There’s something kind of unique about the last paradigm shift in American Psychiatry [see roots… and agendae…]. It didn’t happen just because of changes in the ways people thought or some scientific advances. It was orchestrated by the American Psychiatric Association and effected by a change in the Diagnostic System [which nail?…, a card laid…]. The changes were dramatic, and instituted by the professional organization itself instead of being put together after the fact. The 1980 DSM-III was a cause rather than a result. 
I don’t think it was imposed, because it caught on so quickly. But it wasn’t a grass roots change for sure. What it meant was that there was a concentration of power in the APA. The organization was put in charge in a different way. That’s a speculation on my part, but I think it’s pretty close. Since then, American psychiatrists have looked to the APA for direction. One could also say that in 1980, American psychiatry became homogenized. The internal discord that came before essentially faded away. Instead of being a forum where dissidents shook fists at each other, dissidents just faded away. Again, that’s my speculation based on my own observations – evidence-based but with a very small sample. In that sense, Levine and Whitaker are using the word «psychiatry» correctly to describe the homogeneous APA membership [in a guilded cage…].
The DSM-III was a raging success. Psychologists and Social workers gained more access to third party medical reimbursement by agreeing to accept the carriers’ terms. The insurance companies paid psychiatrists well for Med Checks. The analysts finally got around to settling for a role as psychotherapists and began training psychologists and social workers after losing a suit. PHARMA was generous to the academics with grants, and the drugs flowed out of the pipeline at a steady rate. Over the ensuing years, psychiatrists became medicators, the role Managed Care assigned to them. Tom Insel talked on about Clinical Neuroscience.
And then the Primary Care Physicians began to prescribe psychiatric medications, and a subset of the new academic psychiatrists got exposed as crooked; many of the industry-funded RCTs were questioned; the pipeline ran dry; the wondrous brain discoveries didn’t materialize; the medications didn’t turn out as planned; the cost-cutting kept happening; and the DSM-5 bombed; the anti-psychiatry forces were on the ascendancy… well, you know the rest. And I expect psychiatrists are looking to the APA for guidance. After all, that was now the seat of power, the self proclaimed compass for the medical specialty of psychiatry.
- Population Studies suggest that the incidence of untreated mental illness is high.
- Most psychiatric medication is prescribed by primary care physicians.
- Mentally ill people are high service users of medical facilities costing billions.
Although we have effective pharmacological and psychosocial treatments for most common mental disorders, they are not widely accessible, and only a minority of patients receive them. Many patients are not on medications at therapeutic doses or for long enough to see positive effects, while others continue to use medications even if they are not effective. As few as 20 percent of patients started on antidepressant medications in primary care show substantial clinical improvements. The situation is not much better for those referred for psychotherapy. Many who are referred don’t go. Others may receive an insufficient number of visits or ineffective forms of therapy, leaving big opportunities to close the gaps between what we know and what we do.
One way to help close these gaps is for psychiatrists to work more closely with our colleagues in primary care using a collaborative care approach. Originally developed and tested by Dr. Wayne Katon and colleagues at the University of Washington in the early 1990s, collaborative care has been examined in the treatment of depression and anxiety disorders in more than 80 randomized, controlled trials and has consistently been found to be more effective than care as usual. In such programs, psychiatrists work closely with primary care physicians and mental health care managers [usually a licensed clinical social worker, nurse, psychologist, or therapist]. Each team has a designated psychiatric consultant who provides systematic treatment recommendations on patients who are not improving as expected…
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on Psycritic: On Integrated Mental Health Care, Assimilation vs. Independence
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on Mad in America: The End of Psychiatry
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on PsychPractice: APA-thetic
… So I don’t believe it will be possible for psychiatry to change unless it identifies a new function that would be marketable, so to speak. Psychiatry needs to identify a change that would be consistent with its interests as a guild. The one faint possibility I see – and this may seem counterintuitive – is for psychiatry to become the profession that provides a critical view of psychiatric drugs. Family doctors do most of the prescribing of psychiatric drugs today, without any real sense of their risks and benefits, and so psychiatrists could stake out a role as being the experts who know how to use the drugs in a very selective, cautious manner, and the experts who know how to incorporate such drug treatment into a holistic, integrated form of care. If the public sees the drugs as quite problematic, as medications that can serve a purpose – but only if prescribed in a very nuanced way – then it will want to turn to physicians who understand well the problems with the drugs and their limitations. That is what I think must happen for psychiatry to change. Psychiatry must see a financial benefit from a proposed change, one consistent with guild interests.
