In my home town, there was a 19th century bridge across the Tennessee River. It was designed with bolts that were intended to be tightened and loosened with the seasons, but that never happened. Over a 90 year period, the subtle stresses and strains of seasonal expansion and contraction rendered it unsafe for auto traffic – unfixable. It’s now a tourist attraction as a pedestrian bridge.
The APA’s DSM-III revision in 1980 ultimately lead mainstream psychiatry to an exclusively biological focus and a deep entanglement with the pharmaceutical industry. My primary "dog in this hunt" has been the resulting corruption of the industry sponsored clinical drug trials in our peer reviewed psychiatric literature, and the collusion of the academic KOLs who signed on as authors. But the ‘subtle stresses and strains‘ from the ensuing three plus decades of inattention to the traditional domains of psychiatry have taken their toll in many arenas, and left the specialty ill prepared for the challenge of a dramatic change in the healthcare landscape and a growing disillusionment with the medication-heavy approach to matters mental.
Beginning in 2007 when Senator Grassley exposed a number of academic psychiatrists who were failing to report personal drug-company income, there followed a steady stream of revelations of scientific misbehavior and corrupt practices eroding confidence in psychiatry in general. Then, the exit of PHARMA from CNS drug development three years ago took things from bad to worse. The DSM-5 Revision had begun life a decade earlier dreaming of a triumphant transition to a biologically based diagnostic system, but floundered in a desert of non-confirmation – limping to its release barely even revised. Periods of paradigm exhaustion in science are rarely smooth, but this one has been abetted by disillusioning revelations and a reactionary and paralyzed establishment unwilling to deal directly with much of anything.
PsychiatricNewsby Vabren WattsSeptember 15, 2014
PsychiatricNewsby Mark MoranSeptember 23, 2014
PsychiatricNewsFrom the Presidentby Hunter McQuistion and Paul SummergradSeptember 26, 2014
PsychiatricNewsFrom the Presidentby Jurgen Unützer and Jeffrey LiebermanNovember 12, 2013
All healthcare specialties are currently trying to figure out how to fit into the new world of the Affordable Care Act – adapting their traditional identities to a new set of rules and a new theater of operations. Psychiatry doesn’t have that luxury – more starting from scratch, trying to create a new brand – a consultative identity that is as yet amorphous and very different from medication manager of recent years or the general psychiatrist of the past. It’s hard to see through the upbeat rhetoric what they envision psychiatrists actually spending their time doing, or if the primary care physicians they plan for psychiatrists to collaborate with are interested, or if psychiatrists are interested in filling that particular role. And it’s unknown how [or if] they intend to address the widespread misadventures of their predecessors – those longstanding ignored stresses and strains.
The APA is really not in any shape to pull off any far reaching changes in practice. At this point they are basically parroting the SAMHSA/managed care lines of “integrated care”, “collaborative care”, and “population based medicine.” It is a curious phenomenon that other specialists are not clamoring toward the same goals. If Cardiologists won’t forgo their imaging studies and procedures and settle for population based care with statins for everyone, I don’t see why psychiatry should give up a low tech, inexpensive procedure (the interview and assessment) and read PHQ-9 scores. The APA is also missing the boat in terms of how psychiatrists are adapting to the continued rationing and that is going into private practice and refusing to accept steeply discounted reimbursement. They should be following practitioners and supporting that model at least as much as integrated care.
In order for the APA to be relevant again they need to stop kowtowing to the government and the managed care industry. They need to be focused on treatment guidelines and advocating for what needs to be provided to assure adequate treatment. They need to be focused on academics and bringing all psychiatrists up to the highest levels on continuing education. They should aggressively attack anything else that is substandard care. They should stop using the rhetoric of cost effectiveness and promote models of care that already exist and provide a much higher standard than a depression checklist and a prescription for an antidepressant.
George,
Great reading of the subtext. Thanks for saying that side of things so explicitly…
Mickey
it seems to me integrated care is just another way to reduce mental health spending…..across all patient groups …patients with severe illness as well as patients with milder illness
integrated care is a matter of access to mental health care…not medical necessity defined care…appropriate, effective mental health care
integration of medical and mental health makes access to specialized mental health care even more difficult to gain than before…another barrier
integration is being promoted by payers…the federal government, the insurance industry, the states who are eager to reduce mental health spending even further…who seem to feel that any amount of monies spent on mental health care is too much…this campaign started with the psychiatric hospital scandals of the 80s
cooperation between medical doctors who are writing most rx for psychiatric drugs and mental health specialists makes sense….mental health is not part of the primary care physician…
i am wary of this federal and state urgency….i remember the IMD exclusion h was promoted as improving access to mental health care by moving the main site of care to the community…… legions of homeless are visible reminders of the success of that effort
one of the rationales for integrated care is to improve the physical health of smi patients…..it is hard to grasp how poor medical care of smi patients is improved by eliminating mental health specialty care from their treatment regime
It is staff, in the APA’s case Saul Levin, that supplies continuity of policy and focus in a medical society organization. See http://www.washingtonblade.com/2013/05/21/gay-washington-dc-psychiatrist-saul-levin-named-head-of-american-psychiatric-association-apa/#sthash.3XW5603Z.dpuf
“Levin started a heath care consulting company for which he served as president for the next 10 years.”
His background is government agency and managed care. Therefore, expect more of the same from the APA.
Dr. Dawson,
Just wondering, are you still a member of APA and AMA? I don’t want to belabor the point, but you seem to disagree completely with the direction they are going, yet you still financially support them.
To me this is the easiest problem in psychiatry to solve. Choke off their funds if they are leading us off a cliff. Problem solved. But….inertia?….nostalgia?….friends?….what?
I think psychiatry will effectively be irrelevant in 10 years thanks to APA. At least psychiatry under ACA. It will effectively be the equivalent of an expensive private school in a nation of LA Unified School Districts, however, some psychiatrists will not make it such a system.
Dr. O’Brien,
I am a member of both the AMA and APA and as you correctly point out disagree completely with their positions on managed care, the PPACA, and their approaches to advocacy. Both organizations support the PPACA and the various collaborative care models. That said – maintaining my membership does allow me to take a vigorous dissenting position in venues that only members have access to. I am quite sure that many would prefer that I just quit and leave it at that, but I know that quitting favors the special interests within the organizations. One special interests has been managed care.
One of my role models in that area was Harold Eist, MD – former Pres. and several other members. I am content to carry that fight forward, but you may be right. The APA and AMA may continue the march toward irrelevance. That is the same path to the US health care system becoming one big managed care debacle. You could argue that has already happened with psychiatric care but I think there is some hope when I talk with younger members who are not accepting assignment to panels in MCOs or reimbursement from these companies.
Harold Eist was the only President in recent memory who dared raising a finger at mangled care.
I’m afraid the organization is ruled by academics who are either indifferent to or hostile to the realities of private practice.
If APA gets its way with Collabo-care, remember your dues are being used for this purpose.
Psychiatrists aren’t the clearest thinkers when it comes to many real world problems. Or maybe we are collectively hypocrites. The vast majority of our profession favor universal care but won’t accept the reimbursement that comes with that commitment.
I can’t live with the cognitive dissonance (I take cash and make no bones about my opposition to ACA), I’m surprised that so many human behavior experts can.