Never Miss An Opportunity To Harass A Physician

Despite some PR releases to the contrary, pharmacy benefit managers (PBM) continue to harass physicians and waste their time.  My latest inane conversation occurred after a pharmacy left their usual message about prior authorization and an 800 number about a prescription that I had written.  Unless I call the PBM and jump through all of the necessary hoops they will not cover my patient's prescription and it will likely go unfilled.  It was a newer medication and more importantly one that I had not started in the first place.  In other words, the patient had been maintained on this medication before seeing me.  That means the specific prescription had been approved from another physician a few months earlier.  I was writing this prescription because the patient did not have access to the previous pharmacy and I was the physician of record in another treatment facility.  The conversation with the PBM went like this:

PBM:  "Is this a doctor's office or a pharmacy?"
Me:  "Doctor".
PBM:  "Who is the doctor?"
Me:  "George Dawson"
PBM:  "Who are you?"
Me:  "George Dawson"
PBM: "OK - I was just checking.  What is your fax number?  I can fax you the form in 20 minutes"
Me: (fax number given)
PBM: "OK - you will need to complete the form and then fax it back to us and we will have 15 days to make a determination?"
Me:  "Do you understand that the patient needed this medication two days ago and I just got a notification about this today?"
PBM:  "That is the patient's policy.  We can do an expedited review and give you a determination in 3 days if you like?  But that is in the patient's policy.  We have either 15 days or 3 days to make a determination.  Do you have any questions about that?"
Me:  "Well no I do not.  I am only concerned about appropriate medical care and this delay is not appropriate medical care.  I don't care about your policies.  Your policies have nothing to do with appropriate medical care."
PBM:  "Is there anything else that I can do for you today?"
Me:  "No there is not."

I expected to receive the fax in 20 minutes but did not get it until the next day.  The form is designed to waste additional physician time.  It could have been pre-populated with all of my information and the patients information - but it was not and I had to complete the form by hand.  There were two sections on the form that had to do with failed medication trials.  One wanted specific dates.  Since I am a consultant I do not have specific dates and my experience with most patients is that they have a difficult enough time with the names of medications.  I do know that the patient had tried 8 different medications from the same class and stopped them due to lack of efficacy or intolerable side effects.  I added them to the section and wrote "refer to the previous section" on the redundant form.  Total time to complete the form and try to figure out what they wanted was 20 minutes.   I was seeing other patients it took me an additional 2 1/2 hours to complete the form and fax it.  The 72 hour clock started at that point but there was no place on the form to request an "expedited review".  

I have several posts about PBMs on this blog.  They all have the same modus operandi.  PBMs are at the very minimum a significant delaying action.  They are hoping that the physician, the patient, or both just give up and either withdraw the prescription or opt for a much cheaper generic prescription.  There are a couple of significant problems with that theory.  The first is that all generics in the same so-called drug class are not equivalent.  Any physician with a modicum of experience knows that individual patients have highly individualized responses to medications that are broadly similar and that there are generally sound pharmacological reasons for those responses.  Secondly, physicians have been prescribing less expensive generics medications for decades now and if a new unique medication is being prescribed the odds are very high that the person has not responded to that medication.  In the example given here,  I had a list of 8 medications in my record that failed due to intolerable side effects or a lack of efficacy.  They were all inexpensive generics.  I listed them on the form and faxed it back to them.

This behavior does highlight an important difference in ethics between physicians and medical businesses.  In every case where I prescribe a medication for a patient, the medication is carefully selected and monitored for how well it is tolerated and the effectiveness.  The ethical concept here for physicians is to provide continuity of care for the patient.  That is the reason that I am obligated to provide follow up prescriptions to patients who leave one care setting and go to another.  The PBM obviously has no similar constraint.  I would argue that their 15 or even 3 day policy ignores the fact that the patient needs the medication right now.  The telephone conversation makes it explicit - the company cares more about the policy than the patient who needs the medication.

The political process in all of this is frequently ignored.  How is it possible for a private company to waste so much physician time and interfere with patient care?  A long time ago the healthcare industry and its friends in government sold the American public on the idea that businesses should ration health care.  They sold that idea with rhetoric about how physicians were greedy and tended to squander health care dollars on unnecessary tests, surgical procedures and medicines.  They sold that idea in spite of the fact that the largest independent review organization of physicians documented a trivial amount of excessive resource use.  Businesses are now firmly entrenched as middle men whose only job is to ration health care and that includes prescription medications.  They do that in part by having physicians make tens of thousands of calls like the one outlined here every day and essentially leaving that physician and their patient in the lurch.

Health care businesses currently have the best of all possible worlds.  They are funded by mandatory health care insurance that is essentially the second largest tax on all Americans.  The annual health care premiums easily exceed property taxes, state income taxes, and state sales taxes for almost all Americans.  The does not include the amount of physician and patient time that is wasted by these rationing tactics.  In return Americans get a system of corporate management that consistently places the interests of the corporation and corporate profits ahead of them.  They talk like they are competitive businesses - but they are in fact some of the most heavily subsidized businesses in the US and nobody seems to make the connection between the most expensive health care system in the world and this corporate welfare.

It is well past the time for change and the first step should be to return medical decision making to physicians and stop pretending that a for-profit company cares more about patients than the monied interests of the corporation.


