006

"The American Psychiatric Association reiterates its position that psychiatrists should not participate in, or otherwise assist or facilitate, the commission of torture of any person. Psychiatrists who become aware that torture has occurred, is occurring, or has been planned must report it promptly to a person or persons in a position to take corrective action........"

3. American Psychiatric Association: Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. Arlington, VA: American Psychiatric Association, 2013 (p.9):

"...On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement."

4.  The Psychological Assessment of Political Leaders: With Profiles of Saddam Hussein And Bill Clinton.  Jerrold Post, MD (ed). The University of Michigan Press, Ann Arbor 2003, 462 pp.

5.  Steven H. Miles.  Oath Betrayed: America's Torture Doctors.  University of California Press, 2009, 312 pp.

6.  Doctors Who Torture Accountability Project.  Link.

7.  Physicians for Human Rights.  Doing Harm: Health Professionals’ Central Role in the CIA Torture Program.

This document is interesting because it has the qualifier "physicians (including psychiatrists)" four times in the report even though it is based on the original Senate Report.

Supplementary Info:

Supplementary 1:  Photo credit as suggested on WikiMedia:  Derived from File:911 - FEMA - Areas debris impact (graphic).png by Therese McAllister, Jonathan Barnett, John Gross, Ronald Hamburger, Jon Magnuson of the Federal Emergency Management Agency (FEMA) of the United States Department of Homeland Security. As a work of the United States government, it was released to the public domain.

Supplementary 2:  I sent Physicians for Human Rights an e-mail on December 21, 2014 to clarify the qualifier they use in their analysis of the Senate document  "physicians (including psychiatrists)".  I will post their response here as soon as I get it.

Question For APA Candidates? OK Here It Is.

"Why are there no leaders with vision in the APA who can focus us on the best science and the best psychiatry to provide treatment for individual patients with severe mental illnesses?"


I got a message today that I should craft a question for the American Psychiatric Association (APA) candidates.  It is election season and the LinkedIn forum is apparently the place for political debate.  I can recall asking a question last year along with James Amos, MD (The Practical Psychosomaticist).  The questions had to do with Maintenance of Certification (MOC) and the arduous recertification schedule that was essentially invented by the American Board of Medical Specialties.  Dr. Amos has done more to maintain this issue at a high level of visibility than any other psychiatrist.  That includes looking at the paucity of evidence that it is superior to life-long learning and CME as we all know it.  I  went to LinkedIn to look for my post from a year ago and it wasn't there.  The earliest post is from April 29, 2013.  This is a forum that was suggested to replace the long running member-to-member (M2M) listserv managed by the APA.  It was in M2M that members learned their concern about the MOC issue would be ignored despite overwhelming support on the basis that only 25% of the members voted and a 40% vote was required to pass the measure (see supplementary info below).

The events associated with that vote continue to bother members greatly.   It is seen as a continuing symptom that APA membership does not translate into any support for front line psychiatrists.  We have witnessed decades of increasing rationing and onerous regulations that have been basically brushed off at the level of the APA.  There has been minimal activity in responding to politicians, regulators, and businessmen.  It seems that whatever these special interests want to do - the APA is willing.  We had a billing and coding debacle in the 1990s with the rest of medicine.  Instead of pointing out that this was a purely subjective scheme designed to allow the persecution of any physician, the stance of both the APA and the AMA was "we will give you what you need to be better billers and coders."  We have had three decades of managed care utilization review, prior authorization, and pharmacy benefit managers and the response from the APA has been literature on how to be a better managed care psychiatrist.   There was a lawsuit against some managed care payers for a lack of parity but I don't think there is any evidence that the members who were forced to provide free care have gotten much benefit from that.

