transinstitutionalization? IV…

Posted on Saturday 20 December 2014

I’m back from my tangent now. I wasn’t offering my objections to that legal study [An Institutionalization Effect…] as a proof in transinstitutionalization? III…, but more as an example of a place where having the numbers work out in some mathematical model is one thing, but it doesn’t necessarily prove the relationship in the conclusions. My own guess is that the shoddy implementation of deinstitutionalization, the rise in violent crimes from 1980 through 2000, and our becoming the biggest jailer on the planet are definitely related to each other, but that all three are parameters that relate to something else, something unmeasured that has something vital to say about our country’s as yet unwritten history of the second half of the 20th century. I expect that the way we’ve dealt with chronic mental illness in general belongs in that unwritten story too.

I don’t know anything much about incarceration except that it’s something societies do when they don’t know what else to do. The creation of a dual system [prisons and asylums] had an intent apparent in the very names we use to talk about them, and by the mid twentieth century, that distinction between institutions had lost its meaning. The coming of effective antipsychotic medications at the mid-century mark may have been the key that unlocked the door to the State Hospitals, but it was anything but a cure. Whether you think of psychotic illness as biological or psychological, a disease or a collection of conditions, or something else – the antipsychotics are symptomatic medications [nothing like penicillin that cures certain infections or insulin that replaces something that’s not working right]. They are often dramatically effective for the positive symptoms of acute psychosis but do nothing of note for the less dramatic negative symptoms [anhedonia, cognitive deficits, lack of motivation, etc.] nor for the often elaborate delusions seen in chronic paranoia.

One of he things I liked about the articles by Seth Prins was that he transcended all the rhetoric that often goes with this issue and seemed to be after the facts. What was not in his data that I wanted to see was the distinction between jails and prisons. I couldn’t find anything omnibus on jails for mental illness prevalence, but I did, at least, find some comparative total incarceration rates:

I’ll have to admit that I’m overwhelmed by these numbers. I had no idea that the incarceration rates were this high. I keep running across the phrase, "America’s experiment with mass incarceration," a label that seems apt [apparently it was an easier experiment to do than it has been to undo]. And it has hardly been cheap…


Speculations about the causes for our high rate of incarceration and the over-representation of the mentally ill in the prison and jail populations are met with divisive opinions about what to do about either situation. One pole, for example, supports the solutions proposed by the Treatment Advocacy Center advocatng community commitment including mandated medication. On the other pole, there is strong opposition to those methods from civil libertarians groups [see here-we-go-again?]. While the debates are often cached in terms of biomedicine and psychiatry versus other mental health disciplines and the civil liberties, or neuroscience versus humanism, my impression is that the mental health disciplines as a group [psychiatry, psychology, social work, etc.] have been otherwise preoccupied for the last quarter-century, and with the exception of those directly employed by public facilities or those involved in brain research, they have been monotonously saying the same things they said a long time ago. There is so much in this story to decry, and there’s certainly still a lot of decrying going on, but solutions or progress? not so much.

It may not be completely apparent in the segments I clipped from the Prins articles, but his reason for advocating that we focus our attention on accurate assessments of the distributions of mental illnesses in these incarcerated populations isn’t just to document the problem:
    Our ability to accurately measure the impact of such programs, in addition to changes in more fundamental causes of the prevalence of mental illnesses in prisons [such as drug policies], depends largely on the sorts of estimates summarized in this review. Also of interest to policy makers and practitioners is the fact that most of the roughly 2.3 million incarcerated individuals in the United States will be released, contributing to the approximately 4.8 million individuals — a majority of the U.S. corrections population — who reside in the community on probation and parole. About 43% of these individuals will be detained again within three years. As such, accurately measuring the prevalence of mental illnesses “inside the walls” is essential for community corrections planning. Given the existence of brief, well-validated instruments that screen for mental illnesses, such as the Brief Jail Mental Health Screen, K6, and Correctional Mental Health Screen, reporting standards for routine assessments upon intake are clearly feasible.
He’s proposing that we develop a knowledge base that allows us to evaluate the effectiveness of the various correctional programs in an ongoing way, something that might get us away from the endless speculating and ideological bickering. In the journal with his recent article, there was a companion commentary from several authors from the School of Social Work at Temple University that I thought was intriguing:
Commentary: Not Just Variation in Estimates: Deinstitutionalization of the Justice System
by Jeffrey Draine and Miguel Muñoz-Laboy
Psychiatric Services. 2014 65[7]:873-873.

… In 2002, the first author and his colleagues questioned the presumption that the large number of incarcerated people with mental illness was attributable to failures in the assessment and treatment of mental illness and concluded that there is no reliable evidence that directing resources toward psychiatric treatment would have a significant impact on incarceration rates. In this commentary, we argue that this conclusion remains true. In the article by Prins, the implied logic is that there is interpretive value in examining variations in the rates of mental illnesses in jails and prisons to discern the impact of psychiatric interventions. Holding to the principle that the most parsimonious explanation is best, the factor that explains the variation in the proportions of prisoners with mental illness is variation in correctional policy and practice among jurisdictions and over time, rather than variation in access to treatment for mental illness or in how mental illness is assessed or counted in prisons and jails. The more recent variation in rates of mental illness is also likely enhanced by the beginning of a shift in correctional policy: the decline of incarceration in prisons.

Abramson laid the groundwork for examining connections between deinstitutionalization of psychiatric treatment and the rising number of incarcerated people with mental illnesses. Historically, institutions such as orphanages, poorhouses, and asylums have, each in their own time, experienced a profound increase in their populations, which was followed by a period of deinstitutionalization. Initially, the reasons given for deinstitutionalization are humane treatment, but eventually the most persuasive arguments center on cost and efficiency in state systems and the availability of plausible alternatives. In the United States, practice shifted from poorhouses to outdoor relief, charity movements, and social work; from orphanages to child welfare systems, foster care, and juvenile justice systems; from asylums to community mental health; and now from prisons to community corrections.

With the emergence of community corrections and the eventual downsizing of prisons and jails, many people with mental illness once incarcerated in conventional facilities will more often be involved in various forms of community corrections… Correctional health care policy focused on large prisons and jails has not caught up with the impact of deinstitutionalization in the provision of psychiatric care to vulnerable populations. As a result, a growing number of individuals with serious psychiatric disorders are left without reliable access to effective psychiatric treatment. This commentary seeks to refocus attention away from efforts to establish a standard for rates of incarcerated persons with mental illness in conventional facilities with the aim of informing mental health interventions. The action is not there. The place for action in innovation, change, and planning is in community settings. Our goal should be to document variations across place and time in how the differences and changes in corrections practices interrupt effective care and to develop creative ways to recognize as a reality in the justice system the ongoing changes in corrections environments and the broad variation in incarcerated populations.
The title says it all. They’re proposing that the variablility in the data isn’t just some kind of measurement error, but represents a potential source of valuable information about various correctional programs, something that could be further developed to find answers in a data driven system – another kind of deinstitutionalization [this time jails and prisons] that is evidence-based and focused on a community correctional system that includes patients with mental illness. I expect neuroscientists and humanists alike can find things in this approach to worry about. But it would be hard to argue with trying something different informed by a different mind-set, particularly if it proceeded by iteration based on constantly changing and accurate contemporary data. It would be hard to make a bigger mess than the one we have right now…
Mickey @ 9:00 PM
Filed under: OPINION
transinstitutionalization? III…

Posted on Friday 19 December 2014

I started this by reading one paper by Seth Prins and then another, the reports from the Bureau of Prisons, and an international study from Oxford – but I looked at a lot of others along the way. The data available isn’t very good. It’s hard to get excited about self-reporting questionnaires from prisoners as an accurate index of the prevalence of mental illness among the incarcerated. And the more precise information [diagnosis by interview] isn’t comprehensive. Throw in the fact that psychiatric diagnosis has radically changed in the period under question, and things get pretty mushy. But there’s something else that makes all of this infinitely more confusing, at least to me – a ringer. This is the population of incarcerated people in American Public State and Federal prisons:
And here’s the rate of incarceration over a long period of time:
The US now has far and away the largest prison population in the world no matter how it’s measured – the trend starting in the 1970s and continuing to escalate until around 2000 when it finally began to slow [see Incarceration in the United States]. Independent of the reasons for this dramatic change, it makes it very difficult to isolate the forces acting on the Mentally Ill population.

Whereupon 1boringoldman goes off on a tangent

My problem is that transinstitutionalization as a concept both makes good sense and makes absolutely no sense at all. It was a huge happening, moving half a million people into the community, many of whom had chronic psychotic illnesses and a history of having been institutionalized. In my time [1970s], there was plenty of commerce among the jails, the police, the psychiatric emergency rooms, and the dwindling mental hospitals, but there was nothing that felt like it had to do with past history – even then. It felt like a today problem. The problem was with actively psychotic people with no place to stabilize them or chronic patients living on the streets with no place to go. And as brisk as the traffic between the hospitals and the jails, I don’t recall prison being in the mix. We had a model, but no way to adequately implement it. So I went back and started over. I began with this graph in transinstitutionalization? I…:

It’s all over the Internet [Google Images] – little wonder that I found it. It comes from a 2011 Law Journal article that’s not even about transinstitutionalization. It’s about violent crime eg homicide:
by Bernard E. Harcourt
The Journal of Legal Studies. 2011 40[1]:39-83.
[full text on-line]

Previous research suggests that mass incarceration in the United States may have contributed to lower rates of violent crime since the 1990s but, surprisingly, finds no evidence of an effect of imprisonment on violent crime prior to 1991. This raises what Steven Levitt has called “a real puzzle.” This study offers the solution to the puzzle: the error in all prior studies is that they focus exclusively on rates of imprisonment, rather than using a measure that combines institutionalization in both prisons and mental hospitals. Using state-level panel-data re- gressions over the 68-year period from 1934 to 2001 and controlling for economic conditions, youth population rates, criminal justice enforcement, and demographic factors, this study finds a large, robust, and statistically significant relationship between aggregated institutionalization [in mental hospitals and prisons] and homicide rates, providing strong evidence of what should now be called an institutionalization effect — rather than, more simply but inaccurately, an imprisonment or incapacitation effect.
The premise is that in the dip between deinstitutionalization and mass incarceration, there was a dramatic [and related] spike in violent crime – proxied by homicide. On the left below, I’ve lifted and added the homicide rates from Harcourt’s paper [note the scale differences] and on the right, I’ve taken the drama out of it by fitting the homicide spike to the same scale as the other parameters].
As much as I love graphs, regressions, and correlations, I don’t buy that premise for a single second, because that time-span happens to have been my adult life – and I’ve noticed that there were some other things going on: like the Civil Rights Movement, the War in Viet Nam, the Cuban Missile Crisis, the Assassinations [JFK, MLK, RFK], the Cold War, the Sixties Protests and Drug Cultures, Watts, the rise of the Drug problem in the 70s, Watergate, Reaganomics, tax cuts, spending cuts, growing national debt, personal computers, the rise of corporations, massive wealth inequity, the end of the Cold War, the medicalization of psychiatry, the businification of medicine, Monica Lewinsky? – just to mention a few among the gajillion other factors that might matter.