George Dawson, MD, DFAPA

Minnesota Psychiatrist Workforce Shortage

It should be well known by now that Minnesota has a shortage of psychiatrists.  Government officials and administrators everywhere think that the solutions are simple - hire more psychiatrists or (even better from the administrators perspective) - hire more non-physicians to prescribe increasing amounts of medications for psychiatric disorders.  Various posts on this blog elaborate what the real problems are and why it is not a straightforward hiring problem.  There are various markers that point to the real problem as rationing and business approaches to psychiatric care.  At the latest Minnesota Psychiatric Society meeting, there was an invitation to participate in an interview project that is being conducted by the Minnesota Department of Health.  I am posting the following description of that project here as a public service announcement.  I think it offers a rare opportunity to provide direct information on the practice environment to government officials.  Please contact Ms. Morgenstern for the interview if you are interested.  She will provide you with a document of the standard interview questions.  I encourage everyone to be very frank about the practice environment here in Minnesota and what is wrong with it.

The Minnesota Department of Health Office of Rural and Primary Care is doing an interview project on the psychiatric workforce shortage. We wish to conduct ethnographic-style interviews of 30 minutes to a half hour in length with practicing and retired psychiatrists to get their perspectives on job satisfaction, location desirability, and difficulties in entering the workforce. This information will be used in conjunction with other workforce data in a report to the Mental Health Workforce Commission, which is charged with making recommendations to the legislature. If you would like to be a part of this project, please email Gabrielle.Morgenstern@state.mn.us



George Dawson, MD, DFAPA




Attribution:

By Alexrk2 (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons

Dreaming of the EHR

The Dream:

I am at the APA convention.

It is in a crummy hotel attached to a mall. I am going down to the street level in an elevator and it stops at a level where there is a big cinema complex. An 8 year old boy runs excitedly into the elevator and jams in to my left. The elevator is crowded. He looks at my name badge and says: "What would George Dawson say if the Watson computer said he wasn't doing a good job?"

I glance down at him and say: "George Dawson would not care."

The kid says: "That's not good" and laughs intensely.......


It is all a dream. I had that dream early Saturday morning. It doesn't require detailed analysis. That last thing I did on Friday was try to review a 22-page paper record that was generated by a modern electronic health record (EHR) system. With the exception of a few paragraphs it was largely unintelligible. It contained bits and pieces of information. I was looking for imaging (CT, MRI, ultrasound reports) and ECG data, but instead could find only a few lines that summarized fewer results. There were no dates - no hospital admission or discharge date.  Although the hospitalization was longer than a week - there was no medication administration record or MAR - showing the specific dates when medications were changed.  There were no comprehensive reports that I am used to seeing for the past 30 years from Radiologists. There was no discharge summary. The documentation was basically unacceptable as a source of clinical information and yet it was created by a very high end, enterprise wide EHR system. It brought back a memory of a mandatory meeting I had with a "coding specialist" about 10 years ago. That person let me know that I had "passed" the documentation review in that I had ticked off the necessary "bullet points" so that documentation specialists would approve my EHR note for the day and the associated billing document that had to be submitted with each note.  She showed me how I could do things faster by ticking off a series of check boxes and electronically signing the note.  She was shocked when I told her that I really could not sign my name to that document because there was no sign that an intelligent human being had seen the patient.  For all of these reasons, very poor documentation in the EHR is always on my mind.

My attempt to read the last report may have been enough of a reason for the dream, but I also spent time on Thursday with a colleague who really dislikes the EHR for additional reasons. We regaled our spouses with tales of incomprehensible reports.  In addition, his reports require a synthesis of many imaging, lab, and clinical reports.  He previously used a system where all of the reports showed up in a queue and he could go down that list in chronological order to dictate the report.  In the new system, he has to go to tabs to find all of the reports he is looking for.  Some of these tabs are hyperlinked and the reports don't load very well.  In the end, he and his colleagues end up printing out all of the reports on paper so they can dictate then more efficiently without having to search for what they need in real time in the EHR.  That reminded me of an experiment I did about 8 years ago with the same EHR.  I went in and read all of the clinical notes looking for chronic diagnoses that were not addressed.  I came up with an additional 8 diagnoses from 340 clinical notes buried in the EHR. There is generally no good way for physicians to mine data on their own patients to make sure that they have done the most thorough assessment of their problems.  On the other hand administrators can get detailed numbers of mouse clicks by nurses in primary care clinics and rate their productivity in terms of mouse clicks, screen views, or tasks completed.  My colleague's theory was that the current EHR is selected for the administrative capabilities like monitoring doctors or nurses rather than any inherent advantage for medical staff.  The major evidence for that is that many EHR vendors have permanent staff in the hospital and they are making constant modifications to the EHR.  In many cases there are meetings of all the physicians in a particular department about these modifications.  The hospitals and clinics purchasing these systems are purchasing incomplete products that require what seems like constant revisions.

It has been about 15 years since the blight of the EHR hit physicians.  It was originally called the electronic medical record (EMR) but I suppose some business type decided that they could really solidify the corporate stranglehold on medicine by eliminating the word "medical" from another phrase.  Corporate psychology also dictates that they give the impression that they are maintaining health rather than treating medical problems.  That is another good reason for eliminating the word medical from the corporate lexicon.

