other comments…

Posted on Saturday 19 April 2014

… My last thoughts after reading more of Dr. Lieberman’s quotes are, I’m convinced that integrated care is already a done deal; it is just a matter of time before it rolls out across the country. However, I am undecided if the APA leadership is reading the hand-writing on the wall and reacting to it or if they are already positioned in it and are trying to sell it to their membership, and peripherally the public, with the real sell to us coming from the media.

A wise observation. It looks as if they’ve worked out a pretty detailed system:

These concerns notwithstanding, we must collectively make a leap of faith and be prepared to make changes on the ground in the way that we as psychiatrists practice medicine. But this might be focused on specialty mental health care for the most complex patients, while primary care providers increasingly may conduct the first line of mental health screening and provide basic care. It is likely that the relationship between primary care providers and psychiatrists will expand exponentially with brief phone and “curbside” consultations replacing many of the more formal referrals for consultation.

Many psychiatrists will become leaders of multidisciplinary mental health teams providing coordinated services and, in some cases, may be located within large primary care practices. Conversely, we can expect to see primary care providers move into settings such as community mental health clinics to better provide general health care to severe and persistently mentally ill patients [SPMI].

A possible variant of this is that some psychiatrists and allied mental health providers will assume some basic primary health care responsibilities for SPMI patients or may even become their principal caregivers in collaboration with primary care providers. There is an increasing emphasis on addressing health behaviors such as diet, smoking cessation, and exercise as the understanding of the link between mental health and other health behaviors has deepened. Psychiatrists are finding they need to counsel their patients on these issues and even provide more basic medical screening and care to patients or in consultation with primary care providers. Some psychiatrists are even taking refresher courses in primary care to be able to better address this patient need.

To reiterate, multidisciplinary mental health teams will also become more common within hospitals and local health systems. To meet the anticipated demand from more patients while reducing costs, psychiatrists as the team leaders will provide less direct care [again, focusing their direct care efforts on complex, high-risk cases] and more supervision of care, while monitoring and tracking patient progress and increasing their consultative role with other specialists.
The changes suggested here pick up from the Community Mental Health Initiatives of the 1960s  when the State Hospital collapsed. The glue that they intended to hold that system together was Thorazine [and friends]. The thought was that medication would stabilize the patients they are now calling severe and persistently mentally ill patients [SPMI]. We know that story now. It was never fully implemented and naive in its predictions of the power of medications. As Robert Whitaker has pointed out to us all, the reliance on neuroleptic medications persists to the present with these patients. But it also failed in that the ancillary services were never close to what was needed, so many SPMI patients live in our prisons – by default. If what he describes in paragraph two above can do anything for these patients, more power to him – but cost containment is what killed the last attempt, so anyone alive back then is appropriately wary that it will never be appropriately funded.

That the system he’s proposing will ever fund what most people reading and commenting on this blog would like to see happen for less severe illness is a dream probably gone with the wind, so more important right now is to look at the Lieberman System of Collaborative Care for fatal flaws. As anyone alert and awake knows, the Managed Care system in place has relegated psychiatrists to the role of medication doctors focusing on symptoms. That has been true for some time, and psychiatry, particularly APA psychiatry, has essentially become a psychopharmacology specialty with what many of us consider an outrageous expansion in drug treatment. Let me remind you of the SAMHSA report I posted recently [a graph…]:

My concern in both the SPMI and the Collaborative Care models Lieberman is proposing is that the legacy of the Age of Psychopharmacology will be directly incorporated into both arms of the Lieberman System and perhaps even expand. This kind of medical model thinking for psychiatry is the stuff of managed care, perhaps its only stuff, and I’m reading the model as pure managed care. Likewise, the upper ranks of organized and academic psychiatry are largely people who have known little else, so the dangers of overmedication are multiplied. Finally, the notion of primary care physicians delivering even more of the mental health care is a further force for overmedication. So even if the pharmaceutical industry has abandoned CNS drugs, their golden years will be perpetuated and institutionalized in a healthcare system even without their "ask your doctor…" ads on television.