I have no real dog in that particular hunt, but it got me to thinking about what Seth Prins proposed about transinstitutionalization in that first article I looked at [see transinstitutionalization? I…], and my experienced life during the period in question:
    Discussion In the debate summarized above, proponents of the transinstitutionalization hypothesis may be mistakenly drawing a causal connection between two merely correlated trends: the decline in availability of state psychiatric hospital beds and the rise in prevalence of SMI in jails and prisons. More specifically, they may [a] misinterpret deinstitutionalization as a flood of individuals who were released from state psychiatric hospitals only to be arrested and incarcerated, [b] conflate evidence that people released from psychiatric hospitals often require re-hospitalization with evidence that jails and prisons are serving that function [c] erroneously assume that people who require inpatient services are clinically and demographically similar to people with SMI who wind up in jails and prisons and [d] underestimate the effectiveness of high quality community-based treatment. The evidence against the transinstitutionalization hypothesis is compelling because [a] most people released from state psychiatric hospitals do not appear to end up incarcerated, [b] the characteristics of people with SMI in jails and prisons differ from both the characteristics of people who were deinstitutionalized and the past decades’ increasingly forensic state psychiatric hospital population, and [c] many agree that community-based treatment works for the majority of people with SMI.
… and for the same reasons I mentioned above, I agree with him. I don’t questions that our jails in many big cities are functioning like the short-term mental facilities we no longer have, and that the criminal justice system has had to take over some of the functions better handled by an intact community-based, mental health system. And I sure don’t doubt that many mental patients in prisons shouldn’t be there, and wouldn’t be there were there some reasonable system of ongoing care that functioned properly. And if transinstitutionalization were just a slang for the obvious truth – that our society has failed in its basic function of taking decent care of the less fortunate among us – I suppose this wouldn’t matter. But it’s more than that. It implies an inevitability, an excuse for our indifference to the lot of the chronically mentally ill. It’s just way too simplistic and leaves out huge swathes of related history.

[to be continued]
Mickey @ 10:00 PM
Filed under: OPINION
transinstitutionalization? II…

Posted on Thursday 18 December 2014

This is where we left off:

by Seth J. Prins, M.P.H.
Psychiatric Services. 2014 65:862-872.
Objective: People with mental illnesses are understood to be over-represented in the U.S. criminal justice system, and accurate prevalence estimates in corrections settings are crucial for planning and implementing preventive and diversionary policies and programs. Despite consistent scholarly attention to mental illness in corrections facilities, only two federal self-report surveys are typically cited, and they may not represent the extent of relevant data. This systematic review was conducted to develop a broader picture of mental illness prevalence in U.S. state prisons and to identify methodological challenges to obtaining accurate and consistent estimates.
Methods: MEDLINE, PsycINFO, the National Criminal Justice Reference Service, Social Services Abstracts, Social Work Abstracts, and Sociological Abstracts were searched. Studies were included if they were published between 1989 and 2013, focused on U.S. state prisons, reported prevalence of diagnoses and symptoms of DSM axis I disorders, and identified screening and assessment strategies.
Conclusions: Definitions of mental illnesses, sampling strategies, and case ascertainment strategies likely contributed to inconsistency in findings. Other reasons for study heterogeneity are discussed, and implications for public health are explored.

[These are a colorized versions of his figures with lots of tailoring to make them fit, but I think they are at least a reasonable fascimile of his findings for just looking over, but if you’re really interested, get the original. Each diamond represents the results of one of the studies he looked at.]
We don’t have any choice here but to start with his methods in detail:
Methods: A systematic review of the scholarly literature was conducted to identify studies that presented prevalence estimates of mental illnesses in prisons. Articles were included if they were published in peer-reviewed, English-language journals between January 1989 and December 2013, focused on U.S. state prisons, reported prevalence estimates of diagnoses or symptoms of DSM axis I disorders, and clearly identified the denominator for prevalence proportions.
Articles were excluded if they did not present original data; focused solely on axis II disorders, youths, jails, or foreign prisons; selected samples only of people with mental illnesses or substance use disorders; presented only combined jail and prison prevalence estimates; did not present prevalence estimates [for example, presented only mean scale scores or odds ratios for disorders]; or the denominator for prevalence estimates was not apparent. Samples selected on the basis of substance use were excluded given the high rates at which substance use disorders co-occur with mental illnesses among incarcerated individuals, which would therefore not provide good estimates of mental illnesses per se. A review of the prevalence of substance use disorders in prisons was beyond the scope of this report.
MEDLINE, PsycINFO, the National Criminal Justice Reference Service, Social Services Abstracts, Social Work Abstracts, and Sociological Abstracts were searched. For MEDLINE and PsycINFO, combinations of the following medical subject headings [MeSH] were used: mental disorders, mental health, prevalence, incidence, epidemiology, psychotropic drugs, drug therapy, prisons, and prisoners. For the remaining databases, similar keyword combinations, including axis I disorder terms, were searched…
The initial search yielded 3,670 non-duplicated articles. Based on titles and abstracts, 3,388 articles did not meet inclusion criteria and were excluded… Full texts of the 282 remaining articles were reviewed, and an additional 254 studies were rejected based on exclusion criteria outlined above… Twenty-eight articles were thus included in the review…
First off, I think Seth Prins is a real scientist. He took a relatively large unmanageable literature, clipped it down to size using the usually solid techniques of analysis, and presented it without "dolling it up." But 3670-»3388-»282-»28 is quite a bit of paring down, and leaves us with questions about what this sample actually represents. The variability among the studies is equally striking. But that’s not his doing. It’s what he found to work with. Most of his in-depth discussion is about the many sources of variability in his findings and are too much for a blog post, but his message is clear, and I buy it. Debates, opinions, policies, and public dollars are riding on the numbers of mentally ill people in our prisons, why they are there, and how they got there. We need a whole lot better data than we have to make evidence-based decisions about how to proceed. He mentions some instruments that might help in doing that, though I’m unfamiliar with them [I expect most of us are]:
As such, accurately measuring the prevalence of mental illnesses “inside the walls” is essential for community corrections planning. Given the existence of brief, well-validated instruments that screen for mental illnesses, such as the Brief Jail Mental Health Screen, K6, and Correctional Mental Health Screen, reporting standards for routine assessments upon intake are clearly feasible. Even in the absence of such standards, prison administrators, working in collaboration with mental health policy makers and practitioners, can [at relatively low cost] calibrate such screening instruments to their populations and begin collecting valid and reliable prevalence estimates.
In my own dancing around through this literature over the last week or so, I’ve been finding the same thing Prins found in his formal analysis – heterogeneity². There are innumerable local studies, specific to certain areas, places, kind of detention facility, etc, but when I aim for the big picture, what I find is researchers struggling to do some kind of meta-analysis with widely divergent methodologies [big surveys with questionnaires or small focused studies with precise instruments]. This next one is a world-wide study, that’s actually an update from a previous meta-analysis and has broken out the US data longitudinally [and it’s available on-line]:
by Fazel S and Seewald K
British Journal of Psychiatry. 2012 200[5]:364-373.

BACKGROUND: High levels of psychiatric morbidity in prisoners have been documented in many countries, but it is not known whether rates of mental illness have been increasing over time or whether the prevalence differs between low-middle-income countries compared with high-income ones.
AIMS: To systematically review prevalence studies for psychotic illness and major depression in prisoners, provide summary estimates and investigate sources of heterogeneity between studies using meta-regression.
METHOD: Studies from 1966 to 2010 were identified using ten bibliographic indexes and reference lists. Inclusion criteria were unselected prison samples and that clinical examination or semi-structured instruments were used to make DSM or ICD diagnoses of the relevant disorders.
RESULTS: We identified 109 samples including 33 588 prisoners in 24 countries. Data were meta-analysed using random-effects models, and we found a pooled prevalence of psychosis of 3.6% [95% CI 3.1-4.2] in male prisoners and 3.9% [95% CI 2.7-5.0] in female prisoners. There were high levels of heterogeneity, some of which was explained by studies in low-middle-income countries reporting higher prevalences of psychosis [5.5%, 95% CI 4.2-6.8; P = 0.035 on meta-regression]. The pooled prevalence of major depression was 10.2% [95% CI 8.8-11.7] in male prisoners and 14.1% [95% CI 10.2-18.1] in female prisoners. The prevalence of these disorders did not appear to be increasing over time, apart from depression in the USA [P = 0.008].
CONCLUSIONS: High levels of psychiatric morbidity are consistently reported in prisoners from many countries over four decades. Further research is needed to confirm whether higher rates of mental illness are found in low- and middle-income nations, and examine trends over time within nations with large prison populations.
As with Prins, first to the methods:
Method: We identified publications estimating the prevalence of psychotic disorders [including psychosis, schizophrenia, schizophreniform disorders, manic episodes] and major depression among prisoners that were published between 1 January 1966 and 31 December 2010. For the period 1 January 1966 to 31 December 2000, methods are described in a previous systematic review conducted by one of the authors. For the update and expanded review, from 1 January 2001 to 31 December 2010, we used the following databases: PsycINFO, Global Health, MEDLINE, Web of Science, PubMed, National Criminal Justice Reference Service, EMBASE, OpenSIGLE, SCOPUS, Google Scholar, scanned references and corresponded with experts in the field. Key words used for the database search were the following: mental*, psych*, prevalence, disorder, prison*, inmate, jail, and also combinations of those. Non-English language articles were translated. We followed PRISMA criteria. Inclusion criteria were the: [a] study population was sampled from a general prison population; [b] diagnoses of the relevant disorders were made by clinical examination or by interviews using validated diagnostic instruments; [c] diagnoses met standardised diagnostic criteria for psychiatric disorders based on the ICD or the DSM; [d] prevalence rates were provided for the relevant disorders in the previous 6 months.
The full text version on-line has a comparison of the actual studies. Notice that the numbers fall here too – down to 25 different studies. Their method, like Prins, looked only at papers where diagnosis was made by interview. Their significant findings were higher rates of severe mental illness in prison in low income countries; an increasing prevalence of Major Depressive Disorder over time in the US; but no increase in the prevalence of psychosis in the US prison population. If anything, it fell.
So, what about transinstitutionalization?…
Mickey @ 1:54 PM
Filed under: OPINION
transinstitutionalization? I…

Posted on Wednesday 17 December 2014

There is so much divisiveness in discussions of matters that have to do with Mental Health and Mental Illness that it’s sometimes difficult to separate the wheat from the chaff. There’s a strong backlash to the medicalization of psychiatry, the heavy use of medications, the DSM-III etc. diagnostic system, and the claim/implication that all mental illness has some biological basis. On the other side there are claims that psychological counseling focusing on trauma and recovery will clear up most problems now called mental illness. It’s kind of hard to find much to read that doesn’t have some sort of rhetorical bias, visible in the first several paragraphs.

Back in my days on the wards as the de-Institutionalization of mental hospitals was winding down, it would’ve been pretty hard for anyone to maintain a belief that things were going very smoothly. Our admission units were full of people, many psychotic, and hospital beds were evaporating like a sno-cone dropped on hot pavement. At seminars and meetings, the topic was often punctuated by the Szasz meme of that day about the Myth of Mental Illness, and then back to work at the Grady Hospital Emergency room where things didn’t feel a bit mythical at all. Nobody I knew wanted to re-open any huge mental hospitals again. We just wanted short term beds to stabilize patients, and that didn’t mean just medicate, it meant trying to find a source of food and shelter that worked – a social placement, a life. The flow and the dwindling resources worked against that goal, resulting in the revolving door hospitalizations, very high rates of recidivism, and homeless people on the streets and sleeping under the bridges. The back-up promised by the Community Mental Health Movement seemed to be disappearing. The police that had to deal with these patients were fed up and vocal about it when they brought someone in for the second time in a week because the last hospitalization was so brief.