The marketing of the EHR has been masterful.  The political hype promised untold savings.  National candidates seemed to suggest that we could actually "save" enough with the EHR that it would cover a substantial part of American health care inflation.  Any physician involved in the implementation phase of enterprise EHRs knew that was a bold faced lie.  There is no way that annual multimillion dollar a year licensing fees as far as the eye can see are going to save anybody any money.  In fact, I am certain that many clinics and hospitals have had to cut staff and services just to bankroll the EHR. Nobody has ever followed the money on the EHR debacle as far as I know.  Congress is well known to invent businesses and turn people into billionaires overnight.  All it takes is a few Congressional mandates about the need to use an EHR and electronic prescribing.  There is no mandate to keep things cost effective of make sure that independent practitioners can afford it.  There are mandates to implement EHRs and electronic prescribing and the White House brags about it.  The following graphic and text are from a White House document on the EHR entitled: More than Half of Doctors Now Use Electronic Health Records Thanks to Administration Policies.

The problem with the White House statement is that despite spending about $3 billion dollars a year and in some cases $44,000 per physician,  the value of the EHR for the reasons already stated remains in question.  It is very handy to be able to pull up lab results and x-rays on a computer screen.  It is also very handy to be able to send electronic prescriptions to any pharmacy in the country.  On the other hand, it is reasonable to expect that a multimillion dollar piece of software will write a report that any hundred dollar database software from the 1990s could write.  That same software should be capable of allowing physicians to search their own patient results for quality and report writing purposes.  In the end we are left with very expensive, high maintenance systems, and massive amounts of information that is either buried in storage because it is not easily accessible or because it is worthless and generated primarily for justifying a billing document.

That is one of the many real costs of having a health care system run by bureaucrats and politicians.  


George Dawson, MD, DFAPA


Attribution:

Photo at the top of this blog is by Paco Burrola on Flickr and is used courtesy of this Creative Commons license.

NEJM Review of Generalized Anxiety Disorder

There was a review of Generalized Anxiety Disorder (GAD) in this week's New England Journal of Medicine by Stein and Sareen (1).  I just did a bit of a critical review of the concept here and thought I would look at what these authors had to say.  

They start the review with a clinical vignette of a 46 year old married woman with insomnia, headaches, back pain, and excessive worry about a number of daily stressors.  She is also drinking alcohol on a daily basis to "self-medicate".  She is described as a person who comes in frequently for appointments.  After reviewing the phenomenology,  comorbidity, and differential diagnosis - the authors come back to this case and apply what is in the review.

Their review of the diagnosis does highlight a few things that are problematic about the diagnosis.  The key diagnostic feature is chronic excessive worry.  The worry has to be there for at least 6 months.  In their review of other psychiatric causes of anxiety they omit diagnoses that can cause short term worry or anxiety - the adjustment disorders.  They point out that GAD is more common in primary care clinics where it usually presents with a chief compliant of somatic problems rather than excessive worry.  They discuss major depression as a common co-occuring condition and suggest that anhedonia may be a distinguishing symptom for depression.  They also describe anxious depression as episodic depression superimposed on chronic anxiety.  There is no mention of the low diagnostic reliability of the disorder and why that might occur.  I think that any psychiatrist who sees GAD over time experiences the same problem that occurred in the DSM-5 field trials, the diagnosis can seem to change between visits from GAD to major depression, even in the absence of any new stressful life events.  Critics of psychiatry frequently cite this as a problem with DSM-5.  I think that DSM-5 does a good job with the symptom descriptors, but we don't know why this change occurs and I have not heard anyone talk about it like it is a real phenomenon.

Alcohol use is described as a common co-morbidity with 35% of people with GAD "self-medicating."  I put that term in quotes because it suggests that alcohol can actually be used for the purpose of medication.  What really occurs is that over time the person becomes more anxious and sleep deprived because of the negative effects of alcohol on sleep, baseline anxiety, and baseline mood.  Practically everyone I talk with who has an alcohol use disorder can recognize this pattern and modify any remarks about self-medication to "feel better for a few hours" or "knock myself out and forget about my problems".  There is also the issue of alcohol use being the cause of an anxiety disorder rather than temporary relief.  While I am on the topic of substance use and GAD, at one point the authors make the statement: "Data are also lacking on the use, usefulness, and safety of medicinal marijuana for generalized anxiety disorder" (p. 2066).  Many if not most anxious people are averse to the use of marijuana for anxiety.  Initial use of marijuana typically causes a drop in blood pressure with a compensatory tachycardia.  Tachycardia especially if there is a noticeable accentuation of heart beats is not tolerated well by patients with anxiety.  Many have had panic attacks.  Others have cardiac awareness and are sensitive to any changes in heart rate or intensity.  Many people tell me they thought that marijuana was effective for anxiety, but over time it seemed to make them more and more anxious, they developed panic attacks, and they had to stop using it.  These features combined with a tendency of patients to stop talking to their primary care physicians about substance use are good reasons to heavily educate them about these problems at the earliest possible time.

The authors take a risk factor analysis approach to looking at historical features that can also be associated with the diagnosis.  They point out that they are nonspecific and amy be associated with other psychiatric diagnoses.  I would encourage a more developmental approach, looking back at the first recollection of anxiety - usually at some point in childhood and how that developed in the childhood environment.  It is fairly common for the patient to describe one or both parents being anxious and how that was transmitted to them  eg. ) "I started to worry about the same things my  mother worried about" or "I started to worry about my mother because she was worried all of the time - I worried that something was going to happen to her."  Those learning patterns associated with adult anxiety are fairly common and may explain the low heritability (15-20%) of the disorder.  The authors do discuss one feature that is important in this context and that is intolerance of uncertainty.  Clinically that translates to excessive and at times catastrophic worry about uncertain situations.  They are unsure about the biological or experiential origins of the symptom.  I think the important part is that with a careful enough history and sometimes collateral information the learning aspects of this bias can be examined and it can be unlearned in therapy.

