What would you like to see if you had your druthers?I work in an institution that is trying to employ a collaborative-care kind of model. Where PCPs do the prescribing but they consult with a psychiatrist, and they work with a non-licensed person who is trained to do behavioral activation therapy and administer the PHQ-9.
I don’t worry that much about the guy who does it at the practices, I’m familiar with. He’s smart and thoughtful and will probably go to grad school in psychology. He’s only supposed to work with people with mild to moderate depression, but the PCPs frequently use him to facilitate access to psychiatric care – so getting someone with a serious psychosomatic illness, who is burning through specialists, in to see a psychiatrist. But a fair number of patients who have been diagnosed by their primary care docs as having mild-moderate depression have quite a lot more going on – most often substance abuse but also cutting. He promptly refers them to the right level of care, though getting them in can be hard.
Personally, I’d feel better training psychologists in psychopharmacology and having them, rather than PCPs, prescribe psychotropics to the medically uncomplicated [I’m sure I’ll get a lot of blow back on that].
What I would advocate for, is a kind of annual visit with a psychologist that’s comparable to an annual with an internist. Someone who can track your mental health over time, encourage good care and know patients so that if things start to go awry, either that general practitioner or a different kind of specialist can be called in quickly. So, say, if a young person starts to develop psychosis, it can be watched for a while, and if it really does get serious, there’s already a mental health professional in the picture that s/he has known for a long time and trusts.
We overscreen for depression and overprescribe, but a lot of the patients with much more serious illnesses are falling through the cracks.
Mickey, what would you advocate instead of the questionnaire-based screening to help those who are not getting care get it?
He’s only supposed to work with people with mild to moderate depression, but the PCPs frequently use him to facilitate access to psychiatric care – so getting someone with a serious psychosomatic illness, who is burning through specialists, in to see a psychiatrist. But a fair number of patients who have been diagnosed by their primary care docs as having mild-moderate depression have quite a lot more going on – most often substance abuse but also cutting. He promptly refers them to the right level of care, though getting them in can be hard.
A lot of medical care and particularly psychiatric care is already preventive medicine. I keep people out of jail and out of emergency rooms. I write more prescriptions than I’d like because it’s all I’ve got, for one thing, but also because with a little safe medication and support, I can prevent people from going to the GP/PA offices where they throw medicine at them [adding without subtracting]. And when those with more serious mental illness come along, I have to stand on my head to get them what they need – and even then, I have to settle for much less than is really necessary.
Reading those papers on screening or collaborative care, there are multiple conflicting streams. Don’t let a single patient fall through the cracks and keep people away from services that will cost a mint. Treat all the depression and serious mental illness that’s out there and don’t overmedicate them with anxiolytics, antidepressants, and antipsychotics. I personally think that a major force behind the overuse of medications is that everything else has been eliminated as being not "evidence-based" – meaning getting people "well." The truth is that like the rest of medical practice, "well" is not available in most cases. "Better" isn’t guaranteed. Often, the best we can do is keep people from getting "worse." With physical disease, chronic and ongoing care can’t be ignored. In mental illness, it can be ignored – and has been to an alarming degree. The powers that be decimated mental health care because they could, not because it was a good idea.
I do think a medical degree is necessary to prescribe…what I am questioning at this point is the relative benefits of a psychology Ph.D. after the M.D (and licensure) as opposed to psych residency. There are psych internships as opposed to flex…maybe a year of that is really enough foundation on the pharm if you factor in ongoing learning which is really the actual basis of pharm in practice. The part of psych residency in the eighties that really stuck with me was the psychodynamics. The meds have all changed. It was Haldol and Elavil back then. Yes, I use Elavil but at a tenth of the dosage and for pain not depression.
Glad I don’t practice in Rhode Island:
http://www.providencejournal.com/article/20160215/NEWS/160219567
It moreso ties in with your last post, but, think about this for a minute: screening for depression will eventually lead into screening for other “more prevalent” illnesses, and who really benefits, if not the operative word really is “Profits” from considering controlled 1 substances.
The world is going to, wait for it, pot. The degradation of society is not incremental anymore, as the substance abuse lobby gains such strength it is beyond frightening. The screening should be for substance abuse with everyone first, and make sure to include controlled substances by physicians in the screen!
Dr. O’Brien, that is an intriguing suggestion. The current direction is almost the opposite.
It seems to me that the collaborative care model has got something turned upside down. It is acknowledged now that antidepressants are not much better than placebo for mild to moderate depression, which is what is going to be picked up on screening tests. (Severe depression does not require a screening test to detect, does it?) So the mild to moderate cases are going to be referred to a busy family practitioner who is going to prescribe an antidepressant (what else can he or she do?). The severely depressed patients will be seen by someone else, but not really immediately by the psychiatrist, so they may not get a prescription for an antidepressant, which they might benefit from.
