three wishes…

Posted on Thursday 17 April 2014

It’s been over a hundred years since Freud suggested that our wishes can color the workings of what he called the mental apparatus. Think what you will about the old guy, but he was onto something with that wish thing. Here are three personal examples:

  1. In my last post [reason enough…], I interpreted the theme of this year’s APA meeting [Changing the Practice and  Perception of Psychiatry] as some recognition that psychiatry’s reputation is in the tank. But, alas, Psycritic gently informed me that I’d missed the boat:
      I don’t want to a total downer, but when the APA says “changing the practice and perception of psychiatry,” with the “practice” part they are referring to increasing use of evidenced-based treatments and integrated care, and the “perception” part is wanting the public, other doctors, and med students to see psychiatrists as “real doctors” and scientists. Alas, it has nothing to do with the the reasons for change that most of us reading this website believe are important.
    Alas indeed! I could perhaps blame the pollen count, but that’s not the only time that my wishes have overwhelmed my rational thinking recently. To wit:
  2. In early March [before the Spring pollen came], the APA published a preliminary schedule for this year’s meeting. Looking through it, I ran across this:
    That was about a month after Dr. Kupfer’s Conflict of Interest with this company became clear. I thought maybe this had been put together before and they might need alerting, so I wrote the program chairs:
      Drs. Muskin and Carter,
      I’m a retired Psychiatrist and Psychoanalyst who blogs as 1boringoldman. Looking over the preliminary APA Annual Meeting Program, I ran across this:
      [above graphic]
      The presenters are shareholders in a commercial venture [Adaptive Testing Technologies] marketing these very CAT tests. The details are well documented:
      Is it really appropriate for them to be presenting their products in an educational forum like this? Did they declare this obvious Conflict of Interest to your program committee? Don’t we have enough Conflict of Interest problems already?
    And was answered the same day:
      All presenters disclosed.
      Thank you for your message, I will consider the matter closed.
      Philip R. Muskin,MD
    And sure enough, when the definitive program was published, the disclosures [and symposium] were there:

    [reformatted to fit screen]

    [reformatted to fit screen]

    So it’s listed as NIMH Research [Gibbons grant to develop his tests]. It’s disclosed as a coming commercial product. But at the APA convention, it’s a session. How that’s anything but a huge conflict of interest and using the APA meeting to roll out a new commercial product disguised as an educational symposium is beyond my understanding. But back to the wish it was a clerical error – no cigar there.
  3. The third wish interfering with my judgement should be obvious. I apparently still wish the APA would stand up and firmly acknowledge the problems and make some kind of ethical stand about COI, or just about anything else. So I keep acting as if that’s possible. But I’m afraid that’s the most irrational wish of all. They’re not going to do that. They didn’t do it through the DSM-5 process, or at the time of the Grassley investigations, or any time since or in-between. And my continued attempts to view the American Psychiatric Association as anything but a big part of the problem is going to have to accede to Freud’s Reality Principle – and fade away.
I guess Psycritic‘s right, the APA plans to barrel ahead with "increasing use of evidenced-based treatments and integrated care" and to get "other doctors … to see psychiatrists as ‘real doctors’.” It’s hard for me to see how moving ahead without addressing the tsunami of the academic·pharmaceutical fusion and its attendant conflicts of interest and scientific misbehavior is going to achieve those goals. But what I do see is that my wish for some kind of coming clean and reappraisal emanating from the APA is a just fanciful dream I had…
    April 17, 2014 | 10:09 AM

    I don’t thin the APA’s initiative on collaborative care has anything to do with getting other doctors to see psychiatrists as real doctors. Psychiatrists who practice like real doctors are seen as real doctors without PR fluff form the APA. The emphasis on collaborative care by the APA is a function of their political ineffectiveness in supporting the current practice environment and it is also the way oligarchies function. Once managed care friendly contingents get a hold inside of the organization and “cost effectiveness” and “evidence-based” become buzzwords the resulting corporate approach is predictable. If Ioannidis has taught anything – it should be that anyone can come up with the evidence they want and there is ample evidence for that.