There was a concept, transinstitutionalization, frequently mentioned in these discussions:
    transinstitutionalization A process whereby individuals, supposedly deinstitutionalized as a result of community care policies, in practice end up in different institutions, rather than their own homes. For example, the mentally ill who are discharged from, or no longer admitted to, mental hospitals are frequently found in prisons, boarding-houses, nursing-homes, and homes for the elderly.
    A Dictionary of Sociology , 1998

I must’ve internalized the idea. I recently used this graph from this article to illustrate it in a few blog posts [functional improvement…, what they’re for…]:
Ever since I wrote those posts and read the interesting comments here, I’ve found myself looking for more actual data. Who are the people involved? What’s known about the jail populations? How many are psychotic or mentally ill people in jail for being afflicted with the age old severe mental illnesses? How many are people on the substance abuse train that’s swept through the world? But I haven’t found as much data as I’d hoped. Then recently, I ran across the article below. It opened with:
    The popular account of why people with serious mental illnesses [SMI] are overrepresented in jails and prisons is usually structured as follows: deinstitutionalization, combined with inadequate funding of community-based treatment for individuals in need of mental health services, has led to the criminalization of mental illness and attendant increases in incarceration rates. This represents a return to the conditions that psychiatric institutions were originally designed to alleviate. Indeed, the mainstream assumption that the state psychiatric hospital and criminal justice systems are functionally interdependent — a phenomenon described as transinstitutionalization — is commonly accepted.
Which is exactly what I thought from long ago. I looked further into the article:
by Prins SJ
Community Mental Health Journal. 2011 47[6]:716-722.

Abstract: Although there is broad consensus that people with serious mental illnesses [SMI] are overrepresented in correctional settings, there is less agreement about the policy trends that may have created this situation. Some researchers and policymakers posit a direct link between deinstitutionalization and increased rates of SMI in jails and prisons, a phenomenon described as transinstitutionalization. Others offer evidence that challenges this hypothesis and suggest that it may be a reductionist explanation. This paper reviews claims from both sides of the debate, and concludes that merely increasing access to state psychiatric hospital beds would likely not reduce the number of people with SMI in jails and prisons. A more nuanced approach is recommended for explaining why people with SMI become involved in the criminal justice system and why developing effective strategies to divert them out of jails and prisons and into community-based treatment is needed to improve both their mental health and criminal justice outcomes.
The abstract was more of a teaser than an abstract, so I commandeered his Discussion section where he fleshes out what he’s getting at:
Discussion In the debate summarized above, proponents of the transinstitutionalization hypothesis may be mistakenly drawing a causal connection between two merely correlated trends: the decline in availability of state psychiatric hospital beds and the rise in prevalence of SMI in jails and prisons. More specifically, they may [a] misinterpret deinstitutionalization as a flood of individuals who were released from state psychiatric hospitals only to be arrested and incarcerated, [b] conflate evidence that people released from psychiatric hospitals often require re-hospitalization with evidence that jails and prisons are serving that function [c] erroneously assume that people who require inpatient services are clinically and demographically similar to people with SMI who wind up in jails and prisons and [d] underestimate the effectiveness of high quality community-based treatment. The evidence against the transinstitutionalization hypothesis is compelling because [a] most people released from state psychiatric hospitals do not appear to end up incarcerated, [b] the characteristics of people with SMI in jails and prisons differ from both the characteristics of people who were deinstitutionalized and the past decades’ increasingly forensic state psychiatric hospital population, and [c] many agree that community-based treatment works for the majority of people with SMI.

This is not to say, however, that conclusive evidence currently exists on either side of the debate. More rigorous analysis to clearly define the causal relationship between deinstitutionalization and the overrepresentation of people with SMI in jails and prisons is certainly warranted [for example, retrospectively matching archival inpatient, arrest, and incarceration records]. The arguments presented above should also not imply that the cases for and against increased access to inpatient services are irreconcilable. Indeed, the most important takeaway from this debate may be a fact that is often overlooked by policymakers working to address this issue: people with mental illnesses are not a homogenous population. Increased access to acute and intermediate psychiatric beds may, in fact, be necessary for a small but high-risk, high-cost group of people with severe mental illnesses who cycle through emergency rooms and the criminal justice system without obtaining the treatment they need [Pasic et al. 2005 ]. For these individuals, shortages of 24-hour hospital care [and for this group and others with SMI, affordable housing more broadly] are indeed a problem.

Nevertheless, increased access to inpatient services may not be an optimal focus for a multi-systemic criminal justice/mental health policy strategy. The ramifications of casting too wide an inpatient net would not only be expensive, but would move away from the goal of full community integration of people with mental illnesses that is the hallmark of the rights and recovery movement [New Freedom Commission on Mental Health 2003 ]. Pragmatically, it might be argued, that reinstitutionalizing people with SMI who become involved in the criminal justice system is the lesser of evils, since treatment conditions in psychiatric hospitals are bound to be better than those in jails and prisons. This reasoning, however, addresses one problem by creating a new [but familiar] one, and avoids tackling the issues at the heart of the matter.

Broadly speaking, the popular account of current mental health policy is correct: people with SMI are being ‘‘locked up’’ in jails and prisons as was the case 200 years ago. Understanding why this is happening, however, is important for developing strategies to appropriately divert people with SMI out of jails and prisons and into the treatment they need to become productive members of their communities. The history of deinstitutionalization provides an intuitive but reductionist narrative about the reasons why people with SMI are overrepresented in correctional settings. At the very least, policymakers and researchers should treat the transinstitutionalization hypothesis with caution and not as a presupposition. Failure to approach this issue with the nuance it requires may unwittingly imply expen- sive interventions that will benefit only a fraction of the population at issue. For the large remainder of people with SMI in jails and prisons, other causes of their involvement with the criminal justice system should not be ignored. In this regard, shifts in philosophy and ideology behind the concept of deinstitutionalization are still relevant. For the majority of this group, the key to staying out of hospitals, jails, and prisons may be a place to live, a job or some income support, a meaningful relationship or social network, quality healthcare, or linkage to treatment instead of frequent arrest for substance use disorders — fundamental needs that can best be redressed in the community, not psychiatric or correctional institutions.
I was looking for numbers, and what I found was a think piece, but it was a good think piece. So I wrote the author at the listed email address asking for references. Of course, the email bounced back not found. But in looking around, I found this next article which is what I wanted to ask him about in the first place:
by Seth J. Prins, M.P.H.
Psychiatric Services. 2014 65:862-872.

Objective: People with mental illnesses are understood to be over-represented in the U.S. criminal justice system, and accurate prevalence estimates in corrections settings are crucial for planning and implementing preventive and diversionary policies and programs. Despite consistent scholarly attention to mental illness in corrections facilities, only two federal self-report surveys are typically cited, and they may not represent the extent of relevant data. This systematic review was conducted to develop a broader picture of mental illness prevalence in U.S. state prisons and to identify methodological challenges to obtaining accurate and consistent estimates.
Methods: MEDLINE, PsycINFO, the National Criminal Justice Reference Service, Social Services Abstracts, Social Work Abstracts, and Sociological Abstracts were searched. Studies were included if they were published between 1989 and 2013, focused on U.S. state prisons, reported prevalence of diagnoses and symptoms of DSM axis I disorders, and identified screening and assessment strategies.
Conclusions: Definitions of mental illnesses, sampling strategies, and case ascertainment strategies likely contributed to inconsistency in findings. Other reasons for study heterogeneity are discussed, and implications for public health are explored.

The reason I had kept on looking is what he says [highlighted in red]. Everything I found went back to only a few references. So Seth Prins went looking for data too. I think I’ll defer what he found [or didn’t find] to the next post before this one runs off the page. Here are the two often quoted reports he mentioned:
The problem with these reports? It’s in the methods – self report questionnaires:
    "Among this handful, two reports by the U.S. Bureau of Justice Statistics have been cited at least 1,100 times, according to a recent query of Google Scholar. These reports used self-report surveys and defined mental illnesses as a current mental or emotional condition, a prior overnight stay in a “mental hospital,” or endorsement of symptoms of mental disorders in the Diagnostic and Statistical Manual of Mental Disorders [DSM]. Prevalence estimates were three to 12 times higher than in community samples, reaching as high as 64%."

Take a look at the first page of each report and you’ll see what he means…
Mickey @ 4:22 PM
Filed under: OPINION
a lot better…

Posted on Monday 15 December 2014

Last week, the group in charge of the NIMH RAISE [Recovery After an Initial Schizophrenia Episode] Study published a compilation of the medications that their first episode patients were on when they were enrolled, medications they’d been prescribed while in the hospital [78%] or had received as outpatients before becoming part of the RAISE Study:
by Delbert G. Robinson, Nina R. Schooler, Majnu John, Christoph U. Correll, Patricia Marcy, Jean Addington, Mary F. Brunette, Sue E. Estroff, Kim T. Mueser, David Penn, James Robinson, Robert A. Rosenheck, Joanne Severe,Amy Goldstein, Susan Azrin, Robert Heinssen, and John M. Kane
American Journal of  Psychiatry. 2014; AiA:1–12; doi: 10.1176/appi.ajp.2014.13101355.

Objective: Treatment guidelines suggest distinctive medication strategies for first-episode and multiepisode patients with schizophrenia. To assess the extent to which community clinicians adjust their usual treatment regimens for first-episode patients, the authors examined prescription patterns and factors associated with prescription choice in a national cohort of early-phase patients.
Method: Prescription data at study entry were obtained from 404 participants in the Recovery After an Initial Schizophrenia Episode Project’s Early Treatment Program [RAISE-ETP], a nationwide multisite effectiveness study for patients with first-episode schizophrenia spectrum disorders. Treatment with antipsychotics did not exceed 6 months at study entry.
Results: The authors identified 159 patients [39.4% of the sample] who might benefit from changes in their psychotropic prescriptions. Of these, 8.8% received prescriptions for recommended antipsychotics at higher than recommended dosages; 32.1% received prescriptions for olanzapine [often at high dosages], 23.3% for more than one antipsychotic, 36.5% for an antipsychotic and also an antidepressant without a clear indication, 10.1% for psychotropic medications without an antipsychotic, and 1.2% for stimulants. Multivariate analysis showed evidence for sex, age, and insurance status effects on prescription practices. Racial and ethnic effects consistent with effects reported in previous studies of multiepisode patients were found in univariate analyses. Despite some regional variations in prescription practices, no region consistently had different practices from the others. Diagnosis had limited and inconsistent effects.
Conclusions: Besides prescriber education, policy makers may need to consider not only patient factors but also service delivery factors in efforts to improve prescription practices for first-episode schizophrenia patients.

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It’s a clever thought, and they treat the results as a microcosm of general prescribing practices – a reach of an extrapolation [~400 subjects »» all of the US], but interesting nonetheless and worth considering. They compare their results to the PORT [Schizophrenia Patient Outcomes Research Team] Guidelines:
Harvard Mental Health Letter
JUN 2010

The PORT recommendations, issued in 1998 and first updated in 2003, were funded by the Agency for Healthcare Research and Quality and the National Institute of Mental Health. Researchers at the University of Maryland wrote the latest update after consulting with leading schizophrenia experts. In contrast to efforts like the American Psychiatric Association practice guidelines for schizophrenia and the Texas Medication Algorithm Project, which attempt to address the full range of situations clinicians encounter, the PORT review is more conservative in scope. The PORT authors limit their recommendations to those interventions that have been tested in randomized controlled trials…