Or am I simply misunderstanding how this new model is going to work?
Was that Rhode Island article “developed” with a “grant” from Woody Harrelson?
jOB- a psychologist with really good pharmacology training could probably do a better job than some of the primary care NPs doing it now.
I live in a state with a high concentration of psychiatrists, and there are still not enough. Having someone who can diagnose and refer to an MD for more medically complex patients seems like a good idea to me. It would be better than having the PCPs do it in 10 minute appointments.
The problem with East Coaster’s response is that he thinks a PHQ-9 score at some level means a person needs to be put on antidepressants. We have the same problem that we have with opioids and are trying to solve it the wrong way. Antidepressants are overprescribed and there are not enough therapists. It may not be noticeable when managed care companies are mismanaging psychotherapy at a greater rate than they are mismanaging psychiatric care. The last thing that is needed is more prescribers. NP and PAC schools are cranking out rafts of prescribers for psychiatric medications.
For the past 2 decades we have needed far more therapists than prescribers.
I don’t really understand how a person with absolutely no medical training is going to prescribe to complex medical patients. But I guess that’s the final puzzle piece in a rationed, low quality system of care. PHQ-9 screening is a deeply cynical approach to psychiatric care.
Dr. Dawson, Shedoes not think that at all. She thinks that the screening tools are almost iatrogenic- likely to depress the already depressed. (Read my second comment in that thread.) What she does think is that it is better for people who do need meds to get them from someone who also does therapy, and nobody seems to have a good plan to create enough psychiatrists to meet the need.
She also knows that patients frequently get lost to follow up and fall through the cracks. They are frequently the patients in a panel who haven’t been in for a while. The more dysfunctional the situation the less likely the patient is to present in an office of his own accord.
“What she does think is that it is better for people who do need meds to get them from someone who also does therapy, and nobody seems to have a good plan to create enough psychiatrists to meet the need.”
I would agree with that statement but not with the idea that Americans need any more antidepressants, antipsychotics, mood stabilizers or benzodiazepines much less opioids or stimulants. More prescribers colludes with the illusion that “collaborative care” as it is currently constructed is little more than managed care PR effort to show that they are treating mental illness.
They are not.
Furthermore – if you ever successfully convert therapists to prescribers – in the current system of care – they will never be therapists again.
GD- I’m sure that that’s true “in the current system of care” your point is true. I’m trying to think about the system of care that would be desirable.
No, I don’t think that larger numbers of people need more antipsychotics. I do think that there are people with actual psychosis who are not getting them or are not getting any care at all.
I think that the current system of medical education weeds out a lot of the people who would be good psychiatrists, and there need to be alternative paths.
Of course, you are free to disagree with me.
But, GD, let me ask you the question I asked Mickey as well: how would you design the system if you could?
Health care agendas proposed by non clinicians, especially politicians and those with business/profit agenda, almost always have NOTHING to do with helping the well being of the populace, but, just special interests and personal gains.
This is not rocket science folks, this is about seeing the truth for what it is, and why aren’t we hearing about everyone get screened for colon cancer, or autoimmune diseases, or sleep apnea, illnesses that have an equal or greater incidence than depression does in this society?
Not a quick and easy buck to make on those disorders, eh?!
Oh, and those latter disorders, they need some objective testing, that seems to cost more to provide, sooo…
is it about the public, or about the profit?
Oh, and a shout out to Dr O’B above, cue Cheech in his car, having his PTSD moment after he realizes he is parked and not driving:
not always helping the situation, THC is a muddled substance, eh?
Think about it colleagues, with the tolerance of marijuana across the country, if pot is helping patients with mental health issues, then, to be as candid and brusk as possible, why the hell are they in our offices!?!?
If the thought is that pot takes the edge of PTSD, the same argument can be made about a couple glasses of bourbon. Which no sane doctor would prescribe for obvious reasons.
The medical pot arguments are basically medical booze arguments and I have no desire to go down that rabbit hole.
I saw a woman decked out in 420 pot leaf gear getting on a commercial flight with her companion toy dog. Might want to revisit how that game plan is working out for your anxiety, I think.
JH- we do have programs for colon, cervical, and breast cancer screening. Those are the major quality measures for my institution’s primary care physicians.
Colleagues
It seems to be the conventional wisdom that anti-depressants don’t work on mild to moderate depressions.
