- on Psycritic: On Integrated Mental Health Care
- on Mad in America: The End of Psychiatry
- on PsychPractice: APA-thetic
- on Real Psychiatry: The Model of Psychiatric Care for the Future, Collaborative Care Model – Even Worse Than I Imagined
- on 1boringoldman: the APA on the move…, tested soon…, two versions…
The blogs above are ones I have nothing but respect for. They are all psychiatrists, but have different perspectives and situations. They’ve all weighed in on various aspects of Integrative Care. I agree with some of what they each say and disagree with some other points, but I recommend them all as serious takes on the topic that should be read by anyone who is interested. We’re going to read a lot about this as the APA meeting in New York gets underway. I would look to the comments of Dr. Paul Summergrad who seems to be the only sensible person in the club, though I haven’t any clue how he ended up on this bandwagon…
And then there’s me…
When I started volunteering up here in the hinterland, I worked at two clinics. At the adult clinic, I see the patients and do some medication management for the other mental health types – all overqualified volunteers. But there was a second clinic, a child and adolescent agency, where I not a primary, but more consultant and medication person. I’m not a child psychiatrist, but really enjoyed masquerading though there was a lot of learning before I became comfortable. What made it fun was working with a group of clinicians who ranged from competent to superb. There was a bruhaha over money and other things and a mass exodus of clinicians from the agency. Their replacements were a different breed who consulted me without engaging me about the cases. There was no collaboration, so I quit. First, I had to start from zero with every case. I didn’t mind that so much, but I had no comfort in knowing the clinicians following them would know when something went wrong. I felt like sooner or later, I was going to hurt one of those kids and I just wasn’t willing to do that. I still miss that clinic. The kids were really rewarding to work with.
So back to Integrative Care, I suspect the Infographic version came after someone looked at the JAMA version and let out a primal howl. I’ve rearranged that JAMA version [two versions…] to highlight what’s wrong with it. First, who needs a psychiatrist to do that. The Primary Care Physician can sign prescriptions. Second, Case Managers can learn what to do with case summaries quickly, and at least have the opportunity to actually see the patient. And finally, no matter how many classes they take, any psychiatrist trained in an environment like that will never learn to be a clinician anyway. There’s no such thing as a proxy clinician. This isn’t Integrative Care – it’s malpractice.
So I expect that what Dr. Dawson says, this is just a way station on the way to no psychiatrist needed, is probably right. Managed Care sees no need for Psychiatrists – never has, and many of our academicians and thought leaders have done their dead level best to help them with that goal.
But that’s just the start of my tirade. I am a Primary Care Physician – an Internist. I practiced as an Internist who was obviously attuned to mental illness. I tried like hell to do what that model suggests, and I couldn’t bring it off, and I don’t think I ever could have. That’s why I did another residency. Mental Illness is different from physical illness and requires a different mindset – no matter how hard our evidence based, measurement based, neoKraepelinian, key opinion leader, clinical neuroscientists have tried to say otherwise. And here’s my most recent simple example.
The adult clinic where I work is truly unique. It’s for the uninsured without resources. There’s only one paid employee, everyone else is a volunteer. We’re all old, retired people including the doctors – all from the upper ranks of the profession. The pharmacy is run by a former Dean. The escorts are retired rich people. It’s truly remarkable. I see way too many patients when I work, write more prescriptions than either you or I would like for me to write. There are no resources much, and psychotherapy is out of the question. So why do I work in a place where I have to do a lot medication management and mostly a ton of social work? It’s because I’m sure I’ve stopped more medications than I’ve started. I’ve succeeded in getting people off of absurd meds like beaucoups of atypical antipsychotics and antidepressant polypharmacy. I can at least stop meds that don’t work, deal with withdrawal and akathisia, and I’m learning the methods how to slowly get people to change their lifestyle rather than pray for stronger pills – including the pills that are ubiquitous on the streets here in Appalachia. My medical colleagues in the community and in the clinic are wonderful people, dedicated doctors all, giving away their srvices, and they don’t have a clue [and I can’t teach them]. They think, "person depressed, give antidepressant" and "antidepressant didn’t work, add yet another" and "anxious, no Xanax these days, use Seroquel."
I can assure you that either version of Integrative Care will lead to even more overmedication, as will screening with the PHQ-9 [or maybe the Kupfer/Gibbons CAT tests]. But I have yet another objection. Even with psychiatrists that have drunk the modern kool-ade and are practicing with brief medication visits filling their appointment books, their prescribing is not nearly so bad as that of Primary Care Physicians. Besides having seen patients on medications prescribed by both sets of doctors, I have another impeccable reference for that statement – PHARMA. I’ll give only one of many examples, this from Eli Lilly and their Zyprexa antipsychiatrist campaign [see Zyprexa: so what’s wrong with Martha?…:
Primary Care Physicians are symptom and minor illness doctors. They sift through the everyday cases and refer people who need more. The drug companies knew that and specifically targeted them to look at mental illness as symptoms in need of meds – as above. If they saw it as psychosis, they’d refer. They prescribe more frequently, more medicines, to more patients, and they don’t take people off of anything. Lilly’s Zyprexa campaign against psychiatrists was the most blatant [and cynical], but just part of a general trend. Even at the peak of the psychopharmacology age in psychiatry, they wanted Primary Care people writing the scripts.