Since the last PORT review, two large clinical trials have compared efficacy of first- and second-generation antipsychotics: the Clinical Antipsychotic Trials of Intervention Effectiveness [CATIE] and the Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study [CUtLASS]. Based on the findings of these studies, the PORT reviewers noted that in many cases, first- and second-generation antipsychotics are equally effective for treating schizophrenia.
First-episode psychosis. The PORT review recommends using any antipsychotic except clozapine [Clozaril] and olanzapine [Zyprexa], because these drugs are most likely to cause significant weight gain and other metabolic side effects. Because patients experiencing psychosis for the first time are both more responsive to medications and more likely to have side effects, antipsychotics should be prescribed at doses that are lower — generally about half — compared with those recommended for patients with chronic schizophrenia.
Relapse. Patients who initially responded to medication but suffer a relapse of symptoms have several options. The PORT team recommends any first- or second-generation antipsychotic other than clozapine, and stipulates that medication be prescribed at the lowest effective doses to reduce side effects. Choice of which antipsychotic to use depends on patient preference, past medication response, side effects, and medical history.
Maintenance therapy. Studies that have followed patients with first-episode or chronic schizophrenia for one to two years have concluded that continuous maintenance antipsychotic treatment reduces risk of relapse. The PORT review recommends that intermittent maintenance therapy — a strategy of stopping antipsychotics until symptoms reappear or worsen — be reserved only for patients who refuse to continue taking an antipsychotic or for those who cannot tolerate the side effects. For patients with chronic schizophrenia, both first- and second-generation antipsychotics are equally effective at preventing relapse. During maintenance therapy, first-generation drugs may be used at lower doses than those required to treat the initial [acute] episode, while second-generation drugs can be prescribed at whatever dose was effective in the initial phase. Long-acting injectable antipsychotics provide another option in maintenance therapy, especially for patients who have trouble taking medication. The PORT review concluded that it is unclear whether injectable medications are any more effective than pills at preventing relapse, mainly because of a lack of randomized controlled studies….
In the AJP article, they reference five different sets of treatment guidelines:
    2. Canadian Psychiatric Association: Clinical practice guidelines: treatment of schizophrenia. Can J Psychiatry 2005; 50(suppl 1):7S57S
    3. Moore TA, Buchanan RW, Buckley PF, Chiles JA, Conley RR, Crismon ML, Essock SM, Finnerty M, Marder SR, Miller DD, McEvoy JP, Robinson DG, Schooler NR, Shon SP, Stroup TS, Miller AL: The Texas Medication Algorithm Project antipsychotic algorithm for schizophrenia: 2006 update. J Clin Psychiatry 2007; 68:17511762
    4. Buchanan RW, Kreyenbuhl J, Kelly DL, Noel JM, Boggs DL, Fischer BA, Himelhoch S, Fang B, Peterson E, Aquino PR, Keller W; Schizophrenia Patient Outcomes Research Team (PORT): The 2009 Schizophrenia PORT psychopharmacological treatment recommendations and summary statements. Schizophr Bull 2010; 36:7193
    5. Barnes TRE; Schizophrenia Consensus Group of British Association for Psychopharmacology: Evidence-based guidelines for the pharmacological treatment of schizophrenia: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2011; 25:567620
    6. Hasan A, Falkai P, Wobrock T, Lieberman J, Glenthoj B, Gattaz WF, Thibaut F, Möller HJ; WFSBP Task force on Treatment Guidelines for Schizophrenia: World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia, part 2: update 2012 on the long-term treatment of schizophrenia and management of antipsychotic-induced side effects. World J Biol Psychiatry 2013; 14:244

Notably absent, the American Psychiatric Association [APA] Guidelines. Their guidelines website is here, and unless I’m missing something, they are "out of date:"
"The guidelines linked on this page, excluding Major Depressive Disorder, are more than 5 years old and have not yet been updated to ensure that they reflect current knowledge and practice. In accordance with national standards, including those of the Agency for Healthcare Research and Quality’s National Guideline Clearinghouse, these guidelines can no longer be assumed to be current."
There’s another reference in the AJP article. It’s from some of the same authors and is itself "dated" [2005] in that it comes before CATIE and some of the other large studies. I was actually surprised to find that it was pretty informative [particularly the pop-up tables], reviewing a large amount of information, and framing the issues better than I expected. I pass it on in part because the whole article is accessible:
by Delbert G Robinson, Margaret G Woerner, Howard M Delman, and John M Kane
Schizophrenia Bulletin. 2005 31[3]: 705-722.

Studies with first-episode populations offer the unique opportunity to examine the effectiveness and side effects of medications without the confounding effects of prior medication use. This review focuses upon studies of [1] treatment of the initial episode, [2] maintenance treatment issues, [3] recovery, and [4] side effects. Response rates for the initial episode are high with both conventional and new-generation antipsychotics. However, we lack data directly comparing the new-generation agents with one another for treatment of the initial episode, and data about options for patients with treatment resistance at illness onset are very limited. With the most commonly used pharmacological therapies, the course of early-phase schizophrenia is characterized by repeated relapses and a low rate of recovery. Medication treatment is also associated with a variety of side effects. Of particular concern for treatment of first-episode patients are the metabolic side effects with the new-generation antipsychotics because they occur rapidly, are very distressful to adolescents and young adults, and have long-term medical consequences. Available data support maintenance treatment to prevent relapse, but questions remain about the optimal duration of maintenance treatment, whether there are differences among the new-generation agents for maintenance treatment, and balancing the benefits of maintenance antipsychotics with their long-term side effects.
Last week’s article has gotten a lot of commentary, even though it’s not available on-line. The authors of the paper and the NIMH see it as exposing prescribing problems that call for an educational effort. They are proposing that the clinicians in the mental health centers who referred them are used to treating chronic relapsing patients, and are applying those dosing standards inappropriately to the first episode patients – ignoring the guidelines’ recommendations to use smaller doses and to avoid Olanzapine. The report in Mad in America emphasizes the over-medication of psychotic patients by psychiatrists:
"The study found that about 40% of patients who’d been diagnosed with having psychotic experiences for the first time in their lives were being too heavily medicated right away."

First episode schizophrenia isn’t that hard to diagnose, so my assumption is that the patients enrolled in the RAISE study fit the bill for that diagnosis. Whether the medications they were on when they showed up are typical for the whole country or represent something else, it’s a bad showing. By my read, it’s worse than these authors say it is. 10% were on no psychoactive medication at all. The only reason I can think of that would explain that is that the clinicians knew they were going into the study and deferred treatment on that basis, but there’s nothing supporting that in the paper. Of the ones on antipsychotics, the big majority were on atypicals [SGAs] in spite of ample evidence that those drugs are no better than the older drugs [FGAs] and the side effects are really no less benign taken en masse. There’s no slightly reasonable explanation why so many were on Olanzapine, and in the higher dose range at that. It doesn’t take Guidelines to know that the weight gain/metabolic profile of that particular drug is a problem waiting to happen, particularly in first episode patients. You can see that in a waiting room. The author’s explanation for the too high dose being related to the treating chronic patients does make some sense relating to using Olanzapine and Haldol, the two drugs given in excess, but that doesn’t make it right. And a third of them taking antidepressants? That’s the kind of thing that happens when doctors equate the class nick-name "antidepressants" with what the drug actually does, and give them to anyone who says "I’m depressed." I know of no evidence that they help people with psychosis who say, "I’m depressed." That’s not who they’re for. We can do a hell of a lot better than what this study reveals. It’s tempting to see this result as a triumph of the "detail men" over science and good sense.

Honestly, I don’t read Guidelines much myself either. They’ve been so contaminated in the PHARMA era that I’m reticent to trust what I read. That they even included the TMAP recommendations which strikes me as bizarre. A few years back, I sat through the Allen Jones and Texas vs J&J trial in Austin Texas where Dr. Shon and others were deposed about TMAP, and I shuddered. Had it not been a Civil case, I thought Shon would’ve been given jail time – in my opinion. But reading the other listed Guidelines now, they all seem to have the taint of the period when we hoped the atypicals [SGAs] were going to solve problems. I hoped that too. But they just didn’t, though apparently that promise lingers in the air. But reading the PORT recommendations in first episode illness, they seem mostly sensible. The answer to the impossible dilemma of "maintenance" treatment will be in a more rational, less divisive, and better-studied future.  I think my experience is skewed in that the patients I personally followed with this illness didn’t come and go. They were not clinic patients, but were my patients who I saw periodically [sometimes frequently, sometimes rarely] or whenever they called. I operated much closer to the model Whitaker and others push, always trying to minimize or eliminate antipsychotic exposure if possible [and it wasn’t always possible]. There’s a study by Gaebel et al from Germany reported in the 2005 Pharmacological Treatments for First-Episode Schizophrenia paper above that somewhat mirrors my own experience. They call it prodrome-based neuroleptic intervention [First vs multiple episode schizophrenia: two-year outcome of intermittent and maintenance medication strategies], but to be honest, it only worked when it worked, which was much more often as time passed and my patient and I learned how to know when it was time to start medications. My experience was that the warning signs were more often unique to the particular patient than mentioned below. And we didn’t just "discontinue," we "tip-toed" back down:
Gaebel et al. report results involving a subsample of first-episode patients participating in a 2-year randomized open treatment study comparing 3 medication strategies: continuous maintenance treatment, prodrome-based intervention, and crisis intervention. Prodrome-based intervention involved the reintroduction of antipsychotic medication as soon as prodromal symptoms [suspected predictors of impending relapse, e.g., restlessness, trouble sleeping, trouble concentrating, tension and nervousness, loss of interest or depression] occurred. Once restabilization was attained the antipsychotic drugs were again discontinued. Crisis intervention provided for the reintroduction of antipsychotic medication only in the case of a full relapse. Relapse rates during the 2-year period for first-episode subjects who completed the study were as follows: maintenance treatment, 38%; prodrome-based intervention, 42%; crisis intervention, 67%.
So I’m glad they published this article from the pre-RAISE experience. I would lay the problems exposed at the feet of systems of "care" that are asleep at the wheel and people in high places who failed [fail] to lead. This illness [or illnesses] is a major deal, one of the biggest that can afflict young adults in the prime of their lives. It deserves the same careful ongoing attention taken with analogous chronic physical illness like regional enteritis or injury like the disabilities of our returning soldiers. And I’m convinced that consistent, available, benevolent personal attention is an integral part of that package. If I had my druthers, I’d make following a certain number of these patients a condition for licensure for all people in any mental health specialty – with oversight and case review. You can do a much better job with a few of these patients that you know very well than as a steady diet in a clinic where the pervasive negative symptoms can be infectous and "burnout" can become endemic. If there’s to be a "prescription for life," I think should be prescription for some well informed person who will stick with any given patient and be available when needed. My practice taught me that there’s much more to treating this illness than just "meds" or "med-checks" or "relapse prevention." Some of them just won’t or don’t stick around, but a lot will if they have some helpful place to stick. Personally, I hope that the RAISE initiative can iterate into a program that will provide a lot more of that than we have now.

That’s why I keep writing about RAISE, because while I think it has a long way to go to be the kind of treatment/recovery program that’s needed, I believe they’re at least trying. In this case, my negative comments are intended to be constructive criticism – mainly focused on the IRT [Individual Resiliency Training] Manual which I think ‘talks down’ to and gives misinformation to patients:
So as we sometimes say, hope springs eternal…
Mickey @ 8:00 PM
Filed under: OPINION
looking back…

Posted on Thursday 11 December 2014

New York Times
October 3, 2008

One of the nation’s most influential psychiatrists earned more than $2.8 million in consulting arrangements with drug makers from 2000 to 2007, failed to report at least $1.2 million of that income to his university and violated federal research rules, according to documents provided to Congressional investigators.