Psycritic’s post about Collaborative Care [On Integrated Mental Health Care] is excellent. In taking about worst case scenarios, he mentions a comment from Sandy Steingard that was on this blog last month that made us all shudder:
I was at a conference where a psychiatrist enthusiastically described her experience with collaborative care. Every morning, the treatment team would get together [the “huddle”]. She gave an example of why this was so helpful. One day, someone mentioned that someone’s PHQ-9 had gone up by a few points [this is a nine item screening for depression]. The presenter said something like, ”So we agreed to increase the fluoxetine from 20 to 40 mg and we were all set to go!”
At the risk of being a broken record, these developments even heighten the importance of full transparency about clinical trials and adverse effects covering all drugs currently still in use – in this case from Prozac forward [1987+]. If this is the service that’s going to be provided, it’s going to rely heavily on these existing medications. The efficacy and adverse effect information remains heavily skewed by this last twenty-five years of marketing department distortion. I would even think that new, longer clinical trials of heavily used drugs long out of patent might well be in order. I expect that some astute bean counter in managed care land has already figured out that as the drugs in the above graph go generic, their costs are going to take a dive.

In Psycritic’s post, he mentioned a situation from his experience in a Collaborative Care setting that will surely become endemic:

I thought that the vast majority of patients I saw would have benefited from psychotherapy, yet very few of the clinics employed therapists, and none had access to more intensive treatments like dialectical behavior therapy. Even in the clinics that did have therapists [usually LCSWs], they were usually full and could not readily see new referrals. Because of the therapist shortage, I often ended up prescribing a medication by default. And of course, other forms of integrated care may be much more compromised than what I experienced. For example, managed care organizations seem to focus much more on cost containment, screening using rating scales, and then using medications to get those numbers down.
So back to where we started and the "done deal" – it’s unclear to me why the APA would actually be promoting this model other than that they feel the alternative is extinction, at least third party extinction. I find the notion that psychiatrists are going to close their offices and join group medical practices to fit this template extremely unlikely, but who knows…
    April 19, 2014 | 6:36 PM

    The huddle concept is a managed care speciality that they apply across a number of settings.

    The emphasis on antipsychotics and the rhetoric form Whitaker really minimizes the impact of community psychiatry as applied by the Stein and Test model. Assertive Community Treatment offers a much better approach than seeing a psychiatrist in an office every 1-3 months for a brief period of time. It is successful at helping people stay out of the hospital, decreasing their medication requirements and getting their associated medical problems treated. The problem is that it costs and average of $10,000/years and considerable higher for some approaching the cost levels of being treated in a state hospital as opposed to the relatively low cost of a few “med checks” per year.

    April 19, 2014 | 6:54 PM

    After reading Making a Killing, I think clinical trials are even worse than I thought and don’t think meta-analysis is sufficient. I had assumed that at least grad students in psychiatry were assessing test subjects. Social workers who aren’t even trained in a common language in which to make those assessments? Unbelievable. This reminds me of a Jack Handy joke:

    Instead of having “answers” on a math test, they should just call them “impressions,” and if you got a different “impression,” so what, can’t we all be brothers?

    I recognize that the CAFE study may be an outlier, but the fact that the University has managed to prevent it from being legally challenged convinces me that clinical trials are, at this time, so corrupt that their results should not be considered as legitimate evidence of anything but marketing.

    We need to start over and treat all drugs with FDA approval with a critical eye and this information needs to be available to patients. I’ve researched effects of amitriptyline many times, but now— all of a sudden— I find that it increases the risk of heart attack by 35%. An article in a cardiology journal I stumbled across had a full list of drugs for people with heart disease or serious risk of heart disease that patients should not take, and amitriptyline was on that list. Somehow, the drug itself ends up in heart muscle. If I had no risks of hear attack, at my age, I would consider the 35% risk significant. Patients who do not have this information are not capable of making decisions with informed consent, because they aren’t getting the information they need to make decisions on their own behalf. I think this is obvious and incontrovertible.