The two missing concepts are demoralization and atypical depression. Demoralization comes from taking some bad hits and concluding it is your own fault. Jerome Frank made a good case that’s what brings people to psychotherapy (where behavioral activation and vacations work). The other issue is that most MDs have suppressed MAOI attention since both patients and MDs are unduly afraid of them. However early onset atypical depression is a large component of outpatient practice considered moderate–the don’t get hospitalized or talk suicide ‘DSM even includes them as a parenthetical modifier. It’s true ssri snri are not useful-may make some worse. But MAOIs work and the ridiculous situation that you have to prescribe thru Canada to bring in Moclobemide (the very safe RIMA) is intolerable-but tolerated since there is no professional push to bring them out of their status as Experimental Drugs–Note sold all over world by Roche ,who on misguided economic advice never brought it to FDA as depression Rx.
Cordially
Don Klein
Hey, EastCoaster, I am not saying Marijuana has NO place in the medical community as an intervention, but, I don’t see it as a viable, reliable substance for treating 95% of psychiatric illnesses. Note I leave random chance 5% to validate the infrequent legitimate exceptions…
Again, think about it from my perspective for a minute, please. Patients come in and tell me how pot helps improve their mood, thought, and anxiety issues, and then want me to prescribe other controlled substances to allegedly help these same problems. Umm, it is drug seeking folks, and talk to people in recovery the past 3 or so years, and they will admit that there is a growing effort of active addicts to get their booze, coke, and heroin from White Coat Dealers per the Benzos, Stimulants, and Opiate Rxs respectively.
SO, I am deeply offended by the lies and manipulations, and I will NOT be an enabler or codependent supporter. Nope, if the pot works, there are ways to get it these days in most states, in reasonable quantities mind you, that don’t need a doctor to validate the treatment intervention.
So, let’s stop the disingenuous and dishonest efforts of pot addicts and call it for what it truly is: denial, projection, minimization, deflection, and pathetically pathological rationalization.
Hmm, the defenses of the addict and personality disordered. What a nice package deal for many I have seen in my travels over the years.
Hey, the somatic providers will be more than eager and willing to fill this alleged void, after all, they write for more than 80% of antidepressant Rxs these past what, 15 years, and my bet, over 66% of benzos, and we know who writes for at least 80% or more of opiates.
Thank you for passing my office door, which will be closed permanently at the end of June as a private practitioner, you can read the post at my blog tonight if interested, and not per this issue specifically.
Cheers, this Bud’s not for you!
Dr. Klein, do you think there are a number of instances where SSRIs don’t work (or make things worse) where an MAOI would be of benefit but a SGA is used instead? Where features that in the past would have been thought of as atypical depression are now thought of as “bipolar spectrum”?
““collaborative care” as it is currently constructed is little more than managed care PR effort to show that they are treating mental illness.”
“if you ever successfully convert therapists to prescribers – in the current system of care – they will never be therapists again.”
Both important points.
Huge points!
I’m glad someone else is supporting MAOIs in clinical practice so I don’t come off as a broken record. Why are we deathly afraid of tyramine reactions (which is not even an issue in transdermal seligiline) and indifferent to serotonin syndrome, NMS and TD?
1boringyoung- I don’t disagree with your first point at all. I worry about the model quite a bit. The person I know doing it doesn’t worry me that much, because he doesn’t apply the model rigidly. He works around it under the radar. In other words, I think he does good and useful work despite the model.
Patients who need help do benefit from a warm hand-off to the hospital’s psych services and not just a list of local therapists in the area. Again, I’m not advocating the current model of collaborative care.
I was asked if the creeping bipolar spectrum includes patients who better fit atypical depression. If close attention is paid to the cardinal features of atypical depression ,as well as to its differential course, there is no reason to think of patients who only manifest those features as bipolar.
It has been claimed that “atypicals” are actually bipolar 2 but not my experience and I don’t believe independently documented.
However ,conversely, those with clear episodic hypomanias or manias almost always also have depressive episodes . I think these are heterogeneous some having melancholic features and respond to ssris et al and ECT. However many others (40-50%??) have atypical features-prominently overeating,oversleeping,while maintaining pleasure in food and sex-These often respond to MAOIs but not to the agents primarily used–SSRIs and ECT (maybe for two weeks and quick relapse).
The conventional wisdom is that bipolar depression is hard to treat. I think this view is largely due to lack of differential diagnosis among bipolar depressions , as well as the general aversion to MAOIs among doctors and frightened patients. That MAOIs cause such doctor aversion is probably due to the remote possibility of an attributable acute episode in comparison to the slow onset of obesity etc, from the new generation of anti-depressants and anti-psychotics.
Cordially
Don Klein
Extremely informative response Dr. Klein. Thank you very much for your time.
Dr. Klein, just curious, do you have any experience with EmSam?