conflicted…

Posted on Wednesday 21 August 2013

From the President
Psychiatry News
by Jeffrey Lieberman, M.D.
August 15, 2013

Medical research often takes a slow and unpredictable pace. The hours spent defining the question, setting up the experiment, and acquiring and then analyzing the data before getting to see the results makes for a long and arduous process. When you then add the time that it takes for new research findings to be translated into clinical practice, the rate of change in health care can be glacial. Psychiatry is certainly no exception to the seemingly snail’s pace of progress in health care. But despite this pervasive pattern, research does periodically gain sufficient momentum to make inroads into clinical practice and move the field forward, as was the case with the introduction of antipsychotic and antidepressant drugs, lithium, community mental health, the development of time-limited forms of psychotherapy [for example, cognitive-behavioral therapy, interpersonal therapy, and dialectical behavior treatment] and cognitive remediation.

I believe that we are at another game-changing moment in psychiatry with the rise of the early detection and intervention strategy [EDIS]. This new therapeutic strategy and model of care could have a significant effect on our ability to treat and limit the morbidity of mental illness beginning with schizophrenia and related psychotic disorders. While schizophrenia has been historically associated with a therapeutic nihilism due to its devastating and often irreversible consequences, research over the last two decades has changed attitudes and inspired optimism. Studies show that the earlier patients are diagnosed and treated, the better their responses to treatment. This leads to improved outcomes and higher chances of full recovery. The corollary to this is continued engagement of patients in treatment following their recovery and relapse prevention.

Among the reasons for this are findings from neuroimaging studies showing that the hallmark clinical deterioration of schizophrenia is associated with cortical gray matter atrophy, reflecting the loss of cell processes and synaptic connections. Unlike Alzheimer’s disease though, for which there currently is no “disease-modifying” treatment, early intervention and relapse prevention methods for schizophrenia coupled with antipsychotic medication may prevent illness progression. Moreover, additional research and first-person reports indicate that resilience, coping skills, and peer and family support can substantially contribute to favorable outcomes and recovery. Collectively, these findings have suggested the value of early detection, intervention, and sustained engagement with treatment to enhance recovery and prevent disability… Many individuals in the earliest stages of psychosis do not have health insurance, and even if they do, their plans do not cover comprehensive psychosocial and rehabilitative services. And while the public mental health system is designed to serve individuals without health George W. Bush, Yale Cheerleaderinsurance and to provide services not covered by insurance, the system favors individuals who have already become disabled by mental illness, limiting the availability of services for patients in the early stages of psychotic disorders. However, there are signs that state governments are beginning to grasp the implications of this new care model and implement it…

This model of care requires financing schemes that will support sustained patient engagement and community functioning and that extend across adolescence to adulthood. More than a century after Kraepelin initially defined schizophrenia as a progressive illness leading to clinical deterioration and 60 years since the introduction of antipsychotic drugs, psychiatry has within its grasp the potential to limit the morbidity and disability associated with this disorder. EDIS could be the next great advance in psychiatric medicine and mental health care.
I did my editorializing about Dr. Lieberman with my graphics. Actually, ever since a Medscape presentation he made a couple of years ago when it became apparent that the DSM-5 grand plan to include biological markers had gone belly up [psychiatry inc…], I’ve thought of him as a spin-meister, something like a cheer-leader. He started his tenure as APA President in May with "Seize the Moment!" [carpe diem…]. Now we have, "The Time is Now!" In between, we’ve been told psychiatrists have nothing to be defensive about and that now would be a good time to reengage with PHARMA [gulp!]. So when I read this, I thought it was just more of the same – more something from a motivational speaker than a leader. Then I tried to figure out how what he’s saying here is any different from the Community Mental Health Movement rhetoric of the 1960’s and 1970’s – the years of my early training. Or how it was any different from some of Dr. McGorry’s programs in Australia [the story continues…]. I decided it isn’t any different. If it was a good idea 50 years ago, or in modern Australia – intensive focus and services for early psychosis – it seems like a good idea now. I think I’ve always thought it didn’t fly back in my youth because no one wanted to fund it. In Australia, McGorry’s program has been funded [amid controversy because it bled money from other programs]. Lieberman dolls up his version with his usual neuroimaging speculations and implies that early intensive intervention might prevent cortical thinning [I’ll believe that when shown by a rigorous neuroscientist – not a fund-raising cheer-leader]. But this isn’t just his usual toast-master talk. He’s serious. This article in is almost identical to one he has in the new JAMA, Early Detection and Intervention in Schizophrenia, A New Therapeutic Model, published as a Viewpoint piece. He’s going for a funded enterprise, similar to Dr. McGorry’s program down under.