The authors advocate for a stepped approach to treatment and I certainly agree.  This approach would include an initial medical assessment to look for common medical conditions that can cause anxiety followed by education about anxiety and lifestyle changes to address sleep, exercise, caffeine intake and alcohol use with monitoring response to those interventions.  Those first two phases could be accomplished at the initial visit.  If those initial interventions don't help moving on to "low intensity psychological interventions" like self-help books, computer-assisted psychotherapy, and support groups.  The next step up is more intensive psychological interventions like individualized cognitive behavioral therapy (CBT) or pharmacological management based on the patient's preference.  The highest level of care would include pharmacotherapy and more intensive CBT alone or in combination with other therapies (psychodynamic or acceptance and commitment therapy (ACT)).  The practical issue with this 4 step algorithmic approach to care is that it is generally not available in primary care settings.  In many of those settings, the patient is screened with the Generalized Anxiety Disorder 7-item questionnaire (GAD-7) and the patient is treated with a medication.  This is viewed as "cost-effective" care by managed care systems because an inexpensive prescription and a 20 minute appointment with a physician is apparently much more "cost effective" to the organization than maintaining computerized psychotherapy or educational and monitoring systems.  There is also the largely undetermined effect of the patient taking a completely passive role in their care.  There is a significant difference between a patient who is actively engaged in lifestyle changes and self education and one who expects a complete cure from a pill.  The actively participating patient has better outcomes.   

The authors include a table of 16 medications used to treat GAD.  They point out that the effects of medication are modest at best and no single medication has better efficacy.  They discuss vilazodone as a promising medication in clinical trials and do not include it in the list.  My current prescribing information says that it is FDA approved only for major depression, but only 4 of the 16 drugs on the list are approved for GAD: paroxetine, venlafaxine XR, duloxetine, and buspirone.   The authors comment on the practice of using hydroxyzine for GAD and suggest not to use it.  I am in complete agreement with that recommendation and think that any anti-anxiety effect comes from the non-specific sedating effect of antihistamines.  The side effect profile is also not very favorable.  They point out the benzodiazepine paradox with GAD - they are recommended for short term (3-6 month) use but the condition is chronic.  There is even more subtlety there.  Some early studies of GAD treated with antidepressants suggests that patients needed to take the medication only 30% of the time over ten years of treatment.  I don't think you will see a similar study with benzodiazepines and I think it has to do with the behavioral pharmacology of the drug.  The single-most important issue when it comes to benzodiazepines is the informed consent and letting the patient know that they are taking a potentially addictive drug.  

The  authors are silent about the fact that GAD may be the most heterogenous of all of the DSM-5 categories.  In October and November of this year, I went to three excellent conferences.  One of the central themes was phenotypic diversity in DSM-5 categories and what it implies for biology and genetics.  GAD seems to offer some of the best clinical features for distinguishing intermediate phenotypes and I outline a few in my previous post.  There are problems with a diagnostic category that says "excessive worry" is a discriminating feature and ignores real physiological markers like persistent tachycardia, hypertension, body mass index, and hyperarousal at the time of sleep.   This also points out how basic science can drive clinical diagnoses in psychiatry and hopefully at some point in the near future we will see this kind of research.

    

I think that we have gotten as much as we can out of the GAD diagnosis at this point and it is time to break it down into what can be more reliably observed. 

George Dawson, MD, DFAPA

References:

1: Stein MB, Sareen J. Generalized Anxiety Disorder. N Engl J Med. 2015 Nov 19;373(21):2059-68. doi: 10.1056/NEJMcp1502514. PubMed PMID: 26580998.

Sprituality.....

I was born and raised a Methodist.  My father was a Catholic and had some problem with that church despite the fact that many of his siblings were devout.  To this day, I have a vague notion of what being a Methodist means.  I remember going to a church that looked like a large house from the outside.   It was a very modest building.  There were a hundred or so people on the inside.  They became familiar faces over time.  I was always interested in what the clergy had to say and the message varied considerably.  I did not know it at the time, but being a protestant clergy is a very political position.  People have to like you or they start to talk and that talk can eventually undermine your ministry.  Even as a kid I thought I could figure out how serious the minister was by what he said.  Was it a rote presentation or did he brings things alive.  I don't mean in the entertaining sense.  Could he (we only had male ministers in those days) get a serious lesson across in an inspirational way?  I was always impressed with how little commentary there was about this central feature of the church service.  It seemed routine to go there, listen to the sermon, sing a few songs and leave.  No enduring message or feeling.

It wasn't until I was a teenager that I saw the inside of a Catholic church.  I was there for my father's funeral.  Several of his devout siblings arranged for the funeral service to occur in the Catholic church despite the fact that (to my knowledge) in my 15 years on earth at that time - he never set foot in church.  In assessing what the church looked like, I recall thinking that "this is the big time."  The structure was huge compared to the Methodist church and the architecture was inspiring.  No wood framing.  There were concrete arches, stained glass, symbols, and actual sculptures of Christ on the cross everywhere.  In a Methodist church there is usually one large plain wooden cross.  The stained glass is always basic with the words: "Faith, Hope, Charity".  The acoustics were definitely different.  Words spoken in a Methodist church tend to project out about 15 rows and rapidly drop off in volume.  In the Catholic church the sound carried and echoed all the way back to the last row.  That last row was at least 4 times the distance of the last row in the Methodist church.  Since then I have been in many churches Catholic and Protestant - typically for weddings and funerals.  Even though the church architecture can be an impressive instrument for the speaker - it all really comes down to the clergy.  Are they doing more than dialing it in?  Are they inspirational?  Is there intellect behind the spoken words?  Can they convey the idea that there is something much larger than our individual conscious states out there?  Those were my first lessons in spirituality.

