From the PresidentPsychiatricNewsby Paul SummergradSeptember 11, 2014… At the same time, when looked at from the outside — from the perspective of observation and syndromic coherence — these disorders are highly correlated with genetic and neurobiologic abnormalities as well as disruptive environmental events. Two recent studies [among many] — one on the genetics of schizophrenia based on the largest pool of genomewide studies and a smaller study of the genetic and neuropathologic basis of autism — reinforce this understanding.
Why is the tension between the experience of these illnesses and their etiology so important? In part because it is easy for psychiatry, and more broadly the mental health community, to come down strongly on one side or the other of this divide. This split can influence the research and public policy we need to develop treatments for mental illness and provide access to care.
Moreover, when this divide — which is sometimes inaccurately framed as a battle between the recovery community and a misunderstood “medical model” — affects the Substance Abuse and Mental Health Services Administration [SAMHSA], the impact can be of even greater significance. SAMHSA is the principal federal agency dedicated to leading public-health efforts to improve mental health and reduce the impact of mental illness, including substance abuse, on America’s communities. As a central component of its directive, SAMHSA recently released a draft of its FY 2015-2018 strategic plan, titled “Leading Change 2.0: Advancing the Behavioral Health of the Nation”.
There is much to support in SAMHSA’s draft. Efforts to reduce disparities in access to care, which disproportionately afflict minority communities, are laudable, as are efforts to reduce the number of those with mental illness in the criminal justice system. However, for an agency with such a broad responsibility, the proposed plan is striking for what it leaves out: a focus on the appropriate medical care of patients with serious mental illness and the development of a physician workforce that is essential for their care. In APA’s letter to SAMHSA Administrator Pamela Hyde, J.D., responding to the draft strategic plan, our CEO and medical director, Saul Levin, M.D., M.P.A., noted, “APA is strongly concerned about the lack of explicit recognition of the psychiatric treatment needs for Americans suffering from mental illness and substance use disorders, and in particular for the 13 million Americans who suffer from debilitating serious mental illnesses [SMI].” In addition, we urged SAMHSA to develop explicit goals for evidence-based medical care for serious psychiatric illnesses…
I like Dr. Summergrad. He doesn’t lead with the arrogance of his recent predecessors, doesn’t make assumptions about the primacy of psychiatry in the mental health cosmology, and while he wears a white coat – he wears it loosely. But it will take more than a long absent humility to achieve "explicit recognition of the psychiatric treatment needs for Americans suffering from mental illness and substance use disorders, and in particular for the 13 million Americans who suffer from debilitating serious mental illnesses" primarily because for thirty years, psychiatry has itself had a monocular view of those needs. He speaks against SAMHSA coming down on one side of "the divide," yet psychiatry itself has helped to create and both actively and passively nurtured the division.Absent some lofty rhetoric along the way, psychiatry proper has offered the same treatment option for chronic psychosis since the arrival of Thorazine – antipsychotic medication maintenance – and ignored the social problems. While decrying the long-term effects of medications, the recommendations haven’t changed to take that into account. Psychiatry’s other offering has been an expensive and non-productive research effort to chase down a biological etiology and/or new biological treatments. In practical terms, that effort has yielded nothing. During this period, the deinstitutionalization of mental patients has resulted in the reinstitutionalization of mental patients [what they’re for…, justification for “what they’re for”…], again often decried in rhetoric, but otherwise unaddressed. So the search for etiology and for new treatments has failed and the actual fate of these patients has been ignored.
The Recovery Movement arose outside of psychiatry, and is premised on the idea that an intense focus on the interpersonal, societal, and cultural needs of the chronically mentally ill will lead to recovery. In this model, traditional diagnosis takes a back seat [or is considered detrimental]. It is the official approach of SAMHSA [Substance Abuse and Mental Health Services Agency], focusing on block grants to the States for community programs following the Recovery model.
For many, the Recovery Movement has the additional meaning of recovering from psychiatry itself – hospitalization, antipsychotic medication, commitment, the ‘disease model’, the ‘medical model’, etc. And many of them feel that this request, "we urged SAMHSA to develop explicit goals for evidence-based medical care for serious psychiatric illnesses" is part of the problem rather than the solution. So the "divide" is increasingly an active process being fueled from both "sides" – often driven by intense ideological conviction. Meanwhile, as this controversy rages, resources dwindle and our prisons fill [see George Dawson’s recent Shut Down The Psychiatric Gulags – Don’t Build More!].