Reading this is nothing but conflict for me. Having seen a career’s worth of young adults who had psychotic illnesses, I’ve always felt that if the resources were really around, we could have a lot better outcomes just knowing what we already know. While some recover and are able to move on, way too many get lost in the illness and deteriorate in ways not dissimilar to the time of Kraepelin and Bleuler a century ago. I worry that any such program devised by Dr. Lieberman et al would ignore the wisdom of Robert Whitaker and his colleagues that medications are for episodes, not for life. I worry that the buzz-word "evidence-based" therapies [CBT, DBT] will over-ride common sense in helping these patients find their way; that eagerness to get a piece of the Affordable Healthcare Act will interfere with the kind of careful thought needed for such an undertaking. In ancient times [my early days in psychiatry], I don’t really think funding was the only reason for failure. Some of it was the hidden agendas ["empty those expensive hospitals"]["get these people on meds"]. Some was naïveté – assuming the patients wanted to "get well" in the way the programs wanted them to; not really understanding the dilemmas and paradoxes of the illness itself; and using rehab models from other situations that don’t really fit.

I think my view of this illness must be idiosyncratic. As disruptive and dramatic as ouvert psychosis can be, I don’t really see psychosis as the essential feature. In fact, one can make a pretty good case that psychosis is a solution rather than the problem itself. I tried to talk about this before [1. from n equals one, 2. from n equals one, 3. from n equals one] and won’t repeat it all here except to say it’s what biological psychiatrists call "negative symptoms" and others call Anhedonia. It’s a relative deficit in using emotions as a compass and a cognitive problem with abstract thought – intuition. My thought is that the task is to help the patient find an individual adaptation to these more basic problems that fits them. In medicine, we talk about "following the patients." With these patients, "following" is essential, "following" until they find a life that works for them, then helping them get it. I hate to be so vague, but it at least lets me say what I want to say about Dr. Liebermans’ articles and plan. It sounds like he wants to lead them out of the wilderness. Leading patients with this illness is like "herding cats." And I’ve never known where a given patient is headed without "following." They don’t know either. But if you stick with them and help them stay out of trouble, using medications when you have to, stopping the meds when you can, many can find a way with help to live with the more basic problems the illness presents – rather than becoming a "chronic patient."

We badly need to give them our fullest attention rather than waiting for future drugs to treat "negative symptoms" [I doubt they will come, at least come without knowing a lot more whys than we know now]. On the other hand, I worry that we’ll be off and running with some fancy-dancy cheer-led program that just peters out like it did before. I told you I’m conflicted…
  1.  
    August 21, 2013 | 3:38 PM
     

    Mickey, what do you think about the model used in Portland, Maine, which is now being adopted elsewhere in the US? I’ve previously blogged about it here.

  2.  
    August 21, 2013 | 5:40 PM
     

    Hear the lie enough and it becomes truth.

    Part of the APA play book, in my opinion.

  3.  
    TinCanRobot
    August 21, 2013 | 6:19 PM
     

    Psycritic, I noticed the statment in the ‘Portland, Maine’ link, “Severe mental illness is the fifth-leading cause of disability and premature mortality among all medical disorders.”

    I decided to check that, the best i could find from the US Census Bureau was >17 million people disabled from neurological/psychiatric illness.
    http://www.census.gov/newsroom/releases/archives/facts_for_features_special_editions/cb10-ff13.html

    According to the NIMH, 6% of the population has ‘severe mental illness’ and is disabled, while 1/4 of the adult population has a diagnosable ‘mental disorder’.
    http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml

    Shocking that ~15 million people are disabled from ‘severe mental illness”… (or maybe the treatments cause disability?)

    —-

    I remember years ago i read an article about how the discovery and treatment of neurosyphilis took about 1/3rd of psychiatric patients from psychiatry. I’m not sure if the number was accurate, since there was not, and still is no, psychiatric patient reporting system in existence.

    I used to wonder “why psychiatry is still expanding” when medicine kept advancing and each time discovering ‘psychosis’ or other symptoms were actually caused by a medical condition that caused the nervous system to dysfuction.

    ‘Early intervention’ just seems like a way to streamline diangosis and treatment at a time of high controversy, increasing prescriptions. I hope i’m not, but maybe i’m just cynical.

  4.  
    jamzo
    August 21, 2013 | 7:19 PM
     

    FYI

    August 20, 2013 | 3:54 PM | Carrie Tian

    Helping Primary Care Treat Minds As Well As Bodies

    Sometimes, medical doctors view their patients only from the neck down.