The psychiatrist, Dr. Charles B. Nemeroff of Emory University, is the most prominent figure to date in a series of disclosures that is shaking the world of academic medicine and seems likely to force broad changes in the relationships between doctors and drug makers. In one telling example, Dr. Nemeroff signed a letter dated July 15, 2004, promising Emory administrators that he would earn less than $10,000 a year from GlaxoSmithKline to comply with federal rules. But on that day, he was at the Four Seasons Resort in Jackson Hole, Wyo., earning $3,000 of what would become $170,000 in income that year from that company — 17 times the figure he had agreed on….
This article is where all of this started for me. After leaving Emory in the mid-80s in the wake of the DSM-III revolution, I had pretty much disassociated myself from the world of organized and academic psychiatry altogether, continuing to teach in the Emory Psychoanalytic Institute and the college, but unconnected to the psychiatry department itself. I guess I dropped out as we said in the 50s and 60s. I don’t think I realized at the time, how cloistered I really was. By 2008 when that article came out, I was retired five years. I had started volunteering in a local charity clinic and was mystified by the medication regimens patients were on [mystified translated = horrified]. About that time, I read the article about Dr. Nemeroff and a lot of things I hadn’t understood began to click. I combed the Internet and didn’t find a whole lot: Dr. Bernard Carroll’s posts on Healthcare Renewal, Stephanie on Soulful Sepulcher, Bob Fiddaman of the Fiddaman Blog, and then there was the Carlat Psychiatry Blog. It was enough to get me started, and Danny’s Blog was an indispensable part of that time for me because I had a lot of catching up to do. When he stopped blogging in 2012, it was a loss, though by then there was some momentum as more and more people began to catch on to the corruption that had lurked in the background. Well, Danny Carlat is back from a two year hiatus, having involved himself in the nuts and bolts of Senator Grassley’s Sunshine Act. So here’s Danny…
The British Medical Journal
The Carlat Psychiatry Blog
by Danny Carlat
November 6, 2014

After substantial delays, the Open Payments website was launched on 30 September. The website was mandated by the Physician Payments Sunshine Act of 2010, and it is a comprehensive registry of payments made to physicians and teaching hospitals by drug and device companies…

Although the website is not complete, it still provides unprecedented insight into the extent and nature of financial relationships between physicians and industry. In total, companies paid $3.5bn [£2.2bn; €2.8bn] to 546 000 physicians [about 60% of all US doctors] and to 1360 teaching hospitals over the five months…

Breakdown of $3.5bn payments made to US doctors in last five months of 2013

Reason for payment Amount ($)

Research 1.5bn
Physician investors/owners 1bn
General: 1bn
Royalties and licences 302m
Promotional speaking 203m
Consulting 158m
Food 93m
Travel and lodging 74m
Education 36m
Gifts 19m

…The Sunshine Act is only a transparency initiative and does not regulate what doctors can or cannot receive. However, the new website has been launched within a broader context of increasing pressure to reform industry payments…

For several years, many of the larger companies have published their own physician payment registries, most of which were required by settlements of lawsuits alleging illegal marketing practices. As these payments have been made public, several companies have decreased their spending for promotional talks, and one company, GlaxoSmithKline, is eliminating such payments altogether. Like industry, the medical profession is regulating itself. In 2008, the Association of American Medical Colleges published strict conflict of interest recommendations for academic medical centers, which have responded by strengthening their policies. From 2008 to 2014, the percentage of medical schools that ban their faculty from giving promotional talks has increased from 4% to 49%; the percentage of schools banning gifts and meals has also risen sharply. Since 2007, the American Medical Students Association has tracked such conflict of interest metrics in scorecards, which it publishes annually []…

How will the Open Payments database be helpful in the future? Although the Sunshine Act was ostensibly passed to allow consumers to make more informed healthcare choices, it is likely that the site will have even more value to researchers and policy makers. The degree to which industry payments actually influence medical care has not been resolved because until now there were scant data with which to properly investigate the issue. But researchers will now be able to compare a trove of industry payment data with other databases recently released by CMS, such as detailed disclosures of physicians’ prescribing patterns.

Even before Open Payments, one research group merged the prescribing database with industry payment data aggregated by the investigative journalism organization ProPublica. They found that payments were strongly correlated with increased prescriptions of companies’ products. Such results, if replicated on a larger scale, may well lead to stricter government regulation of financial relations between companies and physicians. Such regulations, in turn, would hopefully lead to more evidence based healthcare and improved patient outcomes. If so, Open Payments will turn out to be an enterprise well worth the effort.
It continues to feel surreal to me, all of this. I still remember reading that 2008 article about Dr. Nemeroff, chairman of the department I had left, had remained affiliated with, am actually still affiliated with. There had been prequels where Dr. Nemeroff had conveniently left off his financial interests in papers [Treatment of mood disorders, 2002] [VNS therapy in treatment-resistant depression:, 2006] called to task in both cases by Drs. Carroll and Rubin. But it was the revelations of Senator Grassley and Paul Thacker that finally made it so obvious that this was no fluke, but an enduring pattern. And there were so many others in equally high places doing the same thing, taking money from PHARMA. Now we read in Carlat’s piece that "In total, companies paid $3.5bn [£2.2bn; €2.8bn] to 546 000 physicians [about 60% of all US doctors] and to 1360 teaching hospitals over the five months…" – a staggering statistic. In the last post about Dr. Relman’s 1980 comments [we were warned…], we read…
I am not referring to the companies that manufacture pharmaceuticals or medical equipment and supplies. Such businesses have sometimes been described at part of a "medical-industrial complex’ but I see nothing particularly worrisome about them. They have been around for a long time, and no one has seriously challenged their social usefulness. Furthermore, in a capitalistic society, there are no practical alternatives to the private manufacture of drugs and medical equipment.
… which seems so far off the mark in the light of recent history. Rather than see that particular comment as an index of Dr. Relman’s naïveté, I actually find it strangely comforting. If someone as in-the-know as he obviously was couldn’t see what was going to happen, it helps me feel not so bad for being so blind myself.

I used to feel guilty for not seeing how corrupt things had become in the alliance between academic/organized psychiatry and the pharmaceutical industry – guilty for having dropped so far out of things. At the time, it honestly felt more like psychiatry left me than vice versa, but that’s neither here nor there at this point. Lately, I’m kind of glad to have been so isolated. It allowed me to practice in a way that I felt good about, retiring with a feeling that I’d been able to do what I set out to do. And the five years between retiring and the awakening that article brought were a good respit from a long career. Reading Danny’s post, and skimming through his older posts put me in a reflective mood, and had me thinking about medicine as a whole rather than just psychiatry. The same thing happened reading through Dr. Relman’s articles. Medicine has changed in my fifty years of being around, and I’m not talking about the scientific advances. I’m talking about its businessification, and about the resultant changes in the fabric of its morality.

So as long as I’m musing on the changes in medicine and psychiatry over my time in the service, I ought to mention another blog that’s older than the rest of us – one that has maintained a steady focus on these changes for the worse in medicine. Today was actually the tenth anniversary for Dr. Roy Poses’ blog, Healthcare Renewal. He celebrated by reviving his very first blog post from ten years ago where he said what he was setting out to do. It’s exactly what he has done along with his associated bloggers [he’s added links to later posts on each topic]. He’s been an inspiration for us all. A hat-tip to Roy for a decade well spent:
Health care around the world is beset by rising costs, declining access, stagnant quality, and increasingly dissatisfied health care professionals. Discussions with physicians and other professionals revealed pervasive concerns that the core values of health care are under seige. Patients and physicians are caught in cross-fires between conflicting interests, and subject to perverse incentives. Free speech and academic freedom are threatened. Psuedo-science and anti-science are gaining ground. Causes include the increasing dominance of health care by large organizations, often lead by the ill-informed, the self-interested, and even the corrupt. However, such concentration and abuse of power in health care has rarely been discussed openly. This blog is dedicated to the open discussion of health care’s current dysfunction with the hopes of generating its cures.
Mickey @ 10:00 PM
Filed under: OPINION
we were warned…

Posted on Wednesday 10 December 2014

by Relman AS.
New England Journal of Medicine. 1980  303[17]:963-70.

The most important health-care development of the day is the recent, relatively unheralded rise of a huge new industry that supplies health-care services for profit. Proprietary hospitals and nursing homes, diagnostic laboratories, home-care and emergency-room services, hemodialysis, and a wide variety of other services produced a gross income to this industry last year of about $35 billion to +40 billion. This new "medical-industrial complex" may be more efficient than its nonprofit competition, but it creates the problems of overuse and fragmentation of services, overemphasis on technology, and "cream-skimming," and it may also exercise undue influence on national health policy. In this medical market, physicians must act as discerning purchasing agents for their patients and therefore should have no conflicting financial interests. Closer attention from the public and the profession, and careful study, are necessary to ensure that the "medical-industrial complex" puts the interest of the public before those of its stockholders.
It’s an old article, a classic, but I couldn’t locate a full text version on the Internet. So I purloined his introduction…
…and his concluding thoughts:
Dr. Relman got a lot of things right, but if you’ve followed the history of psychiatry since he wrote this in 1980, he got the part highlighted in red very wrong [about the pharmaceutical and device industries]. I can’t blame him. If I had been asked in 1980, I would’ve said the exact same thing. What actually happened was something of a shock to me. As bizarre as it sounds today, what he has to say wasn’t lost on a lot of us even earlier, and it was a part of why I moved to psychiatry – thinking I might side-step the coming industrialization of medicine [speaking of being dead wrong – so I’m no visionary either]. But the thrust of what Dr. Relman wrote was, indeed, visionary – a tragic vision as it played out. And his comments, highlighted in blue, are crystal clear – an obvious prescription for salvation that was ignored. Flash forward to now:
Pharmalot: WSJ
by Ed Silverman
Dec 4, 2014

Walk into any physician’s office and promotional messages about medicines can be seen no matter where you look – brochures are typically displayed on a counter and advertorial messages are often playing on a flat-screen TV mounted on a wall. This type of patient outreach, which is called point-of-care marketing, is hardly new, but what is different is that the pharmaceutical industry and other companies selling health products are relying on this form of promotion more than ever before, according to a new study.

Since 2010, the amount of money spent on POC marketing in physician offices, hospitals and pharmacies grew 10% annually, reaching $400 million this year. Nearly 90% of that spending was done by drug makers, says Hensley Evans of ZS Associates, a consulting firm that conducted the study. Moreover, spending on POC is expected to exceed $500 million within the next two to four years. “This is clearly growing in importance,” says Evans, adding that POC communications are second only to television advertising in terms of reaching consumers.

Of course, patients waiting to see a doctor are the classic captive audience. ZS points to another study that found 89% percent of patients say they watch television in a waiting room, and 76% of patients recalled information they read or heard in a waiting room. Moreover, ZS notes that patients can wait 20 to 40 minutes to see a physician, and wait times are expected to rise over the next decade as the number of visits to primary care doctors reaches 565 million in 2025, up from 462 million in 2008. ZS also cites data indicating 65% of patients find POC materials credible because there is an implied endorsement from the doctor. This is a subtle but important distinction from DTC advertising on television, if only because the consumer receives the message at home or in some other surrounding.

Meanwhile, the growth in direct-to-consumer advertising for prescription drugs rose 1.3% on a compounded annual basis. As a result, ZS calculates that POC spending will have accounted for 10% of all DTC spending this year, up from slightly less than 7% in 2010. The shift reflects a few developments. For one, drug makers are increasingly trying to remind patients to take their medicine, since adherence boosts revenue. And ZS notes that a logical forum for delivering that message is in a location where diagnosis and treatment are discussed.

At the same time, drug makers are selling fewer blockbusters to the widest possible patient population and, instead, are increasingly marketing therapies targeted at specific patient groups. This shift calls for more customized marketing than what television commercials may allow, according to ZS. The marketing is apparently having the desired effect. ZS cites data indicating that 84% of patients who visited waiting rooms and were exposed to POC communications report that the messages made them interested in the product.

Nonetheless, Evans does not believe that POC marketing will overtake or supplant other forms of marketing. Rather, she believes that drug makers are simply increasing their POC spending in response to changing business models. “But we are seeing more consumers become more engaged,” says Evans. “They can have a more educated conversion with physicians and not just about a promoted brand [product], but also about broader information for treating a condition.”

If this sounds familiar it is because this is the same explanation that the pharmaceutical industry has used to explain why DTC advertising is beneficial. Some doctors, however, complained that patients were not given complete information or were unnecessarily prompted to ask for certain medicines. Now, though, the marketing is increasingly shifting to the physician office. In effect, the physician has become more of a marketing partner with the pharmaceutical industry.

