by Matthew J. Press, M.D., Ryan Howe, Ph.D., Michael Schoenbaum, Ph.D., Sean Cavanaugh, M.P.H., Ann Marshall, M.S.P.H., Lindsey Baldwin, M.S., and Patrick H. Conway, M.D.New England Journal of Medicine. December 14, 2016DOI: 10.1056/NEJMp1614134
For example, under CoCM, if a 72-year-old man with hypertension and diabetes presents to his primary care clinician feeling sad and anxious, the primary care team [primary care clinician and behavioral health care manager] would conduct an initial clinical assessment using validated rating scales. If the patient has a behavioral health condition [e.g., depression] and is amenable to treatment, the primary care team and the patient would jointly develop an initial care plan, which might include pharmacotherapy, psychotherapy, or other indicated treatments. The care manager would follow up with the patient proactively and systematically [using a registry] to assess treatment adherence, tolerability, and clinical response [again using validated rating scales] and might provide brief evidence-based psychosocial interventions such as behavioral activation [which focuses on helping people with mood disorders to engage in beneficial activities and behavior] or motivational interviewing. In addition, the primary care team would regularly review the patient’s care plan and status with the psychiatric consultant and would maintain or adjust treatment, including referral to behavioral health specialty care as needed.
"an initial clinical assessment using validated rating scales. If the patient has a behavioral health condition [e.g., depression] and …"
"[again using validated rating scales] and might provide brief evidence-based psychosocial interventions such as…"
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adjectives saying that something is evidence-based [meaning positive clinical trials]: validated rating scales, evidence-based psychosocial interventions, evidence based psychotherapy, indicated treatments, guideline approved this and that, etc. The gist of things is that only group-certified interventions are valid…
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traditional language is de-psychiatrized and de-medicalized: behavioral health care manager, behavioral health condition, rating scales, behavioral health specialty. behavioral activation.
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strict control, limiting choices and duration of anything: [now we get to brief] – particularly any face to face contact with psychiatrists.
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adverbs implying contientiousness and industry: proactively and systematically [using a registry]
Just a couple of observations. In every example, the cases are universally lite – unlikely reaching anyone’s standards for mental illness proper. I didn’t really know what behavioral activation and motivational interviewing were. I watched a few youtube videos and looked at several trials of the latter [and there have been many] with widely varying results. They’re behavior modification interview techniques. But the main thing I took away from thinking about this hadn’t occurred to me before. In a way, I’ve already done this myself for over thirty years. I did it in the clinic where I’ve been working for the last eight. And when I was on the faculty, I did it somewhere in some affiliated facility on most days. The med students, or residents, or staff saw the patients and presented them. Sometimes I said "fine." Sometimes we talked about the case. And sometimes I saw the patient myself. I expect most psychiatrists have done this kind of thing at some point in their career for years. But I’m absolutely sure I wouldn’t do this one.
The secret to being able to supervise other clinicians in a situation like the one described here isn’t some encyclopedic knowledge of medications, or diagnoses. It’s in being able to get to know how to read the clinician you’re supervising. Early on, I expect I saw most cases a given resident presented. But as I got to know them, I learned when I could trust what I was hearing, versus when something wasn’t right. One almost never knows what’s out of whack from such a presentation, just that you hear yourself saying, "Let’s go take a look." It’s a skill that comes with experience and a lot of it. Of course, the best trainees say, "I don’t know what’s going on with this case. Would you "take a look"? But others don’t know, and so [1] you "take a look" and then [2] try to help them figure out why they were off track, what they missed.
So I guess I know the reason I’m absolutely sure I wouldn’t do this one. That whole system being described up there is designed to keep me out of the room the patient’s in. They don’t need me to help them with behavioral activation and motivational interviewing. They know how to do that certainly better than I. And most of the time, the Primary Care Docs don’t need me to pick an antidepressant. One learns that kind of thing quickly. What they need is someone who has spent a lifetime around suicidal and psychotic patients; who has actually seen most of those unusual medical cases that masquerade as mental illness that most doctors only heard about in medical school; someone who has missed a few diagnoses along the way and knows the dire consequences, is acutely aware when something smells funny. And in this proposed Integrative system, I’m not the one who gets to say, "I need to see this person." Usually, I’m hearing about the case from a care coordinator who may be giving me second-hand information. And even with stable outpatients who aren’t getting better, I wouldn’t have much of a clue how to get the case on track without either seeing the patient, or making sure they’re being seen by someone who really knows the ropes and doesn’t speak new·speak.