    But that is unwise: Over 70% of primary care visits today are related to psychosocial issues – things like anxiety or depression manifesting themselves as chronic pain, stomach aches or heart palpitations.

    And, according to Dr. Russell Phillips, director of the Center for Primary Care at Harvard Medical Center, these underlying problems create all sorts of complications. “Mental health conditions complicate the treatment of everything else,” he said. “If someone has diabetes and depression, symptoms of their depression may make it harder for them to manage their diabetes.”

    Of course, the problem is exacerbated by patients not even being aware that they have any underlying conditions. Doctors have to try to solve problems that “patients can’t even name,” said Phillips. He gave a quick assessment of the system today: overworked primary care physicians struggle to treat conditions in limited time and often with limited resources.

    Phillips envisions a system for addressing all of these issues that would begin with mental health: More extensive mental health screening would allow doctors to detect conditions, even if patients don’t come in and complain about that condition specifically. In this ideal scenario, the doctor would connect the patient to social workers for counseling and continue monitoring how the patient was doing, proactively scheduling followup appointments and reevaluating treatment plans. “It changes the trajectory of care, with more on-going monitoring, more screening, and better treatment that makes sure patients are responding well and adjusting appropriately if they’re not.”

    But how would such a transition be possible? On Monday, Harvard Medical School’s Center for Primary Care announced an initiative that could be a roadmap for getting from here to there. According to Dr. Phillips, the initiative, which starts with six hospitals in the Greater Boston Area, would place mental health resources like social workers right within primary care practices. It would establish a network of specialized mental health workers like psychiatrists and psychopharmacologists, giving physicians better access. And through ongoing conferences and conversation, doctors would learn how to use the new resources and expand coverage to the rest of the nation.

    The initiative is funded by a two-year grant, though its organizers foresee it actually saving money in the future as it reduces hospitalizations and other costly measures.

    Dr. Phillips estimated that changes could take effect as early as January 2014. That’s particularly timely, as states across the country are figuring out the details of implementing the Affordable Care Act, and 30 million more Americans will be covered, swamping primary care physicians nationwide. Though Massachusetts is well ahead of the curve, Dr. Phillips sees the ACA going into effect as another chance for the state to model what it’s learned and share its best practices

    http://commonhealth.wbur.org/2013/08/primary-care-initiative

  5.  
    August 21, 2013 | 9:08 PM
     

    Psycritic,

    Re your post: Preventing Transition to Schizophrenia: What Doesn’t Work, What Might

    Their program looks well thought through. Good resources and enough flexibility to allow clinicians to “follow” their cases. I wasn’t being facetious with my “herding cats” comment above. We may think of them as having a unitary illness, but there’s nothing uniform about them as people except that they don’t react like pegs going into holes – the hole needs to be tailored to the peg. I once ran a crisis service that had an outreach team that was amazingly effective because the members were able to shoot from the hip creatively when problems arose. They we all “naturals.” I don’t think I ever knew their individual credentials, or even if they had any. All I knew was that they had what the patients needed – a “feel” for schizophrenic life…

  6.  
    August 21, 2013 | 9:29 PM
     

    TinCanRobot,

    I’m of a mixed mind about Lieberman from an ethical point of view. He has moved in the circles of the big offenders, defending Nemeroff by signing a letter to the WSJ. He’s had grant support from PHARMA and urges us to “re-engage.” He was part of PHARMA’s CAFE study that tried to challenge his own NIMH CATIE study. So he’s played close to the fire, but hasn’t been burned. In the JAMA version of this report [behind a paywall], he does do the public health justification thing, but it appears to be accurate:

    Schizophrenia is a brain disorder with lifetime prevalence near 1%. This disorder is clinically manifested by psychotic, negative, and cognitive symptoms that typically emerge in adolescence and early adulthood (peak age for males, 20 years; for females, 25 years) and follows a course characterized by recurrent exacerbations and remissions, resulting in a chronic state of residual symptoms and functional impairment. The annual cost of schizophrenia in the United States is approximately 60 billion dollars, including direct medical costs, non–health care costs, and lost productivity. This is because individuals become ill early in life and have high rates of unemployment and psychiatric and medical comorbidities.

    I doubt that he’s trolling for patients or allied with PHARMA with this proposal, but he’s going to face that accusation. He’s going after Federal and State money, but I agree that these are programs they ought to fund. I like the spirit of his proposal but I’m really concerned that he’s too deep into the bio-bio-bio set to bring off an effective program that gives these patients what they need. They may have a “brain disorder” as he says in the first line, but until he comes up with proof of that and a definitive treatment, this is primarily a psycho-social approach [as it should be]. He’s just not a psycho·social kind of guy. So, I’m conflicted…

  7.  
    wiley
    August 21, 2013 | 10:28 PM
     

    I don’t know, jamzo.