Pharma understands with great clarity the most important part of the medical process for them is when the pen touches the prescription pad. They also understand that if they can remove psychiatrist from the process they can remove PCP’s and move to a illness script based system where compliance is the only measure.
The only thing standing in their way are a bunch of boring old men and women who remember a better way.
Steve Lucas
Please allow me to remind everyone that the APA also endorsed a belief system in which meds do all the work, thus psychiatrists are unnecessary http://1boringoldman.com/index.php/2012/10/10/why-wouldnt-they-want-to-hear-that/
Healy noted further that when data surfaced showing a link between antidepressant use and risk of suicide in children, the APA issued a statement proclaiming that “we believe that antidepressants save lives.” “What I believe they should have said is that the APA believes that psychiatrists can save lives because it takes expertise to manage the risks of risky pills,” he said; if psychiatrists’ only role were to dole out drugs, then less trained physician’s assistants could easily replace them, he noted.
It’s a self-inflicted wound and could be fatal, but worse is the damage these drugs will do before anyone with enough authority to slam on the brakes does so. The costs of drug-induced diabetes and organ damage are already in the figures, but no one is trying to assess their causes. No one is even trying to figure out what percentage of psychoses are a result of taking or stopping a psyche drug, as far as I can tell. I’d love to find out otherwise.
In the long run, these drugs and the ease with which they are prescribed are costing too much. Treating misery with more misery is a losing proposition all the way around, no matter who writes the prescription. As much as I respect present company, the field of psychiatry has, in my opinion, at this point, caused more harm than good and is a threat to the health of our species and others, judging from what I’ve read about the effects of all these drugs in our water supplies.
At this point, I think we need social pedagogy more than anything else. We are social animals living in an asocial society that makes most us sick. Whether or not that interferes with our ability to be “productive” isn’t really the most salient factor in the big picture.
Steve,
Big Pharma understands that a pill offers a buffer against the usual managed care discounting that every other service is subjected to. But they also understand that they can get a sweetheart deal with an MCO for a bundled package of meds, including a deal that would eliminate their competitors form the formulary. Removing the physicians form the loop and getting your drug in the protocol is a sure formula for success. especially as physicians are replaced by prescribers.
There are much bigger fish to fry when it comes to protocols than psychiatry and the evidence for protocols is not much better. The editorial and article on protocol based care for early septic shock in the NEJM this week is a case in point. Also has good lessons on how a poorly defined diagnosis can have a marked effect on rates of illnesses of interest.
Thanks again for the shout out.
In a way, this is the essence of my blog – psychiatry becomes the medical specialty with an expertise in prescribing psychoactive drugs. An important caveat is that drugs are considered a minor, peripheral part of the system. In an admittedly provocative twist, I suggested it get subsumed by neurology.
Does anyone else find it ironic that our big role is to dial down the use of drugs? This constitutes treatment of iatrogenic conditions. That sort of counters this whole notion that we need more psychiatrists to treat all of the mental illness out there. You are suggesting we need more psychiatrists to protect people from the actions of our colleagues (and in my experience a good chunk of this stems from the many add on drugs people pick up if they happen to get hospitalized be it for psychiatric or substance abuse problems).
Dr. Steingard,
I considered your comment, and I think the need for physicians as psychiatrists is still there and not just to take/keep patients off meds. Consider the ideal of psychiatry and the practice. If you can get past Dr. Hassman’s emotions and writing style, you can find gems in his comments. I found this statement of his demonstrative of the ideal and very admirable.
…I chose psychiatry over psychology so I could have access to medicine as completing the options to offer for patient care.
So, do you throw out the ideal because the majority of the practice is a train wreck wrought by governmental indifference, poor practioners and business interests? Or, do you package up and call it neurology?
I had a few more thoughts, but I am running late for my job in yet another corporate environment. There, there is no ambiguity. Although they try hide it behind a bastardization of psychology (positivity, motivational theory, whatever they can use), it’s pretty straightforward it’s inhumane.
Polypharmacy is a topic that has appeared on other blogs, but always by doctors whose income is not impacted by upcoding and over medication. There is a cognitive disconnect between patient care and practice income and many times practice income wins.
With more practices being owned by hospitals or other corporate entities the drive for prescribers and enhancing patient revenue it will be an uphill battle to bring some sense of restraint to this issue.
Steve Lucas
This may be the dumbest collective professional suicide of all time.
We are a demand specialty. Cash only psychiatrists are booked for months.