    April 17, 2014 | 11:18 AM

    don’t worry dr mickey, this is a tidal wave they won’t be able to avoid.

    the longer corporate america sits there with it’s fingers in its ears, the worse it will get. we all know the truth now: there’s been a huge pill-filled orgy in the US, where taxpayer dollars were used to cover this exquisite mix of binging on pills and sex.

    corporate america is going to lose both its equity and cash because frankly: it wasn’t theirs in the first place.

    April 17, 2014 | 3:53 PM

    Just finished reading “Making a Killing” from Mother Jones, and was curious about “Taylorism“. What I read in Elliot’s article reminded me of an investigative article in Harper’s magazine in the eighties. Police departments all over the country were seizing the property of drug dealers and users and selling it to make money for their departments. The accused didn’t have to be convicted before their property was taken either. There were even a few departments heads, who, when asked why they didn’t have a budget at all, were instructed to seize one. So, of course, there was an existential pressure to make a priority of making drug busts. Seizing and selling property was a hidden tax paid by a select group of people in a culture that wanted the police to be tough on crime, but didn’t want to pay for it.

    This, and the fact that there is no case law holding studies to reasonable standards to protect test subjects, and the fact that a for-profit board with the mission to protect test subjects was satisfied with a plan to protect test subjects created an atmosphere ripe for tragedy. It isn’t far-fetched to ask why more people didn’t commit suicide. There was an “alleged” homicide. Why on earth would any study of mind and mood altering drugs not exclude a person who is homicidal? Especially when that study took place in a half-way house? Putting Dan Markingson in that study was crazy. Yes— crazy.

    It’s a very sad fact that a lot of leaders in university departments take part in this because it’s the only way or a too easy way to get the funding that the University bureaucrats require them to get in a culture that is increasingly business oriented to the degree that it considers students to be “consumers”.

    I don’t think not killing Don Markingson would have taken heroic effort, but was a natural result of the way these trials are funded and organized. The fact that a social worker was following-up and assessing the mental states of the test subjects in the CAFE study is a result of Taylorism— she was paid less, the cost/benefit business model of the study required as little money as possible be paid in wages. A social worker makes much less than a psychiatrist. It also appears that wedding planners could get paid to organize these studies— no medical experience necessary. The subcontracting also has a tendency to make responsibility more diffuse and avoidable than it should have any right to be.

    So, who is responsible for making laws to protect test subjects, and— just out of curiosity— what did Olsen actually do for this study he put his name on, besides take the money, make money for the university, and recruit patients among the pool of patients he had custodial powers over?

    April 17, 2014 | 3:55 PM

    I consider it a positive sign that a budget number-cruncher replaced politician Kathleen Sebelius as Secretary of US Health and Human Services. Do you think she might look at excessive healthcare expenditures? You bet. The Medicaid findings of excessive antipsychotic prescribing for children and adolescents were only an initial salvo.

    Pharmaceutical spending is in the crosshairs of Medicare and Medicaid spending analysis, as are excessive payments to individual doctors. As Obamacare gets going, statistics for spending are going to roll up to the federal level, too, though this will take years.

    That is why official prescribing guidelines for psychiatric drugs are more conservative in Europe, where they’ve had national healthcare for many years — although from what I see physicians are largely ignorant of those guidelines and are just as promiscuous in their prescribing.

    April 17, 2014 | 6:16 PM

    I was thinking that, too, Altostrata, and also think that this is a good time for health care professionals to organize and lobby to make much needed changes in health care protocols and take down a couple of sacred cows that are golden calves.

    Though I am happy as a clam about the ACA, and take comfort in knowing that the best friend and life partner I’ve ever had does not, along with millions of others, have to die for a lack of health insurance ; I can’t help but wondering how many more people are likely to die from iatrogenic causes now.

    Although I probably don’t even want to hear most of what Senator Grassley thinks about most issues, I’m eternally grateful for his efforts to reign in pharmaceutical companies and trust that his actions will save many lives. Also, this administration has been busting Medicare and MEDICAID fraud like never before and restoring billions to our treasury, and I’d like to see that continue.

    Holder is also making a priority of violent crime and white collar crime. Most of the medicare/MEDICAID fraud is being carried out by professionals in the health care field, while it’s being portrayed as primarily the work of strippers who fake back injuries in mainstream media.