    “Over 70% of primary care visits today are related to psychosocial issues – things like anxiety or depression manifesting themselves as chronic pain, stomach aches or heart palpitations.”

    How have they come up with this number? Does anything that a doctor doesn’t identify in a particular visit get tossed into the “psychosocial” pile? It appears that this system is being streamlined to identify stress, aggravation, grief, and fear as “anxiety” and “depression.”

    It seems that doctors who are aware of their own burnout from being overworked with too little resources should be able to step back and ask themselves, “So how does someone working three jobs for minimum wage in which they are expected to work whenever a manager calls them and tells them they need to come in— how does this person who is raising two small children and taking care of an aging parent, rarely gets enough sleep, doesn’t have anyone helping them around the house and with the kids, who struggles with every decision about spending because there is never enough, and the rent is going up, and the electric bill for their drafty house was nearly $200 and the house was still pretty hot, and the washing machine needs repair, and is having car trouble… — how do they feel?” Might anxiety, fear, and exhaustion be perfectly understandable and not evidence of a mental illness?

    Are the social workers there to actually assist anyone with the stress of handling stress?

    Who benefits from labeling distress as “mental illness?” Surely there are people who will struggle with lifelong mental illness. There are enough, in fact, that the drive to identify more and finer grades of “mental illness” is suspect.

  8.  
    August 21, 2013 | 11:23 PM
     

    Wiley,

    As an Internist seeing only referred patients [while in the Air Force] I actually kept up with the stats. 75% of the patients I saw had symptoms that had to do with stress, not medical problems. It wasn’t a tossing into a psychosocial pile thing – it was real. But I hasten to add that I agree with your point that it was largely “life stress,” not mental illness. In that period. I wasn’t pressed, so I had time galore. I found that identifying that they were stress related symptoms was helpful to the patients. I had no idea how to go further than that, but frankly, that was plenty enough in a lot of cases. It was the ones where it wasn’t enough that intrigued me and that’s the beginning of why I changed specialties.

    I also agree that the label “mental illness” was neither needed nor did I use it [“mental illness” is a loaded term” in the military]. If it meant “hurts in the mental,” that would be fine – but it doesn’t. I can hurt in my mental like anyone else, and need some help figuring out why sometimes, just like most of us – but don’t have a disease [unless it means “dis” “ease” as in “not feeling easy”]. So I agree that the labels are no good for life stresses. But the systems say you have to have a mental illness to get reimbursed treatment, which then becomes a blot and makes further insurability difficult. That’s a crazy system, one that I really hope that health care reform “reforms.”

    Your general point speaks to a central problem, one that doesn’t come up in the other western social democracies with “socialized” medicine. Another point – many argue that physicians should be out of the loop with problems of living and stress related issues. The problem with that is, as I said above, that’s where people go with stress related symptoms because they don’t know that’s what they have, so it gets complicated. But we can sure do a lot better job with this than we’re doing now – that part is guaranteed.

  9.  
    TinCanRobot
    August 22, 2013 | 1:05 AM
     

    Mickey,

    Actually, is it accurate? The NIMH has a 1.1% figure.. and the words “Not reported” over and over for anything at all more detailed.
    http://www.nimh.nih.gov/statistics/1schiz.shtml
    (no citiation is given on this page, or any linked page)

    According to the CDC, it’s 0.5%-1%.
    http://www.cdc.gov/mentalhealth/basics/burden.htm
    (That reference goes to an ‘introduction to psychiatry’ book, published in 2004, but no study.)

    I understand your view, and kinda where you’re coming from. I have never worked with or around unmedicated patients, but I can see why you would possibly want to see it funded.

    I’m just blinded math, all i see is 1% of the population is 3 million people, if only 1/3rd went on to develop Schizophrenia, it opens the door for 9 million potential customers to be ‘preemptively’ drugged. That’s 2% of the population.

    Personally I just see it as a prequsiset to creating premptive treatments for all ‘Mental Disorders’, and lying about the risk to benefits. Should the medications make some of the patients sick, they are labled with ‘mental illness” and drugged forever.

    Schizophr Bull. 1997;23(4):653-61.
    “The evaluation and treatment of first-episode psychosis.”
    http://www.ncbi.nlm.nih.gov/pubmed/16774655
    Sheitman BB, Lee H, Strous R, *Lieberman JA.
    [Free Full paper Available]

    “patients appear to respond to pharmacological treatment
    (Lieberman et al. 1996), even though 10 to 20 percent of
    patients may be resistant to conventional antipsychotic
    medication at the time of first treatment”

    Anyway, that was my take on it. It’s always for pharma.