In 1980, Dr. Relman saw what had already happened in the years after President Nixon opened Pandora’s Box in 1973 [see «parity?»…] with the Health Maintenance Organization Act, "which encouraged rapid growth of Health Maintenance Organizations [HMOs], the first form of managed care." While it may seem far-fetched to propose that things could change in so a short period, that’s certainly how it felt. 1980 was actually probably too late. Dr. Relman was the long-time editor of the New England Journal of Medicine [see Dr. Arnold Relman, 91, Journal Editor and Health System Critic, Dies] who continued the themes in this piece throughout the remainder of his career. I’m not aware of his mentioning psychiatry, but his wife, Marcia Angell, who later also became an editor of the NEJM herself, made up for that in her widely read review of the books of Irving Kirsch [The Emperor’s New Drugs: Exploding the Antidepressant Myth], Robert Whitaker [Anatomy of an Epidemic], and Danny Carlat [Unhinged: The Trouble with Psychiatry] [see in the name of ethics… and no leg to stand on…].

PandoraIt’s such an old story – Pandora’s Box. She was given a box [actually, a jar] as a wedding present with the injunction to never open it. Pandora’s curiosity won out but in opening the box, she unwittingly unleashed all the evils stored inside to spread throughout the world. So the lesson of the story is that some things, once released, can be neither contained nor put back in the box.

In psychiatry, the pen of Richard Nixon wasn’t necessary. In 1974, Mel Sabshin became Director of the APA with the mandate to bring psychiatry firmly into the fold of the rest of medicine, fueled by the neoKraepelinians at Washington University and other centers in the Midwest. Over the 1970s, Dr. Robert Spitzer refined their crude classification [the Feighner Criteria] to produce the widely heralded DSM-III diagnostic manual. In the last post [«parity?»…], I called it medicalesque because it looked medical with [sort of] well defined criteria. But since psychiatry has no disease markers [biomarkers], validity was replaced with reliability [using the criteria, there was agreement among clinicians]. The background agenda, ending the hegemony of the psychoanalysts in psychiatry was quickly realized. The medicalization of psychiatric diagnosis was a surprising public success. Managed Care used it to fix reimbursement by Disorder, and moved psychotherapy out of psychiatry [the non-physician therapists using the DSM-III for billing purposes with their new-found access to insurance payment]. Pharmaceutical companies used the DSM-III for FDA Approval by diagnostic category while detailing primary care physicians to prescribe the drugs based on symptoms. By the time of his retirement twenty years later, Dr. Sabshin was writing:
     "During the past quarter century, the domination of American psychiatry by ideological groupings began to change. Evidence-based psychiatry became more powerful, and empirically based treatment became the rule rather than the exception. These changes occurred in the context of radical changes in the economic principles affecting our entire medical system. Health care in the United States changed from being offered through an almost free market to being heavily regulated. Today, for treatment to be reimbursed, approval of the treatment must be obtained in advance from the managed care company. Length of hospitalization is severely limited and alternative care systems are preferred. In the mental health field, an effort is often made by these intermediaries to have treatment conducted by psychologists or social workers, who, it is assumed, will charge less than psychiatrists. The pressure to limit length of hospital stay and the pressure to produce more rapid results in outpatients have reinforced the use of psychopharmacological agents in clinical practice. Recent developments in psychopharmacology have supported psychiatry’s efforts to cope with the external economic pressures. On the other hand, psychosocial treatments have been made more difficult to support in the world of managed care. The future of psychotherapeutic work by psychiatrists is under attack from several fronts, and strong efforts will need to be made to prevent atrophy of psychiatrists’ psychotherapeutic skills. Several other danger signals to American psychiatry have appeared; indeed, this chapter on the future of psychiatry is being written at a time when much of American psychiatry faces irrational external regulation and constraint."
    The Future of Psychiatry in Changing American Psychiatry 1999

While I would and did argue with the changes Drs. Sabshin and Spitzer brought to psychiatry with the DSM-III, that’s not my point this time. American psychiatry did everything possible to get with the Managed Care program including producing a code book that made things easy for them, gravitating to short sessions primarily focused on symptomatic drug treatments, abandoning traditional in depth evaluations, being empaneled in plans for the insured outpatients, abandoning hospital treatment for the severely disturbed, etc. In addition, Academic psychiatrists "signed on" as authors to papers written by medical writers that exaggerated drug efficacy and minimized adverse events. Many became traveling speakers for the pharmaceutical companies. But it all came for naught. Worse than that, it lead to the routine use of medications for almost anyone who showed up. And now the whole specialty is being appropriately discredited for these practices. Simply put, various industries increasingly controlled the psychiatry from 1980 forward. But psychiatry is just a loud and now very public example of a general trend felt throughout medicine – the one Dr. Relman warned us about in 1980.

In the less well known part of the story of Pandora’s Box, there was one spirit that didn’t escape – Elpis, the spirit of Hope:
    Only Hope was left within her unbreakable house, she remained under the lip of the jar, and did not fly away. Before [she could], Pandora replaced the lid of the jar.
So where is Hope now? Still in the Box? Here’s what Dr. Relman had to say thirty years later [NYT Obituary]:
In 2012, asked how his prediction had turned out, Dr. Relman said medical profiteering had become even worse than he could have imagined. His prescription was a single taxpayer-supported insurance system, like Medicare, to replace hundreds of private, high-overhead insurance companies, which he called “parasites.” To control costs, he advocated that doctors be paid a salary rather than a fee for each service performed.

Dr. Relman recognized that his recommendations for repairing the health care system might be politically impossible, but he insisted that it was imperative to keep trying. Though he said he was glad that the health care law signed by President Obama in 2010 enabled more people to get insurance, he saw the legislation as a partial reform at best. The health care system, he said, was in need of a more aggressive solution to fundamental problems, which he had discussed, somewhat philosophically, in an interview with Technology Review in 1989.

“Many people think that doctors make their recommendations from a basis of scientific certainty, that the facts are very clear and there’s only one way to diagnose or treat an illness,” he told the review. “In reality, that’s not always the case. Many things are a matter of conjecture, tradition, convenience, habit. In this gray area, where the facts are not clear and one has to make certain assumptions, it is unfortunately very easy to do things primarily because they are economically attractive.”

and from that 1989 Technology Review interview:
The solution he suggests [central control by government, doctors being paid salaries, medicine practiced without the profit motives of private enterprise] is the system in most of the Social Democracies around the world.
Sounds good to me. When do we start?
Mickey @ 8:26 PM
Filed under: OPINION

Posted on Monday 8 December 2014

by Paul Summergrad
President of the American Psychiatric Association
December 2014

Many laws can be difficult to enforce effectively, or in some cases, to enforce at all. That’s long been the case with environmental and human-rights laws, often because violations are committed by many and the government’s ability to inspect and monitor is limited. As psychiatrists, we are already keenly aware of the challenges in enforcing the Mental Health Parity and Addiction Equity Act [MHPAEA]. Yet the violations are all too real and are ones our patients and we experience frequently. APA remains committed to ensuring that parity is much more than a symbolic law. President George W. Bush signed parity into law in October 2008. And it was only last year, in November 2013, that the departments of Health and Human Services, Labor, and Treasury jointly issued the final rule implementing parity. Together the law and the regulations make it clear that patients with a mental illness, including a substance use disorder, should no longer be discriminated against by insurers. But how many patients know specifically what a parity violation looks like? How many of us? We know what it feels like. But it takes education and awareness to help patients be able to identify practices that make coverage for mental health treatment more restrictive than for other medical care. Patients who know their rights are better equipped to protect their rights.

That’s why I am pleased to provide you with a new tool to support parity enforcement. It’s a poster, developed by APA, titled “Fair Insurance Coverage: It’s the Law” and can be downloaded here

No, this post isn’t about insurance. I don’t know anything about that, having practiced "off the grid." If my patients used insurance, I was an "out of network provider" and they did their own filing and collecting. This post is about something else…

When I was a medical house officer in the 1960s, there was a widely used term, "supratentorial". The Tentorium is membrane that supports the Occipital Lobe, separating the Cerebum from the Cerebellum [the Cerebrum being the "thinking" part of the brain]. It was a slang, a code word that patients didn’t understand that sounded medical. So in a bedside presentation, the presenter might say, "or this could be a supratentorial problem" – meaning, "it’s in his head" – meaning, a psychological rather than a physical problem – meaning, "there’s nothing really wrong". There were a lot of dismissive terms around like that for people who had what were then called "neurotic" symptoms. And that’s where things usually stopped. We were heroically occupying the front lines, locked in holy battle with "real" life-threatening physical illnesses and had little time or patience for "neurotic" problems. Patients with the major psychiatric illnesses like Schizophrenia or Melancholia who showed up un the medical wards were different – more like "hot potatoes." Psychiatrists were called and speedy transfer was the name of the game.

My own interest came later – in practice. At first, I was awed at how many of the patients who were referred to me as an Internist who turned out to have "neurotic" or "psychosomatic" symptoms [75% – I counted]. Then I started asking them some questions and doing some exploring, and I discovered a whole new world of things were just too interesting not to pursue. But the point here is about legitimacy. In training, physical diseases were the legitimate domain of Medicine proper. And many patients feel the exact same way, feeling discounted by suggestions that their symptoms might not have some physical basis. And if physicians and their patients tend to see a biological basis as the sine qua non of legitimate medical illnesses, the insurance companies paying for medical care are absolutely adamant on that point. It’s not at all hard to see why that is.

A century ago, these matters were less clear. Many of the patients of the day presented much more dramatic symptoms that those seen now – paralyses, anesthesias, blindess. In fact, the term "neurotic" originally meant something akin to "neurology-like," psychologically derived symptoms that looked like brain or nerve problems. Much of what the early psychoanalysts had to say about such cases has been assimilated by our culture, and those "neurology-like" syndromes are rarely seen. The psychoanalysts and other psychotherapists turned their attention in a different direction – personality problems, post-traumatic syndromes, etc. And so about the insurance companies of the 1970s. Since most of us have our glitches or "baggage" from the past, the boundaries between normal and abnormal begin to fade, then disappear. So any given person and any given psychiatrist or psychotherapist could decide on any given day that a long course of psychotherapy was indicated [and frequently did] – aided and abetted by the DSM-II [1968-1980] that legitimized its vaguely psychoanalytic criteria for the "Neuroses."

And then, in what seemed like the twinkling of an eye, the businessification of Medicine [Managed Care, HMOs, PPOs, Hospital Corporations] and the [re]medicalization of Psychiatry [DSM-III, biological treatment, PHARMA] turned everything upside-down. The DSM-III couldn’t achieve legitimacy in the usual medical way [biological markers, etiology], but it did produce a syndromatic symptom-oriented medicalesque classification that made no mention of matters psychological [etiologically neutral]. We all know the rest of that story. The DSM-III legitimized a biologically oriented psychiatry. The DSM-III legitimized the non-psychiatric mental health specialties’ access to medical insurance, albeit in a tightly managed way. It even legitimized the patients’ illnesses – having a named and numbered Disorder, "I have been diagnosed with Bipolar Disorder." It wasn’t "in your head" anymore, it was "in your brain". In practice, most psychiatrists did medication management using the new drugs that flowed steadily from the PHARMA pipeline. Our journals filled with Clinical Trials of those drugs and reports of the advances in biological brain science – genomics, proteinomics, neuroimaging, cognitive sciences, and the like. The mental-illness-as-manifestation-of-brain-disease meme increasingly crept into the discourse, and by 2002, the fledgling DSM-5 Task Force announced that the biology would be added to the next revision of the diagnostic manual.

Apparently, the medication management/therapist split with its managed care reimbursement was an adequate enough compromise, because things settled down and the wars of the 1970s abated. As I said in the last post, it became something of a "therapist"/"psychiatrist" symbiosis. And this was an outpatient oriented solution aimed at treating what the psychologist next door called the walking wounded – the not so very ill. Hospital Care for the more profoundly afflicted was radically trimmed – almost to zero. People were only hospitalized in the direst of circumstances based not so much on treatment needs or treatment plans, but because there were no alternatives [and discharge planning started in the admission office] – very short stays. Patients with psychotic illnesses like Schizophrenia or Mania were mainly treated in the dwindling public sector with service availability varying widely from place to place. If you saw a severely ill patient, getting them adequate treatment was a nightmare with or without their being insured.