When I was in the Peace Corps in the 1970s, a fellow volunteer introduced me to a book called Zen and the Art of Motorcycle Maintenance by Robert Pirsig.  On the surface, it was a book about a cross country motorcycle trip by the author and his son.  Below the surface there were lessons about philosophical approaches to life - both eastern and western philosophies.  There was also a flashback to a crisis in the author's life when he was in graduate school and developed a psychotic depression while in the midst of an academic interpersonal conflict with one of his professors.  The lessons for me from Pirsig's book was that spirituality is really independent of other contexts.  He summarizes it in this statement:

“The Buddha, the Godhead, resides quite as comfortably in the circuits of a digital computer or the gears of a cycle transmission as he does at the top of the mountain, or in the petals of a flower. To think otherwise is to demean the Buddha - which is to demean oneself.” ― Robert M. Pirsig, Zen and the Art of Motorcycle Maintenance: An Inquiry Into Values.

After reading Pirsig's book five times, I concluded that he had an unprecedented intellectual look at what he described overall as values.  He also had a look at spirituality in a very unique way and could see it it places where it is not commonly seen - like welding or motorcycle mechanics.  Moreover, it was also a view that made immediate sense to me.  I had been doing the same thing for years.

That brings me up to my work as a psychiatrist.  In that work, spirituality ranges all of the way from religious delusions to the higher power concept in Alcoholics Anonymous and all points in between.  I don't know how many people I have talked with who believed they were God or Jesus or Satan or The Antichrist - but I have had hundreds of conversations about those topics.  On the quieter end of the spectrum, I have had even more conversations with people who were anhedonic, hopeless, spiritually bereft and who felt abandoned by God.  Many of these folks felt as though any spirituality they had was gone.  They lost interest in it like everything else and they had doubts about whether they wanted to get it back.  Did it really mean anything when they had it?  Getting it back turned out to be a critical part of their recovery.  I try to figure out a way to describe it in my clinical assessments and it is difficult.  Some have suggested using the term to capture the Gestalt of the person, but I think it is more complex than that.  In many ways it is like describing people who are charismatic and trying to use the appropriate descriptors.

There is an experiential aspect to spirituality that requires concrete examples rather than me just writing about it.  For that I will turn to a couple of examples from the best interview program anywhere - MPR's Fresh Air with Terry Gross.  I consider it a laboratory for the spectrum of human consciousness and it contains a lot about spirituality.  The first example comes from a story about Iris Dement.  She is a folk singer who began singing in the Pentecostal Church.  Until you hear an explanation of someone who is in that church or experience what they are doing - it is very unlikely that you know what is happening.  After carefully developing the context during the interview she summarizes it at this intellectual level (1) :

   "I saw my parents use music to survive.  They had to have that music.  My mom had to sing and my dad had to go to church and he had to hear that music washing over him and through him.  It wasn't a, "Oh, this is nice"; it was a, "I'm not going to make it if I don't have that."  So I've felt that that's my job.  That's how I think of what I do.  I have to give people that lifeline, you know, that I saw my parents reach out for, and that I was taught to reach out for, and so that's what I aim to do.  And I guess I don't feel like I can do that without that connection to the spirit."

When I listened to that interview and heard that quote, I realized that had just experienced one of the best examples of spirituality.  I encourage anyone with an interest to listen to the audio and have that same experience.  I think that you have to look past your taste in music to what motivates this artist.  Too many people get stopped in their tracks by thinking: "I don't like folk music" or "I don't like country music" or some appalling lack of knowledge of the Pentecostal faith.  Listen to the audio from the perspective of what motivates Iris Dement and keeps her going.

The second MPR experience on spirituality just occurred and it was the final push for this post.  I heard Terry Gross interviewing the Iranian born photographer Abbas on his series of photographs about what people do in the name of God.  The process of the interview is again very important.  Gross sees a spiritual element in one of the photographs but Abbas does not.  He comments that his relationship with God is purely professional - he has no stake in religion.  At the same time he describes some experiences that were moving while he was engaged in photography(2) :  

"Of course.  You know, I mean, you can't touch such a subject without being touched and moved.  I remember very vividly, for instance, a mass in France among the Benedictines, you know, it's monks. They're different from priests, you know, monks - very moved by a mass.  Normally when there's a mass, I don't listen, I just take photographs because it's always the same.  But this time, you know, the father who was saying mass was very spiritual.  He was talking about Jesus, not as a distant prophet, but as a personal friend.  So suddenly I start listening, and I became very moved.  In most religions, at least one event made me - well, I wouldn't say a believer but a participant....."

Like the Iris Dement story, I encourage listening to the actual audio and Abbas description of his technique before and after this excerpt.

What is spirituality?  It is not the same thing as religion, but for some people it is very close.  I also think that it is not easily acquired.  I don't think it is as easy as declaring a higher power.  Spirituality might be haunting rather than reassuring - it may not be a good feeling but it probably leads to a sense of calm.  I like Abbas's idea that it can make you a participant.  I can see it as an unconscious emotional force that probably has some obvious and many not so obvious origins that leads to consistency and may be noticeable by observers.  Some very spiritual people are described as serene and others as inscrutable.  It is not listed in the DSM-5 and that is a good thing.  It is another aspect of conscious experience that psychiatry neglects for the most part.   As far as I can tell, it is like an experiment in consciousness.  Like the examples I gave - you know it when you experience it.