Note: When I started writing this post, it wasn’t at all clear to me where I was headed. It’s been that way every time I run across a Collaborative Care article or reference. My reaction has been visceral. It wasn’t until somewhere around that lightbulb up there that I finally could put some words to my reaction. Reading the various versions of Collaborative Care, I always feel the same. But now I can at least make sense of why I respond so negatively. In the system as proposed, I can’t do my job – the actual job assigned to me. I can’t be in charge of saying "Let’s go take a look." And if I can’t do that, there’s really no reason for me to be there in the first place.
As a retired Psychologist, I’m interested if what they mean by “validated rating scales.” Their example of a 72 year old man is very generic, since that man could be white, African-American, Asian-American, Native American, Hispanic, etc. Unfortunately, Psychology has a long history of “validating” tests and rating scales on white subjects, but then generalizing those tests and their interpretation to non-white subjects. So, for whom is the scale valid and for whom is the scale not valid? And do they know the difference?
Thanks for these musings. It was very interesting to see the thought processes used by an attending. Thank goodness, I was one of the folks who said “I just don’t know.” I don’t have any sense at all that this ability to question one’s self is at all being supported these days in any area. And you must have had a lovely ability not to show your thoughts during presentations. I was called on the carpet privately, for allowing my eyes to roll by a very kind attending. Though at this point in our medical framework the ability for a medical resident to pick up on eye rolling by a member of the medical team would be a good thing. So many are oblivious.
Regarding your aversion to the lexicon – this reminds me of Orwellian “doublespeak” and therein lies an excellent tool for making human things not human. Again the human connection is purposely left out.
Again a walk back in time is in order here. Back when I started working in a teaching hospital there were the latest and greatest new thing – MBA administrators with graduate degrees but little to no expertise with the medical world of both the professions and the patients. The ones that I knew were clueless in the values and cares of the social work world that I inhabited.
My sister had an engineering degree and MBA -which I helped her with at times. But she was so aware of her world of biomechanics and the acknowledged and actually sought after the patients and their families’ feelings, thoughts, and ideas.
So it was not just the degree. There was something in the air, the water, that dismissed humanity and gave rise to where we are now with the lexicon of robots.
I like this entry and these two comments. Most algorithms present dumbed down views of human beings. Maybe I’m inept, but I’ve often been wrong when I thought I “knew” something about a client without listening long and deeply to them about their lives, relationships, dreams and fears.
“Validated rating scales” offer an excellent way for clients to feel they are neither known nor cared about. And the “evidence base” for meds is mainly spun or fraudulent clinical trials. I’m all for psychosocial methods, but their “evidence base” is messy too. Barry Duncan has it right – there is little difference among psychosocial methods – the big difference is the presence of “common factors” that amount to therapists making real human contact with clients/patients.
What I “know” about theory or about a particular client/patient – even if accurate in some sense – is often less important than whether my client feels they really matter, what’s inside them is important, and they are safe enough in my presence to be who they really are.
Many of us, when we get scared or confused, cling to the need to be and appear “knowing.” When things get confusing, we’re drawn to simplistic “rating scales” that wring the complexity out of humans. And, what can we really know unless we actually get to be with the person we are trying to think about?
Thank you for wanting to actually see people; for noticing that “validated” rating scales often distort; and for simply being aware and smart enough to say so when you don’t know.
Semi-OT. I once saw a presentation on WHAM (Whole Health Action Management) a program for individuals with serious mental illness to take charge of their mental and physical health. A lot of stuff on the relaxation response, building good relationships, exercising etc. It’s put out by people with histories of serious mental illness who try to share their experiences. It might be useful. I don’t know, but they were trying to do some “research” into its effectiveness. The trainer woman said “we’re getting ready to *evidence-base* it now.” So, it’s a verb now, which seems even more pernicious. It’s not exploring an hypothesis but jumping through hoops to “show” that something the practitioners believe to be true is. People do that all the time, but this struck me as the statement of an incurious mind.
I found my 2004 edition of “Standards for Educational and Psychological Testing” which under “Validity” notes that “It is the interpretations of test scores required by proposed uses that are evaluated, not the test itself.” (p 9). and under “Reliability and Errors of Measurement” notes that “…the level of reliability of scores has implications for the validity of score interpretations…the data also bear on the consistency of classifications of individuals derived from the scores.” (p. 30).
I can only imagine what will happen to patients when policy makers and practitioners don’t understand the validity and reliability of their rating scales.