This system may have been an adequate compromise for the reimbursement needs of mental health clinicians, but it wasn’t so hot for the patients who felt the constraints of its limitations – a feeling shared by many of the "providers" who felt as if they were doing First Aid rather that medical care. Patients referred to psychiatrists rarely left without a medication prescription. "Counseling" was often time limited or catch-as-catch-can.  Over the years, there has been an increasing disillusionment with the efficacy [and/or safety] of the ubiquitous psychiatric medications. While it’s true that all medical care has suffered under the system of Managed Care, mental health care has been the most closely watched, the most severely cut, the most vulnerable to being shaped by its control. We may have been declared legitimate, but apparently not all that legitimate. It feels like the whole medical system is run on cutting out everything they can get away with cutting, and in mental health, they can get away with cutting a whole lot. The disparity between medical coverage and mental health coverage was obvious to anyone that looked, and ultimately lead to the Mental Health Parity and Addiction Equity Act, signed in 2008. But, as Dr. Summergrad points out, it hasn’t really even been implemented – thus, this pdf APA poster. I guess it’s supposed to be stuck up on the office wall.

I started with the remembered attitudes towards matters mental from my medical house officer days – those "supratentorial" problems – because I actually think that attitude has controlled our fate [and by "our" I mean all of us – psychiatrists, psychologists, social workers, etc. and our patients with mental health problems]. The late-coming Mental Health Parity and Addiction Equity Act is an attempt to fix something that has largely shaped and contorted our specialties for forty years – another piece of legislation [see Managed Care]:

    Richard Nixon … was the first mainstream political leader to take deliberate steps to change American health care from its longstanding not-for-profit business principles into a for-profit model that would be driven by the insurance industry. In 1973, Congress passed the Health Maintenance Organization Act, which encouraged rapid growth of Health Maintenance Organizations [HMOs], the first form of managed care.
That was an important time. For one thing, 1974 was when I came back from a European sojourn and started a psychiatry residency, so it marks the beginning of my direct knowledge. Much more important, 1974 was the year Mel Sabshin took over the American Psychiatric Association with a mandate to reMedicalize Psychiatry, the year Robert Spitzer was tasked to revise the Diagnostic Manual. It was around the time the Wash U Psychiatric Group published the Feighner Criteria [see the dreams of our fathers I… etc]. Managed Care was coming to psychiatry…

…and vice versa. Psychiatry did everything in its power to fit into the new Managed Care system – "a for-profit model that would be driven by the insurance industry." It created a medical diagnostic system [DSM-III] and adopted the principles of evidence-based medicine. Out came the white coats, and our journals followed suit with the graphs and tables more familiar from the medical journals. Psychiatry accepted the abbreviated sessions of medical consultations and the closing of our non-cost-effective hospitals. The psychologists, social workers, counselors jumped on board and agreed to accept the mandates and control of managed care – happy to be included. PHARMA didn’t just jump into the mix, they dove in with wild abandon, passing out some of the fortune they reaped from the windfall along the way. Researchers began to search for the missing links, the biomarkers that would concretize full membership in the medical fraternity.

But try as we might, psychiatry and the other mental health disciplines never had the bargaining power of the rest of medicine. We just didn’t really fit, in spite of our claims and an inordinate amount of chest-beating. So we’ve been clay in the hands of the bean counters, and had to follow their lead rather than leading – all of us. Worse than that, our patients most in need were left out of the loop. It goes without saying that "a for-profit model that would be driven by the insurance industry" would hardly be expected to focus on a chronic, psychotic [largely uninsured] population – people who need ongoing care and where the goal is often to prevent deterioration rather than effect some measurable cure. So parity? legitimacy? not even close.

I know I’ve spent my time focusing on the unsavory relationship between the KOL segment of psychiatry and PHARMA on this blog. But when I think about mental health care as a whole, I think the major force in shaping how things are for all of us is the one this post addresses – not just psychiatry, but everyone else involved, particularly our patients/clients. Mental health and a lowest bidder cost accounting mindset just don’t fit together. It was an experimental attempt to halt medical inflation that just kept on experimenting without looking at the results in any critical way. The Health Maintenance Organization Act of 1973 didn’t work in general…
… and it sure didn’t work for us. I have no idea if the Mental Health Parity and Addiction Equity Act will have any impact on what has happened in these last forty years. It seems like too little, too late to me. We’re going to need something a lot bigger than that to have a system that fits the needs of our patients. Mental health is not a private enterprise commodity…
Mickey @ 5:24 AM
Filed under: OPINION

Posted on Sunday 7 December 2014

Mad in America
by Allen Frances, M.D. and Robert Whitaker
December 4, 2014

It’s there for all to read so I won’t try to summarize it here. I’d suggest reading it, actually reading it several times. Because it’s so familiar, I tended to skim it the first time through. And it deserves a more thorough reading. The other thing I would suggest is to pretend you are a psychiatrist if you’re not. And pretend you’re not a psychiatrist if you are. We’re in such a rut with all of this, that about all you’ll come away with is having rooted for your home team if you don’t do something to break the frame of your well-worn ideas or ideology.

I have a lot of respect for these men. Both have done something creative and courageous by running against the tide of the times. They’ve inserted themselves into the center of important debates that had grown monotonous, moved things into a much more productive though certainly no less divisive trajectory. I’ve read their writings with interest, and like most, I feel the better informed for having done it. But after reading this debate several times, I was surprised to find that I didn’t really think that either one of them had it quite right – too many straw men [heroes and villains]. But after writing multiple versions of this post, and then erasing them, I decided that I’m not really capable of transcending my own experience of the major issues covered in this debate and would start by talking about that experience.

In the era that came before my time, psychotic people were removed from society to Institutions originally conceived of as asylums:
    a·sy·lum  (-slm)
    1. An institution for the care of people, especially those with physical or mental impairments, who require organized supervision or assistance.
    2. A place offering protection and safety; a shelter.
    3. A place, such as a church, formerly constituting an inviolable refuge for criminals or debtors.
    4. The protection afforded by a sanctuary.
    5. Protection and immunity from extradition granted by a government to a political refugee from another country.

Note that the definition doesn’t say anything about protecting others from the patients, but the opposite. Over time, perhaps a century, those refuges became something else – described as snake pits or warehouses – maintained by State governments. The notion of moral treatment or refuge had given way to confinement and marginalization. I don’t know the origins of de-Institutionalization. It obviously had something to do with the coming of the antipsychotic medication, the deplorable state of our "State" hospitals, and the fiscal burden of maintaining them. Came then the Community Mental Health movement, a federally funded program aimed to move the patients out of the Institutions into the community by providing the necessary support services in the world at large, rather than in the hospitals. I arrived in psychiatry as that program was collapsing as the funding was disappearing.

Even in its inadequately funded days, the Community Mental Health Movement was partially successful. The Asylums disappeared and the patients were, indeed, back in the community. As a psychiatry resident in the first year, I spent my days with the patients who didn’t fit, who were too ill to manage being in open society and were brought or came to the "Emergency Receiving Unit" where I was assigned. In those days, I encountered the writings of Thomas Szasz early from a fellow resident [see Szasz by proxy…]. The model of the times was focused on relapses, episodes of intense psychosis, and the idea was to treat them with medications and return the patients to the community as quickly as possible. It was a laudable goal, but only when it worked. Unfortunately, chronic psychosis doesn’t respond to the medication like the acute illness does, and the patients don’t like to take it for reasons easily discovered if you take only one pill yourself. And so there was a subset of "revolving door" patients who came or were brought back to the hospital regularly. And there was the specter of Tardive Dyskinesia, a potential neurologic consequence of long term medication that you only have to see once to live in terror of causing.

I had not come to psychiatry to be in charge of keeping the streets of Atlanta safe nor to involuntarily treat anyone. I had discovered that many of the patients who came to my office as an Internist were there because of emotional tangles. I could see what was wrong, but I had no idea what to do, so I came to a psychiatry residency to find out. I knew nothing of psychosis – meeting it for the first time in my early thirties in a big city charity hospital in a difficult historical epoch. And that part was, indeed, difficult. I struggled with the same issues I now read about on Mad-in-America. Besides the fellow resident who was Szaszian, I was fortunate to have an advisor, Dr. Jonas Robitscher, a psychiatrist, psychoanalyst, lawyer who had famously written The Power of Psychiatry. While his conclusions were similar to those of Szasz, he was not a "blamer." He was a Civil Libertatian who believed that the right to due process belonged in our courts, not our doctors. As he related it, the historical addition of psychiatrists to the commitment process antedated the coming of medication, and was originally conceived as a reform movement to keep small town judges from "sending away" undesirables to mental hospitals.

Some years later, I had the opportunity to work with a lawyer friend tasked with drafting a new version of our State’s commitment law for the legislature. We changed it to make judicial review mandatory rather than voluntary. On the next iteration, he was able to change it further to take "psychiatrist" out of the mix altogether [see a clarification…]. That was years ago. I believe that’s now a general trend among the States. But what I’m arguing with is not the details. It’s the implication in Whitaker’s debate piece and among those who write on his site that psychiatrists want that power, or hang on to it  [the power to commit] as a tool to retain some kind of hegemony among the mental health disciplines or power over patients. I’ve not seen that to be true. My own complaint is the opposite – that psychiatry proper has ignored the care of the chronic mental patients during the last quarter century just like everyone else – including the other mental health disciplines and governmental agencies. From my perspective, there are no heroes in this story.

While I am much more on the side of Bob Whitaker in looking at what happened in 1980 in terms of the APA and academic psychiatry, I see the forces at work and the motives in a very different way. Both Allen Frances and Bob Whitaker leave out too much of that story for my tastes, and neither addresses what I consider to be the central player in the piece – money. In the 1970s, the major third party payouts by medical insurance in mental health were for inpatient hospitalizations and long psychotherapies. That was not going to continue, and mental health coverage was under attack. That was a major factor in the medicalization of psychiatric diagnosis in 1980 – legitimizing access to third party payments. In that regard, it was successful for psychiatrists and the other mental health disciplines. I doubt it would’ve happened otherwise. What then happened was unexpected, at least by me. The insurance carriers took charge and split up mental health care. The [more expensive] psychiatrists were paid for medical things like medication management. The psychotherapy/counselling was partitioned to other disciplines in carefully controlled and monitored contracts. In-patient reimbursement essentially disappeared. The non-psychiatrists were happy to get access to covered care. Many psychiatrists migrated to medication management. And voila` – that was that. Most referrals to participating psychiatrists came from the now covered psychologists, counsellors, and social workers. It was a symbiosis and many patients/clients spoke of "my psychiatrist" and "my therapist" as an inter-related pair. Psychiatry and the other mental health disciplines needed to change in those days, but the changes that came were driven by economics, and that trend escalated when PHARMA jumped onboard. The chronic psychotic patients were marginalized in the process and the criminal justice system did the only thing it knows how to do – put many of them in jail.

I left those years being involved with the treatment of the psychotic patients feeling much the same way about psychotic illness as that advocated by Dr. Sandra Steingard in the current Mad-in-America CME – antipsychotics for acute psychosis with a constant drive towards as little as possible or none thereafter. I followed some patients with those diagnoses long term and was impressed that a practical psychotherapy tailored to fit the illness was more effective than I might have imagined [see 1. from n equals one  and the posts that follow]. But I was less successful in sustaining zero medication than I would’ve hoped, but I still never stopped trying.