George Dawson, MD, DFAPA


References:

1.  Terry Gross.  Fresh Air on National Public Radio.   For Iris DeMent, Music Is The Calling That Forces Her Into The Spotlight.  October 21, 2015.

2.  Terry Gross.  Fresh Air on National Public Radio.  Photographer Abbas Chronicles 'What People Do In The Name Of God'.  November 19, 2015.

3.  Melissa Block.  All Things Considered on National Public Radio.  A Nephew's Quest: Who Was Brother Claude Ely?  July 14, 2011.

Story of the importance of Pentecostals in rock and roll, especially Brother Claude Ely - with parallel comments about the spirituality involved in that music.  If you doubt it - read the last two paragraphs of the written story first.

APA Misses On The Opioid Crisis - Several Times

The above infographic is courtesy of the CDC (see attribution for the direct link).  To those of us involved in treating addictions talking with many people who are addicted to opioids, getting them to see the problem, and helping them prevent accidental overdoses and death is an everyday occurrence.  The prescription opioid problem is widespread and has been a reality for the last 15 years even though it seems to have hit the news in about the last 5.  That probably coincides with heroin use starting to escalate.  The driving force for that has been economics.  Heroin is generally available in most areas for about a quarter the cost of diverted prescription painkillers.  In the past 5 years I have probably given about 50 lectures on the topic to physicians and graduate students and been actively involved in the clinical care of individuals with heroin addiction only or heroin addiction in addition to a number of other addictions.

When I got a post from the American Psychiatric Association (APA) on my Facebook feed last week it piqued my interest.  Part of what I teach is how failed policy is the root cause of the opioid epidemic and what physicians can do on an individual basis to correct the problem.  I was very interested to see what the APA had to say at a policy level.  Reading through the document that is really a blog post from the Medical Director the answer is "not much".  It appears that the APA has joined a Task Force of other professional organizations that includes that other great laggard the AMA.  They will be working to identify "best practices" and implementing them as soon as possible. Using Prescription Drug Monitoring Programs (PDMPs) is encouraged.  There will also be the focus on stigma.  Dr Levin states: "The APA maintains that substance use disorder is a medical condition that can be successfully treated, and we are actively advocating on behalf of the patients who are too often stigmatized by their community and disenfranchised by insurance carriers who fail to comply with mental health parity laws."

While there is no doubt that most people are biased against people with mental illness and addictions as well as their psychiatrists - I don't think that stigma has any traction in terms of increasing access to care or more importantly access to quality care.  I could argue that the APA support for the collaborative care initiative colludes with stigma-like biases.  That takes the form of "you don't have to see a psychiatrist - take this checklist instead."  I won't get into that today, only to say that I wonder how many people with heroin or opioid addiction are being seen in primary care clinics and being treated for anxiety, insomnia, or depression?  From what I see the numbers are significant.  But it is hard to fault primary care doctors because unless they are the prescribers of opioids, they may not realize that their patient has a problem with them.  There is also the issue of institutional stigma versus public stigma.  Public stigma or the type of stigma that everyday people have is more elastic and it usually depends on their experience with the problem.  If you live in a family where a member has a severe mental illness or addiction - you know that these problems are real, life-threatening, and you are ready to let people know that.  Institutional stigma is the type of stigma that governments and businesses can have, especially health care businesses.  They might grudgingly admit that there is some kind of problem largely because there is such a large secondary impact on medical and surgical services.  In some trauma centers over half of all admissions are primarily due to drug and alcohol problems.  At the same time,  institutional stigma is impervious to change.  It is codified in some texts on healthcare management and as noted in the APA blog post - not even amenable to change when new federal parity laws are implemented.  In terms of managing health care systems there is nothing like having a certain groups of disorders to shift resources away from in a pinch.  Mental illnesses and substance use disorders are that group.  The other considerations would include:

1.  Irrational policy initiatives:  There is no doubt that several policy initiatives to liberalize opioid prescribing were responsible for the start of this epidemic in or around the year 2000.  Making pain the "fifth vital sign", encouraging the use of opioids for chronic non-cancer pain, treating minor conditions with opioids, and a widespread policy initiative that encourage more aggressive treatment of pain even though specific measures were not know are among these initiatives.  I use the word irrational here to mean speculative initiatives that were not based on science.

2.  A serious misunderstanding of the current problem:  When all else fails blame physicians.  That is a highly effective political strategy that worked to consolidate control of the health care system under business and government.  To many of the politicians involved it flowed directly from their negative campaigning experiences.  In this case, the opioid problem is being framed at some level as a problem of inappropriate prescribing by physicians.  Some physicians are being subjected to criminal prosecution for deaths and complications that have resulted from opioid prescribing.  There are no references to the policy changes that occurred in the late 1990's that led to this change in physician prescribing behavior - the loss of gate keep functions in particular.

3.  A misunderstanding of the epidemiology of the problem: The upper decile of opioid prescribers (total number of prescriptions) account for 50-60% of all opioid prescriptions.  These prescribers are almost all family physicians, internal medicine specialists, and mid-level prescribers.  Available databases allow for rapid identification and intervention with these prescribers and that is where resources should be focused and not on all physicians across the board.  A mechanism for feedback on an individual physician's or physician extender's ranking in terms of their prescription of controlled substances is needed as well as individual access to that information.