    Can anyone here argue otherwise?

    AllTrials is a good start, but I do not think that showing one’s math homework is sufficient. The choices of subjects and structures of interviews should be as transparent as the numbers. For the protection of test subjects and for the purposes of peer review and critique, I think every aspect of a study should be videotaped and subject to review.

    When the Indian government puts a ban on clinical trials, we can reasonably assume that the practices have become so egregious that the most powerless people in the world are dying at rates that threaten political stability, forcing governments that may benefit financially from letting pharmaceutical companies use their poor as guinea pigs to apply the brakes and start holding these corporations accountable.

    April 19, 2014 | 6:56 PM

    showing one’s math homework is not sufficient.

    April 19, 2014 | 8:12 PM

    AS I just wrote on Psych Critics blog, I am not at all opposed to the model of collaborative care. It is what we have been doing for a long time. In my clinic,. the psychiatrists are members of a team. Our role is to help to clarify diagnosis (to the extent there is any clarity), and then to offer drugs if we think they are indicated. There is nothing in this model that is either pro or anti drug treatment. In fact, these days we are often in the position of explaining to people why drugs may not help. We work closely with primary care physicians and when people are stable, we often refer to person back to the PCP.
    As I said, there is nothing intrinsic to this model that promotes drugs over other treatments. We are part of a team and many other things are offered, they are just not offered by psychiatrists. It has never been clear to me that psychotherapy of any kind needs to be done by a physician. This is in part an economic decision – physicians are paid more than anyone else in our setting – but in this case, from my perspective economics overlaps with what I consider good care.

    April 19, 2014 | 10:20 PM

    I do think that in dealing with people with serious mental illness there ought to be a role for this, i.e. psychiatrists should be communicating with their patients case managers who see them in a different setting.

    I worked on a project where they were trying to integrate a family NP into a behavioral health team. People who went to the ED a lot had the opportunity (not all followed through) had the opportunity to get visits at home and to have an NP assist their PCP and psychopharm person. (Most people had no therapist, but they were getting psych rehab services).

    The NP had a patient load of 30 or so, and she spent a hell of a lot of time with her patients, getting to know them as people etc. My clients medical needs were being ignored by their medical providers, and an NP who has time to spend 3 hours on an initial appointment and is collaborating with a physician (who may see the patient but less frequently) as part of a team seems pretty good to me. Certainly better than the useless visits with an internist every 2 months for these medically compromised mentally ill individuals.

    April 19, 2014 | 10:56 PM

    Is there something in place, Dr. Steingard, to encourage psychiatrists to reconsider diagnoses that have been given and to help patients safely discontinue those drugs and see how they function without them? At this time, it is nearly impossible for a person to have a mental diagnosis removed, which results in unnecessary treatment and often the denial of personal agency that many people in the system actually have and are capable of using for their own improvement.

    As a caregiver with 16 years of experience, I have worked with three HMOs, a university research hospital, the V.A., social workers, and doctors and psychiatrists contracted by the state. I think that aside from a revolution within psychiatry that people like you, Dr. Nardo, and others here are investing in; the administrative systems make a profound difference. I blanch to think how different a person’s life could be because of administrative decisions made by people with no medical experience and the defensiveness of an organazation’s CEOs.

    April 19, 2014 | 11:43 PM

    The idea of integrated care isn’t what I have issues with as a patient, it is how it will function. Integrated care would be a boon for patients to be able to have coordinated care in one group, at least as far as convenience. I am unclear on outcomes as there is no evidence Medical Homes demonstrate better outcomes.

    If integrated care helps patients with mental health issues with their medical care, anyone with an illness cope, or the few patients with emotional issues presenting as physical issues, that is great. Still, when I know that business is behind it, I also know that everything will be marketed in terms of how great is for patients, providers and global warming (sorry for the bad joke, yet truly nothing is off the table as far as marketing goes). However, a benefit to humanity is far from their driving motivation.