The most telling event about where the APA and AMA are at is their full scale cooperation with the PPACA (aka Obamacare) and so-called collaborative care.  In many if not most of those models of care, a psychiatrist collaborates with primary care physicians in treating depression or anxiety in their clinics.  In many of the models, the diagnosis hinges on a rating scale determination of depression or anxiety.  The rating scale score is the diagnosis.  The treatment modality is a medication - usually an antidepressant.  In some models the psychiatric consultant never sees the patient.  I just realized it, but this is all eerily similar to managed care reviewers several states away telling attending psychiatrists how to manage their patients.  This is managed care - a business centered model of providing medical care.  A model that many (myself included) do not consider a valid method of providing medical care.  And yet, the President of the APA and several other psychiatrists promote this as a model of care.  What physician would do 4 years of residency training to sit in an office, look at rating scale scores, and recommend antidepressant doses?  Why would you train all of those years and know all of that theory for such a simple task?

That simplistic collaborative care model captures the primary problem in psychiatric leadership today.  Here we stand at a crossroads.  We are studying the most complex organ in the body and we clearly know more about it now than at any point in the past.  The literature in brain science as it applies to psychiatry is growing exponentially.  We have some of the best thinkers in the world in all areas of the field ranging from pure neurobiology to psychopharmacology to imaging to neuropsychiatry to medical psychiatry to community psychiatry to psychotherapy.  There is so much to learn about the brain and psychiatry and what are we doing with it at a global level?

Nothing as far as I can tell.  The leadership of the APA is locked into a mindset from the Clinton administration.  The APA is acting like we have a responsibility as a profession to address bloated mental health statistics and provide population-based psychiatric care to the masses.   We have a responsibility to provide cost-effective care to the masses.  We have a responsibility to fight stigma wherever we find it because this is the real reason why people, governments, and insurance companies discriminate against psychiatrists and their patients.  We have to grin and bear it when some clown attacks the profession despite the fact that thousands of our colleagues go to work everyday and many toil with inadequate resources, impossible conditions, a lack of cooperation and they still get the job done.  Thrown into the breech with no support, front line psychiatrists are still getting the job done.

The APA on the other hand has done very little to support that effort.  APA officials seemed to breathe a sigh of relief about the vote on the MOC issue.  I heard one of them speak about it at a local meeting.  She told us all about how the new certification fees were really not a windfall for the American Board of Psychiatry and Neurology (ABPN).  This was really an expensive process after all.  I finally learned that this was really an initiative by the ABMS and that participating boards did not really have a choice.  If most of the boards voted for recertification all of the boards had to participate even if they voted against it.  I had learned about 10 years ago that the American Board of Obstetrics and Gynecology ( ABO+G) had a robust program that consisted of didactic material every year that was designed to bring all members up to speed.  A test was taken every year on that well defined information.  At the time there was no MOC and to me it seemed like an ideal program to assure that all members of a particular specialty were up to date and studying relevant information about what was important for the specialty.  For a while, I promoted this model as the preferred model for ongoing professional learning.    The APA does provide a similar program called Focus that could naturally fill the same role.  Typical MOC exams are not on a focal body of material and the pass rates are high.  Candidates of all specialities typically take time off of work (an off of vacation) to study for these examinations in addition to paying high examination fees for a test that is designed for the test makers and not the test takers.  A test of random facts for the purpose of recertification is not the same thing as a test for professionals to assure they are all up to the same standard.

The APA has just completed a much criticized multi-year effort of revising the DSM and producing the DSM-5.  I think that has been a good effort and with the associated online material it is a definite advance relative to previous editions.  That does not mean I am in agreement with everything in the book, or think that all of the diagnoses in that text exist.  I do think that it covers all of the major diagnoses and severe mental illnesses that psychiatrists treat.  On an academic and clinical level the APA needs to do much more.  Hospitals and clinics currently are being run by administrators with mixed agendas.  We are seeing business people conduct psychiatric care.  The APA used to provide comprehensive guidelines for the treatment of aggression in inpatient settings.  It used to have timely treatment guidelines describing the role of psychiatry and what the standards of care are.  By abdicating that role, we now have business organizations and nonprofessionals dictating care for people with severe mental illnesses.  We have psychiatrists who have to defend their care against those nonprofessional guidelines every day.   That is hardly the expected behavior of a professional organization.