4.  A serious misunderstanding for the overprescribing problem in general exists: As I have previously pointed out, opioids are one small group of medications that are overprescribed in the US.  Practically everyone who wants this problem to go away sees it as a cognitive problem or knowledge deficit.  If the physician involved just knew more they would not prescribe pain medications this way.  In fact, it is a much more complicated interpersonal, social and intrapsychic problem for physicians.  Until there is a widespread acknowledgement of this - all of the CME courses in the world on appropriate opioid prescribing will not change a thing.

5.  There is a widespread cultural problem:  Opioid hoarding in medicine cabinets across the country, neighbors sharing opioids and neighbors and family members discussing what is the best (translation best = most euphorigenic) is a major problem in the US.  Many politicians have agreed that America's "insatiable appetite for illegal drugs" fuels the international drug trafficking problem.  It also fuels the opioid epidemic.  There are very few initiatives focusing on cultural change.

6.  Misunderstanding the problems inherent in prescribing addictive drugs:  Most physicians are not aware of the unconscious and conscious elements that are activated in susceptible individuals when they take addictive drugs.  There are widespread misconceptions in this area that lead to the prescription of addictive drugs during active addiction,  not assessing the risk of prescribing addictive drugs to a person in recovery, and failing to assess some of the indirect signs of addiction in patients who deny that they have a problem with addiction.  There is also a belief among many physicians that if their goal is to help people that well intended prescribing will not lead to problems in the future.  

These are 6 areas that the APA could be focused on.  I don't think that you will see that analysis anywhere else.  I expect that "best practices" will fall disproportionately on the average physician and be a waste of time on their time and energy.  But it does fall back on the time honored political strategy of taking the heat off of the people who really failed and pretending it is a physician based problem.


George Dawson, MD, DFAPA


Attribution:

The infographic is from the CDC at this URL:  http://www.cdc.gov/vitalsigns/heroin/infographic.html#use

The CDC has done great work in this area and their site should be closely monitored for new data relevant to the problem.

Reductionism Is Not A Dirty Word...

A recent opinion piece in the New York Times, by George Makari, MD has me shaking my head.  The thesis was that a recent headline grabbing story (what's wrong with that criteria?) on the effects of comprehensive treatment of psychosis as opposed to treatment as usual surprised many and highlighted the problem with reductionism.  He bemoans the fact that the reaction to the story was one of surprise.  He doesn't specify who was surprised.  I certainly was not surprised.  I attended recent meeting and somebody in the audience asked Daniel Weinberger if he was surprised.  His response: "They spent $15 million dollars showing that good treatment is better than bad treatment."    He certainly was not surprised.  I have not heard about Eric Kandel's response, but based on his 1979 paper on plasticity and what happens in psychotherapy - I doubt that he would be surprised.  The exact population of who might be surprised by these findings seems poorly defined at this point in time but I doubt that it included any psychiatrists.

Speaking for myself, I will elaborate on why I was not be surprised.  At one point, I was the Medical Director of a community support program of a group of about 100 outpatients in the State of Wisconsin.  According to the state statutes, access to the program depended on diagnosis and degree of psychiatric disability.  You could only apply if you had a diagnosis of Bipolar Disorder, Major Depression, Schizophrenia,  or Borderline Personality Disorder had significant associated disability or were at high risk for hospitalization.  The clinical goal of the program was to reduce hospitalizations, maintain independent living, and facilitate employment.  The program was staffed by a psychologist, 2 social workers, three nurses and me.  When I arrived, one of the early dynamics was to frame problems in terms of medication needs.  That translated to increasing the dose of a medication (typically an antidepressant or antipsychotic) in crisis situations or other emotional crises.  The patients in the program had chronic problems and symptoms that did not necessarily respond to medication.  One of my first steps was to start to discuss problems and solutions with the patients.  I met with all of the patients and did supportive psychotherapy when possible.  We had team meetings every morning and problem solved around the needs of the patients in the community, how to solve any crises, and how to approach people in ways other than medications.  I tracked the total dose of antipsychotic medication and days of hospitalization as outcome measures.  At the end of three years, the days in hospital had gone down from about 14 days per person to less than 1, and the total dose of antipsychotic medication had gone down a total of 600 mg chlorpromazine equivalents.

My point is obviously that comprehensive care of patients with severe problems results in improved outcomes.  In this case lower doses of medications were used and the patients spent less time in the hospital and more time at home.  My orientation and ability to implement such a program was not an accident.  I was trained by Len Stein, MD at the University of Wisconsin.  Dr. Stein was a pioneer in the area defined as community psychiatry.  He was motivated by realizing that once people were in large state hospitals - it was very easy to warehouse them in overcrowded conditions.  Nobody seems to recognize it but overcrowding and suboptimal conditions were the state hospital equivalent of managed care rationing.  Once your state hospital is on the spreadsheet of a state bean counter with no accountability to patients or their families rationing and fewer and fewer resources are the order of the day.   In a community psychiatry seminar, Dr. Stein projected a slide of a gymnasium-sized room populated by male patients with hundreds of cots aligned edge to edge.  There was no room to walk between the cots.  That was his motivation for moving people out of these state facilities and into their own housing.  When I trained, there were three programs with independent living and quality of life as the primary goals and the staff involved in the programs was very good at it.  My effort just extended that skill set.  Contrary to the "surprising" results of the quoted study - I did the same thing back in 1986!