I agree with Robert Whitaker about what happened when Managed Care, PHARMA, academic psychiatry, and the APA got together – it was a perfect storm of the worst kind. Pick any post on this blog to confirm that, though most of mine focus on the corruption involved in the clinical trials and promotion of drug treatments. But I don’t at all agree with his blanket indictment of psychiatry in the plight of our chronic mental patients. Psychiatry was just one of many who ignored them, including the other mental health disciplines, our governments, and our culture. I have nothing but respect for those psychiatrists, psychologists, and social workers who stuck with these patients on the front lines in the face of so little support. But I likewise have little positive to say about the KOLs who pontificated about their care from afar and generated guidelines of questionable scientific validity.

One of my objections to Whitaker’s comments in this debate is his idea that the move to get chronic mental patients out of the prison has a hidden agenda:
    Third, psychiatry’s concern about the imprisonment of the mentally ill is being used by advocates of forced outpatient treatment as a Trojan Horse. The advocates for forced treatment in outpatient settings [such as the Treatment Advocacy Center] argue that forced drug treatment would prevent the mentally ill from ending up in prison, and thus their legislation, which in fact curbs the civil rights of citizens in profound ways, comes cloaked in the rhetorical garb of “humanism.” If we are going to have an honest societal discussion about the shame of imprisoning the “mentally ill,” then it needs to be completely decoupled from that legislative agenda.

    Indeed an argument can be made that the growing imprisonment of the “mentally ill” is yet another example of how our drug-based paradigm of care has failed us. The use of psychiatric medications in our society has exploded over the past 25 years; there is great societal pressure put on people diagnosed with schizophrenia or bipolar disorder to take their medications; and yet we now have this problem of hundreds of thousands of “mentally ill” in prisons and jails.

He has every right in the world to argue with Dr. E. Fuller Torrey’s positions. But his charge is bigger than that. It’s that the efforts of psychiatrists to help chronically psychotic patients or get them out of jail come from hidden, ideologically driven and misdirected motives – tricksters all. As one of his Mad-in-America bloggers said recently:
    "I venture to suggest that most practicing psychiatrists, if pressed, would choose to replace or discard any existing treatment or intervention save one: the power to impose a treatment or intervention."
I suppose that after the misadventures of the last twenty-five years, it would be almost too much to ask for this debate to lead to a consensus, or to step out of what has gone before and come up with a more productive path. I personally find the behavior of the APA and academic psychiatry over these years indefensible, and sure don’t see "the APA as a hapless, sad sack organization — not very powerful, and not at all clever." I wasn’t proud of how anyone acted back then, including the other professional organizations involved. And things have gone from bad to worse along the way. But I find the blanket attribution of malicious motives by Robert Whitaker and those around him unnecessarily divisive generalizations.

Nothing in life prepared me for the complexity of the schizophrenias – the acute psychoses, the chronic forms, the residual or negative symptoms, or even the miraculous recovery seen in some. It took years to get a feel for the many different ways they affect the lives of those afflicted, and there are surprises aplenty – good and bad for even the most experienced clinicians. Looking back over the history of the our various approaches, a clear pattern emerges. Each new reform movement has been built on the failures of what came before and ultimately replaced it – accompanied by great expectations bolstered by small samples of evidence. Over time, the refuges of the Quakers became the asylums of Dorthea Dix became the snake pits of the 1950s. The liberation of de-Institutionalization lead to a lot of desperate homelessness with people living under bridges. Szasz’s Myth of Mental Illness was a factor in inappropriately filling our prisons – just another kind of Institutionalism. The miracle of Thorazine became the cause of Tardive Dyskinesia and Chemical Restraint. I like the current Recovery meme, and the Open Dialog approaches of Northern Finland Whitaker mentions. They are hopeful hypotheses awaiting pilot projects and careful study with an eye to what kind of support is needed to see if they can work in an urban America. And while I am personally an advocate of minimizing the use of antipsychotics, I wasn’t nearly as successful as I wished to be. Medications overused? oh yes. Medications essential? more often than I thought. Likewise, I am a lifelong Civil Libertarian, but have seen many psychotic people who can’t manage with no restraint and end up losing all freedom when they would fare much better with much less restriction.

So as much as I appreciate the observation that the medication for life recommendations are often misguided and support the focus on programs aiming towards recovery, I’m troubled by the messianic feel to Bob’s arguments and more particularly those of many of his followers. They remind me of the naive rhetoric of an earlier age – the age of de-Institutionalization I lived through in times past. I don’t believe there is any simple or universal solution to the societal or personal dilemmas of psychotic illness. We make a little progress, then way overdo things – applying local successes too widely and step all over ourselves in the process. We see the therapeutic zeal of the past as the new evil of the present and start swinging at windmills. And we end up throwing out the babies with the bathwater as if we don’t know how to do anything else. The people with the last great solution and those promoting the next great solution go to war rather than working towards a meeting of the minds or generating test programs that might scientifically resolve differences. So, to be perhaps too candid with my words, I had that oh-shit-here-we-go-again feeling reading this debate between two people I really respect. I want them to do it again without the platitudes or preaching to each other, and include others from both sides of this debate. I want them to visit the jails together and take each other seriously. And I want those who weigh in who aren’t around psychotic people to spend time with as many as they can find. It’s time for a change [and these are two of the people who are going to influence that change], but I’m worried we won’t be careful enough in building a broad-based change that will iterate towards programs that endure and grow – that people will just keep talking past each other. Heroes and villains may be the stuff of psychotic delusions, but they have no place in the formulation of our policies going forward…
Mickey @ 1:00 PM
Filed under: OPINION

Posted on Thursday 4 December 2014

    a·nach·ro·nism  (-nkr-nzm)
    1. The representation of someone as existing or something as happening in other than chronological, proper, or historical order.
    2. One that is out of its proper or chronological order, especially a person or practice that belongs to an earlier time.

    from Latin anachronismus, from Greek anakhronismos a mistake in chronology, from anakhronizein to err in a time reference, from ana- + khronos time]

Perhaps I live in a rarified atmosphere out of touch with the pulse of things, but this strikes me as a relic of days hopefully behind us – something in the range of a double-knit leisure suit with bell-bottoms, or perhaps the Ghost of Christmas Past in a Dickens holiday TV special:
Remission in MDD
CME Outfitters, along with faculty experts Charles B. Nemeroff, MD, PhD, Roger S. McIntyre, MD, FRCPC, and Michael E. Thase, MD welcome registration for the upcoming neuroscienceCME Live and On Demand Program: Remission in MDD: What Does the Future Hold for Clinicians and Patients?
December 04, 2014

CME Outfitters [CMEO], a leading accredited provider in continuing medical education, announces its upcoming neuroscienceCME Live and On Demand activity, Remission in MDD: What Does the Future Hold for Clinicians and Patients? The live program will launch on Wednesday, January 7, 2015 at 12:00pm ET. Faculty experts Charles B. Nemeroff, MD, PhD, Roger S. McIntyre, MD, FRCPC, and Michael E. Thase, MD will lead an interactive one-hour discussion that will challenge clinicians to reinvent the future of major depressive disorder treatment which includes increased patient participation in the treatment process, measurement-based care and a re-definition of treatment to remission as improvement of all symptoms of MDD with functional recovery. Psychiatrists, primary care physicians, nurse practitioners, physician assistants, nurses, pharmacists, social workers, clinical case managers, and other health care professionals who share the goal of achieving remission in patients with MDD are encouraged to register.

“We have a faculty panel that exhibit some of the brightest minds in mental health care today,” said Jan Perez, CCMEP, CME Outfitters Managing Partner, “It has been a pleasure working with these experts, and I think the viewers are going walk away from this program with many new clinical tactics that they can immediately implement into practice to improve the lives of their patients with MDD.”

At the end of this activity, participants should be able to:
  • Evaluate all patients with major depressive disorder [MDD] for residual symptoms with a validated tool at each visit.
  • Initiate a treatment plan that involves patient participation to address residual symptoms of depression.
This program will present a lively and interactive one-hour clinical discussion, following by 30 minutes of Q&A via telephone and/or web. Click here for more information about the faculty, financial support, credit information, disclosures, and to register.
Well, this really is a blast from the past even if it does say reinvent the future in the blurb. It’s given by three KOLs from the heyday of what we might call the Antidepressant Era – a time when we’d forgotten the distinction between Major Depression like that seen in Manic-Depressive Illness and Melancholia and the much more common depressions once called Neurotic Depression. We’d forgotten that depression, even the true Majors, was known to be time limited. We’d forgotten that people get depressed because of their life circumstances and were seeing depression more like an affliction of the physical kind, an entity. It was a time when the notion of treating to remission was all the rave and coming to us from TMAP, the STAR*D study, CO-MED, that series of programs and studies arising from Drs. Rush and Trivedi at UT Southwestern. It was a time when depression not responding to medicine gained a moniker of its own – Treatment Resistant Depression [TRD] and was being attacked with schemes like sequencing, combining, or augmenting to enhance antidepressant effectiveness. It was also a period when these presenters were at the top of their game, with Dr. Nemeroff holding forth at Emory. Our journals were filled with review articles and novel treatments. But those were the days before Senator Grassley had revealed the unreported pharmaceutical income flowing into pockets where it didn’t belong [and Dr. Nemeroff abruptly changed universities]. So it’s hard to believe that there’s anyone who hasn’t heard all of what’s advertised here. It’s been around for such a long time. But that’s not why I posted it. There’s a new wrinkle in the fabric:
  • Evaluate all patients with major depressive disorder [MDD] for residual symptoms with a validated tool at each visit.
Back in what I’m calling the Antidepressant Era, there was a push for automation, short-cuts in following patients. They talked about depression like it was a condition like anemia and that one could follow it with something like the serum hemoglobin. Lacking such a marker, there were any number of tries at inventing a simple surrogate. Dr. Spitzer and colleagues developed a brief scale for measuring depression, the PHQ-9 [Patient Health Questionnaire] based on the then new DSM criteria that was distributed by Pfizer. When the STAR*D came along, there were other of self-rated Depression scales, the IDS [Inventory of Depressive Symptomatology] and the QIDS [Quick Inventory of Depressive Symptomatology]. The QIDS was developed as an automated telephone option. And in the STAR*D reporting, these instruments [clinician administered, self administered, and telephone administered] were mixed in ways I never could quite figure out. Also, that was a time of algorithms for choosing the antidepressants, including computer programs to pick and change the drugs – though the actual NIMH funded study of computer directed treatment never got off the ground – the clinicians wouldn’t use it [IMPACT]. All of this was called Measurement Based Care. It was as if this entity called MDD could be diagnosed and treated automatically with almost no human contact [see a thirty-five million dollar misunderstanding…].

Recently, there’s a new kid on the block – CAT-D. A couple of years ago, Dr. Robert Gibbons, a statistician teamed up with Dr. David Kupfer [in charge of the DSM-5 Revision] and others to introduce a new test – a computerized scale using artificial intelligence technology to produce a depression index by answering only a few questions on the computer, or a smart phone. It was later revealed that this was a future commercial product, already incorporated, that was in line with the notion of a new "Dimensional" axis for diagnosis planned for the DSM-5 – raising questions about the involvement of the company’s principals, all of whom had a place in the DSM-5 Task Force developing such a commercial product without declaring the COI [see open letter to the APA…]. Since apologizing for not noting that this is a commercial product in their journal articles [Failure to Report Financial Disclosure Information], these authors/entrepreneurs haven’t said much about their instrument, obviously targeted towards screening for depression or following treatment.

So when I read about this retro and anachronistic CME from Dr. Nemeroff et al, I understandably wondered if the "validated tool" mentioned was the CAT-D. about to make its debut on the world stage as a way to "Evaluate all patients with major depressive disorder [MDD] for residual symptoms" – its time come round at last. It occurred to me because the "validated tool" is so cryptic, and Dr. Gibbons has been at Dr. Nemeroff’s University of Miami Grand Rounds in the last year or so [and they run in the same circles?]. Just a bit of a paranoid fantasy I’m having. Oh yeah, don’t miss the anachronistic COI statements
Mickey @ 4:33 PM
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