But with the ACA, the ability of psychiatry to survive independently is quickly fading. Mickey has addressed this in some of his posts about the move to integrated care. And speaking as a psychiatrist who has spent her career in public sector work – where some of the most impaired and disenfranchised seek care [and have no other option] – we do not have the option to ignore the economic issues. This is one reason why I believe that for change to occur, many of the current functions of psychiatry need to be taken away from psychiatry and medicine. I think it is legitimate and important for there to be branch of medicine whose practitioners truly understand the judicious use of psychoactive drugs. They are complicated substances. I just do not think that function needs to be at the core of what we offer to people who experience the vast array of emotional/cognitive problems that currently fall under the umbrella of psychiatric attention [and to re-state, this is not intended to criticize the work of those who found their ways into doing psychotherapy as physicians. This was a viable career path for many at the time].
I’m going to have to reread this stuff and let it settle…
Update: Sandra Steingard just wrote and clarified her comment above [which I really appreciate]:
I would like to elaborate a bit on what I have in mind because it seems I have not been as clear as I would like. My concept has nothing to do with collaborative models where a physician opines about a person he has never met. It also has nothing to do with assessment scales. It also is in no way tied to the widespread use of psychoactive substances for a myriad of quasi disorders for which drug efficacy is marginally if at all established. I continue to believe that the problems we are trying to address are complex and it often take time to establish a relationship and hear the full story. I see no way around that. And while I think there are ways to use the drugs to help people, I think there is still much we do not understand and this leads me to have a therapeutic conservatism in how the drugs are used. But the drugs are going to be used and some specialty in medicine would do well to make it their business to understand them, to be sophisticated about the inevitable polypharmacy, and to to delve into the consequences of long term use and withdrawal effects.
I would like to elaborate a bit on what I have in mind because it seems I have not been as clear as I would like. My concept has nothing to do with collaborative models where a physician opines about a person he has never met. It also has nothing to do with assessment scales. It also is in no way tied to the widespread use of psychoactive substances for a myriad of quasi disorders for which drug efficacy is marginally if at all established. I continue to believe that the problems we are trying to address are complex and it often take time to establish a relationship and hear the full story. I see no way around that. And while I think there are ways to use the drugs to help people, I think there is still much we do not understand and this leads me to have a therapeutic conservatism in how the drugs are used. But the drugs are going to be used and some specialty in medicine would do well to make it their business to understand them, to be sophisticated about the inevitable polypharmacy, and to to delve into the consequences of long term use and withdrawal effects.
There is a model in Norway that centers around the primary care doctor. A team gets called in and meets with the person and the physician and others in the social network. A psychiatrist is part of the team. But the focus is on the talk and in coming to an understanding of the problem. Others can be brought in as needed – peers, employment specialist, therapists. When I think of collaborative care I have this in mind not checking a person’s latest PHQ-9 and suggesting an increase in the fluoxetine.
Thank you Sandra for this. I also just finished reading your article entitled ‘The End of Psychiatry’ which Dr.Nardo provides a link to in this post and I found it extremely helpful as an elaboration of what you are suggesting. I was particularly struck by your conclusion in this article;
‘ Furthermore, I am suggesting that with regard to the kinds of human distress that has historically fallen under the purview of psychiatry, let medicine – under the umbrella of neurology – stand in the background, quietly in the corner, available for limited evaluations and consultations. I would have the rest of you take center stage.’
As Sandra stated: “But the drugs are going to be used and some specialty in medicine would do well to make it their business to understand them, to be sophisticated about the inevitable polypharmacy, and to to delve into the consequences of long term use and withdrawal effects.”
Personally, I would be tremendously relieved to be able to refer people to psychiatrists in general as the experts in the above. (Currently, I refer to only a selected few.) And if they could minimize the excesses in psychiatric drug prescription by GPs, so much the better.
One further clarification:
The collaborative care model seems predicated on the notion that we have well defined and valid diagnostics and treatments. If this were true, perhaps I would be on board. But this is not true and therefore a more nuanced approach that understands that psychoactive drug effects do not map neatly onto current diagnostic categories, that peoples’ problems are tremendously complex and that many problems are best helped outside of a medical model framework is what I am suggesting.
Since APA has decided to commit professional suicide, I think I may direct my attention toward getting in on the ground floor of the software company that will replace psychiatrists under this model.
Experts in human behavior can sometimes be childishly naive.