Hmm, I have a different take. The issue is that for many people with mental health issues, drugs do not work. But yet, the only thing that psychiatry has to offer is more meds come heck or high water.
How to develop appropriate non med alternative solutions is a whole other post but it definitely has been discussed, including mental health professionals like Dr. Sandra Steingard and Jonathan Keyes, an inpatient mental health counselor who blogs on the MIA site.
AA,
Absolute agreement from me. And those are the kinds of things that I would argue should be [and should have been] addressed by the APA and psychiatry proper throughout the thirty years of wearing the “monocle.” You have to come to the table if you want a seat…
I would say that has about as much chance of happening at the National Association of Realtors electing a president who believes that home prices are too high.
Organizations that are wildly overly optimistic and promotional are in the business of silencing skeptics, not bringing them in. The APA and its related publications are evangelical about psychiatry (save some articles by Dr. Frances and a few others). Psychiatric Times now has a series of blog posts about how psychiatry might resolve the violent tendencies of ISIS. Facts and history be damned. The former president of APA claims psychiatry has saved millions of lives. If you question these ideas or statements, you are considered antipsychiatry.
I’m big in the underpromise and overdeliver camp. But that kind of measured restraint cannot compete with utopian overoptimism.
The APA will “address” the problem by marginalizing the skeptics with a strong dose of the Bryant Gumbel how dare you disapproving stare. Oblivious to who the true fanatic in the room is.
That’s probably right, but I think that your analogy may make my point better that I did above. Self-critical thinking should be an integral part of medicine and particularly psychiatry – where feeling our way along is the rule rather than the exception. Likewise, the notion that medicine’s focus is on only the biological aspects of things, a position psychiatry embraced in 1980, is antithetical to our history. Traditionally, the care of the sick was the focus with the delimiter being primum non nocere [do no harm]. The bio-science came much later. While I am aware that is an idiosyncratic view, I don’t personally think medicine works the other way…
BTW I wasn’t exaggerating on the APAs circle the wagons mindset:
http://www.psychologytoday.com/blog/dsm5-in-distress/201203/am-i-dangerous-man
When you have to resort to this kind of mindless personal attack on the principal author of DSM-4, you’ve lost the argument, APA.
If any part of medicine is all about the bio, a robot can do it and you don’t need a doctor. LASIK is getting close to this, but the rest of medicine is not like refractive error which is pure optics and geometry.
I will admit my inability to properly formulate this concept. My issue is that as the pendulum has swung into the all bio mental health care and such concepts as recovery are fighting their way back there is a great number of people being mislead and mistreated by in great part GP’s.
Today we see a drug rep, a one page flier, and a prescription pad become the basis for mental health care, as noted in the computer approach to medicine. There is never a referral to a mental health professional, nor is there any plan for discontinuing any drug therapy.
My dentist and eye doctor both have been very open about problems with patients who are on not only multiple meds but very powerful antipsychotics. Imagine being a physically small woman with a person in a darkened room whose head is locked in a device and watching their eyes change as they have difficulty with the situation.
My dentist is often contacting multiple doctors in order to simply fill a tooth.
We have moved from “mother’s little helper” into a world of very powerful drugs that should not be expected to be used on a long term basis in most cases.
Social and work interactions have become a mind field as you do not know what many people are on, but are aware they have been “diagnosed” by a GP who has supplied a prescription, all done in a five minute or less interaction.
There does need to be a focus on recovery and a balanced approach to mental health with medications being set at the lowest dose possible and monitored over time. I for one am tired of going to a party or work and wondering who I am going to meet, the nice person, the crazy person, or the zombie who cannot function.
We as a society, and on a personal level, are paying a price for not attempting to find that level of recovery an individual is capable of and supporting them both in the process and at that end point.
Steve Lucas
1) I do not understand why recovery, by whatever means, is not an explicit objective in psychiatric treatment, and how the psychiatric establishment can continue to deny the essential humanity of this goal.
2) I don’t understand what Dr. Summergrad means by Serious Mentnal Illness. If he’s talking only about schizophrenia, he should say so.
When the rhetorical occasion suits, Serious Mental Illness can be psychosis, or psychosis and depression and bipolar disorder, or an estimated 25% of the population suffering from whatever. Sometimes it includes Alzheimer’s.
Serious Mental Illness is a phrase that’s nothing but a bloody shirt waved before the mental health community.