Here is what comes to mind for me Mickey when you presented this hypothetical patient with high blood pressure and diabetes who is 72 and has depression.
I wondered if anyone had reviewed his blood pressure meds to see if they are causing his depression. Beta blockers particularly are known to do this.
Regarding his diabetes, he most likely was referred to a CDE who advised him to eat a moderate to high carb diet and cover blood sugar fluctuations with meds. Many people on diabetic board followed that advice and kept getting worse which naturally they found depressing. It also couldn’t have helped their mood to go from extreme BS highs to lows.
It was only when they found out about how high fat, low carb diets stabilize blood sugar, that their health greatly improved which of course was a mood booster.
Of course, I am living in fantasy land because it is much easier to throw a psych med at the problem and send the patient on their merry way vs doing any investigating of whether depression is related to physical issues. I would like to repeat what I think of this practice but I don’t want my post to be rejected.:)
Thanks for hearing me out.
I use validated rating scales (the Outcome Rating Scale and the Session Rating Scale) in each session with my clients. I am a big fan of using them, to measure if clients are experiencing less psychological distress, and their sense of therapeutic alliance with me.
However, they are NOT the sole answer. They are to be integrated into an ongoing therapeutic dialogue with the client about why they responded to the scales in the way they did, what the scores mean to them, and what changes they want to make in their life. The scales are important and meaningful, in the way that blood pressure readings are important, but they need to be woven into a full understanding of the client and their life.
You make an excellent point – see the previous post [big thing, small package…] “Check out the hardware [a medical condition or medication that might be contributing].” Sure, it might be easier to throw an antidepressant at it but it won’t help the side effects of other drugs a bit. You’ll never be rejected for making that point here. In medicine, the general rule is that you don’t institute a symptomatic treatment until after you rule out treatable underlying causes! And in the elderly, a depressed mood is often a call to stop some medications rather than start some new ones…
What an excellent idea. If only medicine would adhere to treating underlying causes for mental health problems. Yesterday, my clients were in distress as a result of a) PTSD from workplace and physically abusive father, b) severe bullying in childhood at school, c) being raised by alcoholic parents d) mother being extremely controlling and e) emotionally abusive mother.
The underlying causes to their distress was clear. There was no reason for them to be on medication, because the cause(s) were clear, and treatable.
If this principle was applied rigorously in psychiatry, then vast numbers of people would be off any psychotropic pills, until the childhood trauma or stressful life event had been treated with therapy.
Our managerial class overlords have mastered the rhetorical art of appearing to care and while doing nothing of actual value. It’s all pure sophistry and linguistically this garbage is so laden with status and mind-set signifiers it makes coded fraternity talk at the midsemester kegger look dignified and intellectual.
Much as I dislike the collaborative care model, I will say that the one situation I’ve seen involves a geriatric psychiatrist who usually encourages PCPs to wean their elderly patients off of benzos. If the patient’s been on Librium for 50 years, the PCPs seem to ignore that advice – at least if the patient even once says, “I’m perfectly happy the way things are. Thank you very much.”
My hospital does have an e-consult service for a lot of specialties which seems useful. A PCP doesn’t know how a kidney issue should be managed and puts in a request with some specific questions to a nephrologist. The doctor is paid a small amount to review the questions and notes. If they think the PCP can manage it, they give them some suggestions. If not, the patient is referred to the appropriate specialist.
“If the patient’s been on Librium for 50 years, the PCPs seem to ignore that advice – at least if the patient even once says, “I’m perfectly happy the way things are. Thank you very much.””
That doesn’t happen because the PCP is ignorant of the drug’s side effects but because the PCP is cognizant of the role of patient satisfaction scores and the like.
Once again, bad medicine as a result of trusting apparatchiks and their phony quality metrics.
Mickey, thank you for your response. It is greatly appreciated and I will definitely check out the link.
As much as I hate Benzos, I am not sure it would be prudent to put someone who has been on Librium for 50 years though possible withdrawal issues, particularly if the patient .doesn’t want to get off of the med.
EastCoaster, I hope the psychiatrist is not tapering the patients off of the benzos too quickly, particularly if they have been on them long term. And are they replacing the medication with anything?
Thanks!
JO- I don’t think they’re worried about patient satisfaction scores. I think they don’t want to rock the boat or get in an argument with the patient. In these models the psychiatrist only makes a recommendation. The PCPs feel that the responsibility is being dumped on them and that they’re the ones who have to deal with the patient.