Any psychiatrist should be concerned about the fact that their professional organization does not seem to support the members doing the work of psychiatry.  Any psychiatrist should be concerned that the APA does not vigorously defend the profession and that it seems to have adapted the pseudoscientific methods of governments and managed care organizations.  Any psychiatrist should be concerned that the APA has adopted the questionably valid ABMS preparatory school model of professional education that is unfocused and a waste of time and money.  Any psychiatrist should be concerned about the fact that we have some of the greatest minds in American medicine in our medical institutions and our professional organization is lurching back to the Clinton administration of the early 1990s.  Back to the time when a few political insiders thought that managed care was a good idea.  All of these things considered the question I will post to the candidates is:  

"Why are there no leaders with vision in the APA who can focus us on the best science and the best psychiatry to provide treatment for individual patients with severe mental illnesses?"
 
That is how I was trained and how every psychiatrist I know was trained.  It is time our professional organization consistently gives us what we really need.


George Dawson, MD, DFAPA



Supplementary 1:  This was the APA 2011 election report I got on the following referendum to basically eliminate patient feedback and maintain a cognitive exam very 10 years.  Although the APA maintains that it requires a vote of 40% of the voting members, the vote to support these measures exceeded the votes for the President Elect and the Secretary (both national candidates) by 1373 and 1388 votes respectively. (Reported February 18, 2011)

The APA was petitioned by members to hold a referendum on the issue of informing the ABPN as follows regarding its proposed maintenance of certification requirements.

1) The patient feedback requirements for the purpose of reporting to the Board is unacceptable, as it creates ethical conflicts, and has the potential to damage treatment.

2) The requirements other than a  cognitive knowledge examination once in 10 years, regular participation in continuing medical education, and maintenance of licensure, pose undue and unnecessary burden on psychiatrists.

Member Referendum	Support	5,525 (80%)
	Do not support	1,418 (20%)

The referendum did not pass. APA received ballots from 25% of the voting members.

The APA Operation Manual states the following regarding member referendums: “The adoption of a referendum shall require (a) valid ballot from at least 40 percent of the voting members, (b) the affirmative vote of at least one-third of all the voting members of the Association, and (c) the affirmative vote of a majority of those members who return a valid ballot.

Supplementary 2:  Another one of the sorry miscalculations made by the APA and its officers is the image it projects to potential trainees.  Applying the dynamic I point out in this post, any potential resident ends up asking themselves:  "Why would I want to join a speciality that seems to want its members to have less expertise than they used to rather than more?  What other speciality does that?"  I tried to address that as a response to a current resident written on his blog and for some reason the response was never posted.  You can read his original post here and my response below:


The most significant reasons why psychiatry has the image problem that you discuss is that the profession is politically inept and our largest professional organization is not addressing the problems that psychiatrists face on a day-to-day basis on the front lines. The biggest front line problem is that practically all systems where psychiatrists work have mercilessly slashed resources for treating the mentally ill. We also seem to attract a number of ideas from critics that are not helpful. The example you posted about a prescriber with watered down qualifications is a case in point. In what other specialty does anyone suggest that the practitioners of the future should be less qualified?

That type of nonsense only happens in psychiatry and it is completely inconsistent with current research. In this weeks’s Neuron there is a perspective on Computational Neuropsychiatry. As neuroscience becomes more relevant to daily practice psychiatrists need that level of training in addition to medical and psychotherapy skills. We seem to have a lack of visionaries right now who can put all of that together.

I would encourage psychiatrists of the future to be thinking more along these lines, than the rationed managed care model of care that is currently being promoted. It turns out that “cost-effective” psychiatric care is frequently the same as no care at all.

GD