3) In practice, 90% of those taking psychiatric drugs are on antidepressants, and only about 15% of those have a diagnosis of major depressive disorder.
As Steve Lucas noted, psychiatry’s empire-building has led to millions of people on dangerous polypharmacy (yes, often prescribed by GPs, handmaidens to the empire) as though they had Serious Mental Illness. They get no hint that “recovery” from their non-existent mental illness is even possible.
So Summergrad condemns “recovery” for whom?
So SAMHSA wants to emphasis recovery interventions. Good for them. With respects to Dr. Summergrad, academic psychiatry has had zillions in funding getting drunk on Big Pharma money for biological research and treatments. When has Big Pharma supported recovery with funding? Oh yes they bankrolled NAMI just so long as NAMI promoted the anti-psychotic medication message. So now Big Pharma has puled out of psychiatric drug studies and lo and behold the psychiatric establishment is crying foul and wants the public trust to fund them! They are acting like addicts going through withdrawal.
There has to be an end game in all of medicine. Perpetual med checks, or 90 day office visits, generate revenue, but do not solve problems. We have built up this myth that all medicine is good and there now exists a dependency that is not healthy, nor is it financially sustainable.
Mickey and others have noted the issue with polypharmacy and the resulting physical and mental issues associated with over medication and drug interactions. My experience with this issue is this is often mentioned by doctors out of the main stream and not practicing in a suburban environment.
One can turn weekly to such things as an article concerning a cardiologist doing unnecessary testing and procedure. Recently highlighted was a lab paying kickbacks to doctors since Medicare will pay $1,000.00 for blood work. We all have our favorites and there is a never ending supply of stories.
Recovery should be the goal of all medicine. Low T, PSA test, everyone is a cancer survivor, and you can never be sure all drive revenue. The real question in and out of mental health is: How do you feel today, and then an appropriate amount of time should be spent exploring this question.
The question should never be: How do I maximize revenue from this widget (patient). There are enough sick people to fill all of the doctor’s offices.
Steve Lucas
“Recovery should be the goal of all medicine.”
That is certainly how I was trained. I was also trained in the case of treating the incurable and dying to alleviate their pain. I was also trained to never give up if I didn’t know what the hell was going on but to consult and find out what was needed. I was also trained to help people adjust to their disabilities. I was also trained to identify new and unrelated medical problems and address them. I was also trained to treat chronic problems. It would certainly be a bleak world if the rhetoric about physicians and psychiatrists was even 10% true.
SAMHSA reworking a word that they have taken from a much larger and more well known recovery community doesn’t affect me or the way I was trained:
“We find joy as we start to live by the principles of recovery. It is the joy of watching as a person two days clean says to a person with one day clean: “An addict alone is in bad company.” It is the joy of watching a person who was struggling to make it suddenly , in the middle of helping another addict to stay clean, be able to find the words needed to carry the message of recovery” Narcotics Anonymous 6th ed, p 52.
Dr. Dawson, you can see for yourself what Summergrad, representing organized psychiatry, thinks of the concept of “recovery” in his elision of it.
Presumably he had training similar to yours. Medicine has changed. It is a bleak world, particularly for patients.
“Recovery” is just a word. The smart thing for organized psychiatry to do would be to incorporate “recovery” into its own rhetoric. (Just as “efficacy” is smoke and mirrors, psychiatry doesn’t even need to address how “recovery” might be incorporated into practice.)
I find it telling that, rather than seize this opportunity for rhetorical repositioning from an indefensible model of endless medication, psychiatry casts it as a power struggle between a High Priesthood and the rabble.
“I find it telling that, rather than seize this opportunity for rhetorical repositioning from an indefensible model of endless medication, psychiatry casts it as a power struggle between a High Priesthood and the rabble.”
That is because you have a completely unrealistic (and indefensible) view of psychiatry.
I actually practice psychiatry not your idea of it.
I don’t “rhetorically reposition myself” so that I am aligned with the business musings of SAMHSA.
http://real-psychiatry.blogspot.com/2014/09/is-samhsa-managed-care-company.html
Dr. Dawson, I thought I made it clear that I was commenting on Summergrad’s statement as representative of organized psychiatry, not of the way you or any individual practices psychiatry.
Summergrad’s statement is self-evident.
As to what I think about psychiatry, that would be a very long discussion. I do not believe I’ve had that discussion with you or anyone else commenting here. Your idea of what I think is your own projection.