If it is true that we have known for 30 years that comprehensive care for psychiatric disorders trumps "treatment as usual" what is all of the rhetoric about?  Dr. Makari seems to want to make this into a mind-brain argument.  In other words, the biopsychosocial approach and the uncertain effect it has on the mind as opposed to a brain based approach that looks at specific mechanisms of action and seems to be focused on psychopharmacology.  He points out for example that the highlighted study would possible not qualify for current NIMH funding unless it looked at specific brain mechanisms.  He throws around the word "reductionism".  Anytime reductionistic or reductionism is used rhetorically in the same sentence with psychiatry it is pejorative.  My old psychoanalytic teacher would refer to anyone who talked about brain biology as a "dial twister".  The implication is that the reductionists are somewhat simple minded largely because they cannot accept the uncertainty of dealing with an organ that has poorly defined inputs and outputs.  Kind of a double whammy of rhetoric - you are a unsophisticated reductionist and you really can't see the big picture.  Are things really that simple?  Are these arguments accurate?  Are there problems with equating reductionism with "bad".

Of course there are major problems.  The first is the statement that inherent to the proposition that mental illness is a brain disease is "the implication that psychological and social events somehow are not also brain events."  This is a serious misreading of the definition of plasticity or experience dependent changes in the brain.  When I give my neurobiology of the brain lectures. I use Kandel's original New England Journal of Medicine article that discusses brain changes in a patient and a therapist conducting psychotherapy and how those changes are associated with brain plasticity.  I give further examples - weightlifting,  playing the violin, and how the typical stream of consciousness is profoundly altered by drug addiction.  There is no neuroscientist or biological psychiatrist I know who would suggest that psychological and social events are not brain events and there are numerous experimental paradigms that look specifically at how these events occur in the brains of animals.

The second aspect of Dr. Makari's argument has to do with reductionism.  His specific comment is:

"With luck, studies like Dr. Kane’s, which undermine these suppositions, will help move us away from such narrow thinking and embolden the substantial community within psychiatry that has never accepted such reductionism."

The suppositions in this case are that mental illness is a brain disease and that social or psychological events have no brain representation.  The argument is based on that false premise.  But further the use of the term "reductionism" is instructive here as previously noted.  By definition reductionism applies to many proposed etiologies of psychiatric disorders.  Those etiologies can be studied at a molecular level or at a higher level.  Schaffer (2) says that a model is reductive if it "employs standard biochemical and molecular entities to account for psychiatric symptoms and disorders".  Non-reductive models discuss "causal connections at higher levels of aggregation."  He illustrates these definitions by looking at Kendler's non-reductive account of major depression.  Kendler has used path analysis to look at clinical variables relevant to psychiatric disorders and although I do not have access to the one used in the book, here is a typical example.  The model looks at life stages, familial factors and psychological factors and all are higher levels of aggregation than molecular mechanisms.  At the reductive side of things he examines Harrison and Weinberger's proposed genetic susceptibility genes for schizophrenia.  At the time the book was written the author limited the discussion to 5 genes.  He also looked at the continuum of psychiatric genetic models ranging from basic and advanced genetic epidemiology being non-reductive, gene finding partially reductive, and molecular genetics fully reductive.  It seems perfectly logical to me that the study of brain biology proceeds in the same way that the biology of all living organisms proceeds.  The difference is that we are studying an infinitely more plastic organ with significant computational power.  There is clearly a lot of phenotypic heterogeneity that is unexplained in psychiatric diagnostic categories.  It is highly unlikely that refining diagnostic descriptors or applying clinical methods will lead to any significant change in the diagnostic or treatment process.  I don't understand the reluctance to go after more specific mechanisms or treatments.

The idea that a molecular or clinical focus in psychiatry is the problem with psychiatric services is also misleading.  As I hoped to point out by my mental health center example, psychiatrists know all about comprehensive care but they are rarely able to provide it.  They have known about how to provide it for decades.  State asylums became overcrowded and not therapeutic due to the financial management of the system by state governments.  The bean counters have moved out of the asylum and they are now integrated at every level in the health care system.  They all have a very strong bias against the comprehensive treatment of mental illness.  They insist that patients with severe psychiatric problems do not get comprehensive evaluations, that they are discharged before they have been adequately treated, and that any associated addictions are poorly treated.  They do not have the same biases against people hospitalized for medical or surgical illnesses.  They have in effect, moved the poorly run, overcrowded asylum model into the general health care system.  Any comprehensive care for severe mental disorders in such a system is an advertising phenomenon rather than reality.

The reductionism argument is good for New York Times opinion pieces.  It may sell a few more papers or get a few more clicks online.  Unfortunately it perpetuates an old pattern of blaming people and psychiatrists in particular for the shortcomings of a non-system of mental health care in this country that is set up to favor large health care businesses.  You can blame psychiatrists all you want for that - but until people realize that the real problems are the product of business and politics - and not the scientific interests of psychiatrists - nothing will change.


George Dawson, MD, DFAPA

References:

1.   George Makari.  Psychiatry’s Mind-Brain Problem.  New York Times.  November 11, 2015.

2.  Scaffner KF.  Etiological Models in Psychiatry - Reductive and Nonreductive Approaches in  Philosophical Issues in Psychiatry.  Kenneth Kendler, Josef Parnas (Eds), The Johns Hopkins University Press, Baltimore, 2008:  pp 48-98.

Attribution:

Image is Microscope 1 by Bill3t Hughes on Flickr.  Reposted as noncommercial via Creative Commons License on 11/14/2015.  The original work is not modified.