That would be David Kupfer’s company, Psychiatric Assessment Inc. (PAI). http://blogs.discovermagazine.com/neuroskeptic/2014/01/19/psychiatrists-another-dimension/#.VUvB-ab5qGs
That’s not the same thing. That’s psychological assessment material, not a decision tree algorithm for medication.
Why are we not surprised? That’s the Altostrata we all recognize – spraying half-baked opinions.
Can the APA be committed as “danger to self”? Or “danger to others” might be more appropriate since the membership and their patients will suffer more than the brass on university payroll. Too bad Chestnut Lodge isn’t an option anymore, self-defeating personality traits take time to work out. And no, APA KOLCHOS, medication won’t help.
In my lifetime I have never seen an idea that more pathetically represented turkeys voting for Thanksgiving (if the GOP nominates Jeb Bush that will be a close second). From experts in human behavior. Chew on that for a minute.
Begging your pardon, how do you think a PAI product would be implemented?
I don’t know. But I’d bring it up at your next coffee klatch with the senior faculty at UCSF and the Fava brothers.
Dr. O”Brien said:
“”That’s not the same thing. That’s psychological assessment material, not a decision tree algorithm for medication.””
Hmm, this exert seems to be supporting Alto’s point:
“”The Gibbons et al paper presents a software program to help rate the severity of depression, an ‘adaptive’ questionnaire. Whereas a normal questionnaire is just a fixed list of items, the new system chooses which questions to ask next based on your responses to previous ones (drawing questions from a bank of items adapted from existing depression scales). The authors say this provides precise measurement of depression across the full continuum of severity.””
Dr. Carroll said:
“”Why are we not surprised? That’s the Altostrata we all recognize – spraying half-baked opinions.””
I am not sure how attacking someone is helpful to this discussion. It might help if you feel someone is missing the boat to explain the error in her thinking in a respectful manner.
AA
Rating the severity of depression is not a medication decision tree. You’re comparing apples to asparagus. I’m trying to be respectful but this is pretty basic stuff.
Neuroskeptic on PAI and CAT, part 3 http://blogs.discovermagazine.com/neuroskeptic/2014/03/12/psychiatrists-another-dimension-part-3/:
“….Touted as a revolutionary new way of measuring depression, the CAT-DI is a kind of computerized questionnaire, that assesses depressive symptoms by asking a series of questions about how the user is feeling. Unlike a standard questionnaire, however, the CAT-DI is adaptive because it picks which question to ask next based on previous responses.
The CAT-DI’s creators have said that the commercial release of the product (and related CATs) is under consideration. They’ve formed a company, Adaptive Testing Technologies (ATT) [AKA Psychiatric Assessment Inc.]. This commercial aspect has led to fierce controversy over the past few weeks, with accusations of conflicts of interest against some very senior figures in American psychiatry….”
http://readeroffictions.com/wp-content/uploads/2014/03/train-off-the-rails.gif
I like the idea of a decision tree for selecting psychiatric medications.
The brochure/samples method of drug choice is not useful. Lundbeck reps’ pushing of Brintellix has caused enough vomiting and toilet-flushing to prolong the drought in California even if it were to rain every day, along with full-body itchy rashes, headaches & disappointment, and nothing especially good of note.
Many factors would go into an AI Drug Advisor. Physical health history including dates, duration and frequency of symptoms and episodes, dosing of and responses to previous medications initially, once established, and after their discontinuation, life circumstances, patient’s desires (e.g., more energy vs better sleep), age-hormonal-status-sex-weight-pregnancy & co-morbidities, overall drug risk tolerance (wrt to safety of MAOI, TCA, SSRI, SNRI), per-side-effect risk tolerance (e.g. weight gain, hypomania), ability to adhere to a dosing schedule, ability to avoid contraindicated exposures, current and past rec. drugs and alcohol, affordability, presence of caring others to watch for and help with adverse events, and patient’s metabolizing attributes. Genetic data? Blood-relative drug responses?
I don’t mind AI for diagnosing, but clinical experience and MD/patient rapport are probably pretty helpful there. (OTOH an advantage of AI is it might increase candour.)
An AI Diagnoser would be a big task to design in its own right. It could integrate with the Advisor.
Data that inform decisions at every node would be a challenge to collect and arrange. Ideology would necessarily influence results, e.g., in the handling of past mania triggered by psych drugs. DSM-IV said it should not lead to a bipolar diagnosis; DSM-5 says it should.
Of all the specialties, psychiatry is least likely to require physical contact for diagnosis and treatment, which is why this sort of thing has a chance. Could AI put psychiatrists out of business? Not if they get some laws passed, and they would.
Would be a fun project to work on.