    So, I consider where they think they can save money. They can pay less physicians to cover the same patient populations. And, they can also save money by offering less medical care. Maybe by declaring a patient’s undiagnosed symptoms a mental health issue and shifting the burden to behavioral health. I already see this happening without integrated care.

    I’ll give you another example entirely outside of this discussion and psychiatry. There was a recent article about the acceptance of alternative medicine into academic institutions at Respectful Insolence. There was much discussion around how could scientifically thinking individuals buy into things like Reiki and acupuncture. Simple me, who figured that the majority of these logical, scientific or business thinking people wouldn’t discard a lifetime of their beliefs so quickly, came up with the conclusion that they did it because it sells, or has the potential to sell. That alternative medicine may offer palliative care and comfort for people, I am grateful for, and in many places it is free. However, once the public believes this type of stuff is medical care, then it will be charged for it and it will be presented as medical care.

    But, I am open to being wrong. I actually hope I am.

    Note that I am not equating alternative medicine with mental health care. The idea is to shift the costs of medical care to a more cost effective process in any way possible, whether or not it is warranted.

    April 20, 2014 | 6:05 AM

    I can’t speak from a system perspective but my personal belief is that there is always room to reconsider diagnoses. First of all, psychiatric diagnosis is at most a label to put on a certain collection of symptoms. We should be careful to not reify them. I am reading Richard Noll’s book, “America Madness” about the history of the concept of Schizophrenia. It is fascinating. The notion of Schizophrenia was a hypothesis – an attempt to get at some underlying unifying pathology. We are not there yet and many would agree that this is a label that at best reflects many different kinds of “things”. Anyone who reads this blog, knows the vagaries of psychiatric diagnosis.
    There is also room to taper medications. The notion of chronic treatment is a relatively new one. I have come to believe that we (psychiatry) have paid inadequate attention to the distinction between “relapse” and “withdrawal.” I am not sure they can be so easily distinguished and withdrawal symptoms are often assumed to be relapse. You can read more about what I have been doing here:
    That focuses on neuroleptics. I have found that just explaining to people that coming off or reducing doses of their drugs is possible is often revelatory since so many people have made an assumption that they are needed for life. Ironically, working with people to reduce drugs is now perhaps more apart of my practice than starting new ones.

    Steve Lucas
    April 20, 2014 | 7:56 AM

    Like Mickey, another doctor often blogs about the dangers of accepting a diagnosis. He also works with older and often low income patients and finds diagnosis are often accepted and then medications are add too, but never taken away.

    Add to this the tendency to up code and prescribe patented medications and you have folks walking around unable to pay for their medication in a drug induced fog.

    Over 50 medical societies have adopted Choosing Wisely where doctors are suppose to look at the long term cost and benefits of a test or procedure. The blow back from doctors has been unexpected along with the lack of adoption by hospitals. In my community the more aggressive of the two hospitals owns a number of practices and supplies their EMR’s which automatically compares insurance with possible test and treatments making them mandatory for the doctor to prescribe.

    Our medical cost in this country will soon reach 20% of GDP, almost twice that of other countries. This financial burden, combined with the negative impact on patients, must be curbed and stopped.

    A Dutch study several years ago found that frequent office visits and the associated testing did nothing to improve long term outcomes, but did add to cost and suffering of patients. This study received little play in the US. The world of medicine is global and we do not need to reinvent the wheel just because we are the US.

    We need to get a grip and treat the sick while leaving the healthy alone instead of the opposite which generates more income for the system, but leaves those most in need untreated.