  10.  
    wiley
    August 22, 2013 | 10:03 AM
     

    Thanks for the response, Mickey.

  11.  
    August 22, 2013 | 3:57 PM
     

    I recently had to make a series of emergency room visits for demonstrably medical problems and in every instance the attending also suggested my symptoms were caused by a mental or emotional problem.

    I very emphatically told them they were not. (To their credit, they all accepted this and dropped the line of inquiry.)

    Patients will have to practice defensive medicine to prevent their doctors from taking shortcuts into half-baked psychiatric diagnoses and the inevitably arbitrary prescription of a prescription drug.

  12.  
    jamzo
    August 23, 2013 | 11:07 AM
     

    there are many reports of success in community programs which address failings in treatment for early incidents of psychosis

    i suspect the research program described here is an aspect of the current biomedical strategy – personalized medicine/predictive medicine… in this case the incident of psychosis (labeled as early) is interpreted as a predictive marker in lieu of a genetic marker…

    Personalized medicine

    http://en.wikipedia.org/wiki/Personalized_medicine

    “Personalized medicine or PM is a medical model that proposes the customization of healthcare – with medical decisions, practices, and/or products being tailored to the individual patient. The use of genetic information has played a major role in certain aspects of personalized medicine, and the term was even first coined in the context of genetics (though it has since broadened to encompass all sorts of personalization measures). ”

    “Traditional clinical diagnosis and management focuses on the individual patient’s clinical signs and symptoms, medical and family history, and data from laboratory and imaging evaluation to diagnose and treat illnesses. This is often a reactive approach to treatment, i.e., treatment/medication starts after the signs and symptoms appear.

    Advances in medical genetics and human genetics have enabled a more detailed understanding of the impact of genetics in disease. Large collaborative research projects (for example, the Human genome project) have laid the groundwork for the understanding of the roles of genes in normal human development and physiology, revealed single nucleotide polymorphisms (SNPs) that account for some of the genetic variability between individuals, and made possible the use of genome-wide association studies (GWAS) to examine genetic variation and risk for many common diseases.

    Historically, the pharmaceutical industry has developed medications based on empiric observations and more recently, known disease mechanisms.[citation needed] For example, antibiotics were based on the observation that microbes produce substances that inhibit other species. Agents that lower blood pressure have typically been designed to act on certain pathways involved in hypertension (such as renal salt and water absorption, vascular contractility, and cardiac output). Medications for high cholesterol target the absorption, metabolism, and generation of cholesterol. Treatments for diabetes are aimed at improving insulin release from the pancreas and sensitivity of the muscle and fat tissues to insulin action. Thus, medications are developed based on mechanisms of disease that have been extensively studied over the past century. It is hoped that recent advancements in the genetic etiologies of common diseases will improve pharmaceutical development.”

    http://en.wikipedia.org/wiki/Predictive_medicine

    Predictive medicine

    “Predictive medicine is a field of medicine that entails predicting the probability of disease and instituting preventive measures in order to either prevent the disease altogether or significantly decrease its impact upon the patient (such as by preventing mortality or limiting morbidity).[1] While different prediction methodologies exist, such as genomics, proteomics, and cytomics, the most fundamental way to predict future disease is based on genetics.”

  13.  
    August 23, 2013 | 11:37 AM
     

    It takes a bunch of endocrinologists to show concern about the adverse effects of antipsychotics on children:

    http://www.medpagetoday.com/Endocrinology/Diabetes/41126?xid=nl_mpt_DHE_2013-08-23

    Antipsychotics Raise Risk of Diabetes in Kids

    Antipsychotic medications were linked to type 2 diabetes in children and young adults, particularly with longer use at higher doses, a Medicaid study showed.

    Diabetes risk was elevated 3.03-fold overall after going on antipsychotic drugs, with hazard ratios rising from 2.13 to 5.43 at progressively higher cumulative doses, Wayne A. Ray, PhD, of Vanderbilt University in Nashville, Tenn., and colleagues found.

    The number needed to harm was 633, for an estimated 15.8 additional cases of type 2 diabetes per person-year of antipsychotic exposure, the researchers reported online in JAMA Psychiatry.

    “However, this number should be applied cautiously in clinical practice because the baseline risk for a child or youth will vary substantially according to age and body mass index,” they wrote.
    ….

  14.  
    August 24, 2013 | 11:38 AM
     

    Everyone should look at this woman’s video http://beyondmeds.com/2013/08/24/lauren-spiro/ regarding “early detection.”

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