The APA asking its members to take a “leap of faith” for this cause is like asking Jennifer Lawrence to troll for dates on Craigslist.
Why do people act desperate when they are in the driver’s seat?
Private practitioners who still belong to the APA really need to examine the rationality of their membership.
Dear Dr. Nardo,
I’m writing to express my deep appreciation for your blog, and my joy that you exist and choose to pursue the causes you pursue. I’m a psychiatrist just a little behind you in age (I trained at the University of Kentucky 1972-75). I aso know your part of the South, having grown up in Eastern Kentucky and going to college at Wake Forest. I’ve spent my years on the fringes, more interested in family therapy than in pharmacotherapy, but almost always involved in one way or another in the training of Family Medicine docs. During my residency, I witnessed first-hand the infiltration and takeover of my department by Wash U-trained psychiatrists who were medicalizing everything with reckless abandon.
I have trouble staying calm and restraining myself enough to sound sane to my colleagues about the many things that are wrong with psychiatry today. Your blog gives me the most consistent and reliable balance of current information to support my arguments and (relatively) calm, considered compassion in arguing for change.
This particular post is a fine example of what I have come to depend on you for. I’m still working full-time in an ever-more-corporatized hospital in the Chicago suburbs, trying to help future family doctors have a sane approach to dealing with psychosocial problems and not overly medicalize them. I hope that when I retire I can use my energies in the ways that you model so well.
With great affection,
Gene Combs
Sandy, what is the basis of your conclusion that in the brave new scheme of things, the role of psychiatrists will be to dial down the use of drugs? What I’m seeing is a trend towards psychiatric drugs to accompany medical treatment for widely assumed “co-morbid” conditions.
In other news, here’s an overview of the APA meeting agenda http://www.medpagetoday.com/MeetingCoverage/APA/45527 I’m not seeing much mention of the APA’s promotion of “integration.” Perhaps they’ll spring that on the membership next year.
Alto
Integrative Care is what that bottom line refers to.
I think there are many wonderful ways to be of help to people who might find their way to a psychiatrists office that do not involve drugs. I welcome Dr. Coombs and I count narrative therapy as among those things. I also believe that psychiatrists are capable of offering more than drugs. I also believe there are good people who also happen to be psychiatrists who have been of help to people.
However, I do not think a medical education is necessary to be able to offer these things. A medical education is expensive and people who endure it expect to be paid a lot.
In my role as an administrator of a CMHC, I would be hard pressed to explain why we would want to pay a psychiatrist to do psychotherapy when we can pay a well trained highly competent clinician to do the same thing at a much lower rate.
Dr. Mickey, if the Medpage people have interpreted it correctly, it looks like the new practice and perception is neuropsychiatry or, if you will, the bastid child of neurology and public relations.
The reason I see a need for a physician who also understands mental health is two-fold, and it has little to do with psychotherapy.
One, is for diagnosing those with medical problems that masquerade as mental health problems – and they should be paid for doing so. It is too easy to either medicate, or to send away to a therapist, the person with sleep apnea, anemia, low B12, etc. In my case, two psychologists are the only thing that stood between me and a depression diagnosis. Note, that I wasn’t Ph.D. shopping, just pursuing my own differential diagnosis; something my PCP of 8 years wasn’t doing. The first psychologist I went to was through EAP and the second one I went to was affiliated with the sleep clinic I go to. Both had their own practices. However, had they been embedded into the primary care practice and working closely with my PCP, I doubt they would have been as willing to tell me I had a medical problem, not a mental health one. As it was, my PCP tossed the letter from the first one aside in disgust. He never saw a letter from the second one, as he was no longer my PCP at that point.
Two, is for those with a mental health diagnosis that need medical treatment. I think it takes a special breed of physician who wishes to work with the mentally ill. There are too many horror stories of their medical maltreatment because of labels assigned to them to think that those without experience working with the population take them seriously when they relate their symptoms. I agree that in this situation having primary care physicians and certain specialists embedded in mental health clinics is a huge benefit. When they are few in number working in your environment they can adapt to your attitudes vs. the opposite situation I described above.
I understand that they are psychiatrists who do things now that are the same or worse than I the things I’ve mentioned, and that good and bad alike are only being paid for prescribing drugs. However, I’d like to see that remedied instead of trashing the idea of the combining a knowledge of treating organic illnesses with a knowledge of psychology.
Dr. Nardo,
Thanks for rearranging the JAMA version. I hadn’t noticed it before, but what really stands out in yours is how many points of failure there are in this model. There is only one direct contact with a physician and one redundancy, and since I doubt that patients will be reporting their symptoms to the PCP after the initial few visits, both of those will disappear.
In the infograhic, they were smart to put the patient in the center of it, even if it is just pretend. And, looking at it, I keep thinking that this is the model we already have today, if only insurance would pay for it and the different providers would communicate with each other.