    Steve Lucas

    Joseph Arpaia
    April 20, 2014 | 12:45 PM

    The root of the problem is that with the corporatization of medicine the patients (who eventually are all of us) are treated as a source of income by the business owners. The goal is to maximize profit even at the expense of health. This is not just true in psychiatry but in many medical specialties. The “best practices” in the treatment of diabetes, hypertension, … are not improving long term outcomes and clearly make people worse in some cases. However that is irrelevant to those who are consumed by the greed for profit, Essentially the medical establishment is behaving as a parasite sucking the life from its host, the people. Like all good parasites it uses various tricks to evade its host’s defenses, most especially misrepresenting itself as beneficial.

    gagan sidhu
    April 20, 2014 | 12:47 PM

    y’know, aside from the trooper-psychiatrists like dr steingard, dr Carroll, dr nardo, and others who are interested in making true psychosocial impact, i am disappointed with the dialogue here on the future of psychiatry. I think the biggest need in medicine is clinical psychiatrists conducting active research in primary care facilities.

    Somewhere above us, both dr lassen and dr ingvar are disappointed with this dialogue. Dr Franzen too (but I think he’s still alive). Psychiatry is for those who truly want to help. Those who aren’t afraid to empathize, understand, and treat (where this last step is often less necessary if the two former steps are done with diligence).

    It is time to research the nervous system and how neuropsychiatric disorders manifest themselves in well defined. It is going to take passion and dedication, but I do not doubt there are many who are willing and able to undertake this significant task. In my opinion, the most important part with obamacare is to remove the medicare part D subsidies that are being used to tranquilize seniors, children and inmates. That money needs to go to practicing psychiatrists in the aforementioned facilities.

    It is time to move from an office to a facility in which psychiatrists can begin putting the big picture together– as Sir Sherrington himself envisioned over a century ago.

    Psychiatrists who are unwilling to question their current understanding of the neurological manifestations of neuropsychiatric disorders are those who, I believe, came into the profession to prescribe and profit.

    To dr kupfer: get out.
    To dr weinberger: your 1980 AJP study emphasizing the dlpfc in schizophrenia was an insult to Ingvar and Franzen’s 1974 study. Get out.
    To dr callicott: if you’re not willing to update your understanding of schizophrenia using PROPER fMRI data: get out.

    To any “psychiatrist” who discounts human beings’ individuality, and how this individuality affects a diagnosis: get out.

    This era of psychiatry will no longer be defined by the salaries. All psychiatrists who do good research, or are focused on making a huge psychosocial impact (like dr steingard), are all this field needs. We are better off with a handful of dedicated and considerate practitioners who are focused on helping, not those focused on increasing their paycheque by increasing the amount of a subsidized and expensive drug.

    Signed by the 26 year old “non doctor” (who hopes to become a doctor eventually) could probably shame most (not the likes of dr steingard, carroll, or nardo, ofc) psychiatrists and neurologists today.

    Sorry for the rant

    April 20, 2014 | 1:10 PM

    I am sorry, but is it just me, or, isn’t this faux push to be integrated just to rationalize and justify medicating and pure somatic focus on psychiatric disorders, forget the “-psycho-” and “social” portions to what is the “Biopsychosocial Model”?

    Enjoy the de-evolution of psychiatrists, they clamored to be psychopharmacologists for most of late 1990’s thru most of the 2000s, and now the term is “Neuropsychiatrists”.

    What next colleagues, back to the white coats and stethoscopes over our shoulders in our offices? I think a lot of you don’t get it at the end of the day, assimilation is so covert at times, you don’t see you have been made into the “Borg” of the leaders and influential academic trend setters until you look in the mirror and see the proverbial metallic eye staring back at you.

    Or, hear the shrieks of your patients once they realize they have entered a room with a cyborg just monotonally saying “resistance is futile, take the script and let the pill heal you”.

    Again, art imitates life in so many arenas, eh?!

    James O'Brien, M.D.
    April 21, 2014 | 1:11 AM

    Dr. Steingard, you may be comfortable with the collaborative care model. I’m comfortable with prescribing MAOIs and forensic psychiatry. But it’s not for everyone and I am not comfortable advocating any one size fits all top down approach for psychiatric practice. Lieberman’s speech could have been given by Ezekiel Emanuel, because it’s the same great leap forward overpromising nonsense statists and totalitarians have been pushing for years. I’m surprised he didn’t throw in a 5-year plan. These ideas never work out.

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