    April 17, 2014 | 9:14 PM

    Regarding the APA’s push for “integrative care” and more specifically about having psychiatrists embedded in internal medicine/primary care practices as the Brave New World. I was chewing the fat with my suite partner in my private practice, who is an excellent psychiatrist doing mainly medication management and consultation for psychologists and social workers. He’s a good guy with 35+ years of experience. After discussing Kupfer’s COI issues and the use of “computerized adaptive testing” for depression and anxiety, he shrugged and offered: “It won’t go anywhere. The Internal Medicine docs hate us” (meaning psychiatrists). I laughed. APA at work for you! Not!

    April 18, 2014 | 12:21 AM

    Just saw this article by Jeffrey Lieberman today on integrated care. Some real gems in there, including this:

    There is a historic and exciting opportunity for psychiatrists to influence the future of medical care and occupy our rightful position in the field of medicine.

    “Occupy our rightful position.” Doesn’t that smack of insecurity and wanting a more “medical” identity for our profession? What do you think, Dr. Dawson?

    April 18, 2014 | 7:56 AM

    Why do internal medicine doctors hate psychiatrists?

    Also, I thought the integration push was largely towards the primary care setting? I can see where this may not go over well because of the competition I have seen between PCPs and specialists. However, are PCPs able to be convinced it is a good thing because it would relieve their burden of having to deal with patients with unexplained medical symptoms, and for those with identifiable medical conditions, better outcomes on whatever scales PCPs are going be rated on for their job performance?


    I appreciate your insights into this. One question did come to mind about what you brought up.

    Do you think those in power at the APA are insecure about the profession’s medical identity or are they just playing on the insecurities of their membership to sell them on something?

    April 18, 2014 | 1:09 PM

    Why even show interest in whatever the APA has to say? It keeps them in the loop to even mention them as an alleged valid resource of opinion and influence.

    Find out who are members and once these APA acolytes explain how they are concerned, invested, caring physicians and yet belong to a corrupt and immoral organization, ask these people how they maintain such an incongruent relationship. It may surprise you to find out what other possible inconsistencies exist in these physicians as well.

    If you want to marginalize a person or group, it is sad to offer it but ostracizing is an option. Forget using shame and humility as mature defense options with a bunch of old, rigid, inflexible power hungry men who want to rule and dictate policy, not care and encourage dialogue for further intervention opportunities.

    Sheesh, I long for the day to read a reliable resource say “the APA is an irrelevant resource for psychiatric reference”.

    Won’t happen as long as these “caring and committed colleagues” maintain membership. And spare me the counter argument by the naive and terminally optimistic that change can only come from within the organization.

    I’ve heard that line for over 15 years now from these invested colleagues, yeah, when is that change for the better coming???

    April 18, 2014 | 3:02 PM

    Arby, I don’t think internists hate psychiatrists. I’ve tried to post a somewhat nuanced view of integrated care on my blog, which hopefully addresses your question to me.

    James O'Brien, M.D.
    April 19, 2014 | 2:05 AM

    I see Lieberman is still giving that same speech about stigma that Paul Fink gave in 1980. But it’s not psychiatric patients who are stigmatized (Tony Soprano effectively killed that once and for all), but rather psychiatrists. The reveal is in his desire for a hypothetical model of care where psychiatrists are valued by other professionals. Never mind that it actually marginalizes the profession even further.

    The problem is, we deserve it. DSM-5 is considered a pseudoscientific joke in the world of empirical medicine. Had we just stuck to the 15 or so solid diagnoses that the St. Louis group suggested circa 1970 instead of making every problem in life a mental disorder, other doctors and insurance companies would take us seriously. Adjustment Disorders are NOT diseases just like pancreatic cancer or neuroblastoma and insisting on parity of soft diagnoses makes us look foolish and greedy.

    The fact that any psychiatrist is foolish enough to embrace collaborative care actually justifies the stigma of psychiatrists being wordy but not worldly. What other profession is naive enough to give up its core skill set? Talking to people is what we do…and we want throw that away to take on more malpractice risk? I’d say there is a collective combination of self-defeating personality disorder and Stockholm Syndrome affecting organized psychiatry.

    April 19, 2014 | 3:21 AM

    Talking to people is what ya’ll used to Dr. O’Brien. The last time I “talked” with a psychiatrist, I considered it progress that he got up and walked away. He appeared to be learning that he was wasting our time.

    There was a time, long ago, when working with psychiatrists could be a powerful and empowering experience— it was challenging and rewarding and could help a person change in deep and meaningful ways. And it wasn’t
    difficult to find somebody who could help in some significant ways, at least and help to fortify a healthier and more fair of thinking about oneself and others.

    Stockholm Syndrome? Who isn’t being held captive by biological reductionism in psychiatry? It’s now “common wisdom” that the chemical imbalance “theory” is a law of science and all those problems are now solved with medication. The stigma is gone too, and you can tell, because when people think you’re broken and can’t control your behavior without psychoactive medication, then they trust you m—


    James O'Brien, M.D.
    April 19, 2014 | 1:40 PM

    All good points, Wiley.

    Can you imagine if the president of the American Assn. of Clinical Oncology or the Cardiology Assn. said the equivalent of what Lieberman said about collaborative care? That their new role was going to be consulting with primary care doctors but letting the primaries do the procedures? They’d be proverbially tarred and feathered by their membership. Maybe it’s beyond Stockholm Syndrome, the APA leadership are acting like battered spouses. Let me tell you a stigma that psychiatrists better lose in a hurry…being Niles Crane beta males and easy marks.

    Their was a time, not to long ago, where the oral examination on the boards was considered ESSENTIAL, because psychiatrists were expected to know how to interview and relate to a patient. And the same people who are now discarding that skill at one time feverishly embraced the old model. Disgraceful.

    April 19, 2014 | 5:45 PM

    Didn’t primary care physicians,and some specialists, already take on mental health care of the working and the exceedingly tapped out middle classes by default?

    With about 70% of Americans living paycheck to paycheck, there isn’t a lot of time or money for therapy. Some of this is a matter of priories, since there is usually time to go out and have a beer with friends. Although shouldn’t that be just part of life. However, when things get really rough while you have to remain functional, going to your PCP for a medication appears to be a practical, if sometimes desperate, choice. Of course, I am referring to the patients formerly-known-as-neurotic* and not the severely or chronically mentally impacted patients above. I figure that prison is fast becoming their de facto destination of very little care.

    So, where do psychiatrists think the optimal care that can be practically delivered for either population best resides?

    *That is an awesome expression of yours, Dr. Nardo. Neurosis was already gone when I studied psychology, but I think the concept was archived way too soon.

    April 19, 2014 | 8:10 PM

    Arby, I remember seeing an article before the biological hypothesis (dream?) became the reigning paradigm, that said that most people who visited psychiatrists were satisfied after one to two visits. They merely needed an objective third party who was required by law to keep their confidence, to bounce things off of and to make their thoughts manifest and obvious in a way that speaking them to someone generally does.

    With the bio-paradigm and Market Based Medicine that expresses itself even in our culture’s fiction, the whole idea that we can change our thoughts and way of thinking has become immaterial and helplessness in the face of biology that can only be rectified with bioengineering mental states with chemicals is the answer now. What can anyone do? It’s science. We must lie helplessly prostrate in the face of science and invest ourselves in it’s solutions. Believe, or be a technology hating Luddite and flat-earther.

    The focus on expanding mood disorders is a guaranteed money maker in a society suffering from mass phenomena like the biggest financial collapse in the history of money, and an ever widening gap between the rich and poor that requires the average person to go into hundreds of thousands of dollars in debt just for a chance to get into the middle class; and even then, one is still a very replaceable cog in a machine that prides itself on its ability to cut costs by screwing employees.

    Pardon the vernacular. A lot of people on the DSM-5 committees wanted to create a new diagnosis concerning “excessive bitterness”. Many of them had noticed that a lot of their clients were “excessively bitter.” Imagine that.

    As far as neurosis and psychiatry, at this point, I’d say that they have an adjustment disorder and are “avoidant”.

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