1 Boring Old Man

Posted on Monday 12 May 2014

Director’s Blog: From Research to Practice

N.I.M.H.

By Thomas Insel and Pamela Hyde, SAMHSA Administrator

May 1, 2014

Conventional wisdom says that there is a long delay between a research finding and putting that finding into practice. Based on treatments for hypertension, that delay is usually described as 17 years. So it is especially worth noting an announcement last week from the Substance Abuse and Mental Health Services Administration [SAMHSA] that 5 percent of the Mental Health Block Grant allocation would be used to implement evidence-based treatments for first episode psychosis [FEP]. The overall approach – team-based, youth-oriented specialty care – was developed in consultation with the National Institute of Mental Health [NIMH], and is based on similar programs operating in Australia and Europe, as well as lessons learned in the Recovery After an Initial Schizophrenia Episode [RAISE] project. While part of the RAISE study is ongoing, completed studies in New York and Maryland have already demonstrated the feasibility of implementing this complex approach in community settings in the United States. Rather than a 17-year delay, the feasibility component of the RAISE project was completed in December, 2013, and is now being implemented by SAMHSA about 17 weeks later – a vast improvement in the timeline for moving research into real-world settings where it can truly have the broadest impact.

How did this happen so quickly? SAMHSA provides states funding via the Mental Health Block Grant to support local mental health programs. In this year’s budget, Congress directed SAMHSA to require that states set aside 5 percent of the Block Grant funds to support “evidence-based programs that address the needs of individuals with early serious mental illness, including psychotic disorders.” With recent experience demonstrating the feasibility of creating FEP treatment programs in U.S. community treatment settings NIMH staff developed an overview document for state planners and providers, Evidence-Based Treatments for First Episode Psychosis: Components of Coordinated Specialty Care [CSC], as well as a resources page that includes a variety of CSC program development materials, such as treatment manuals, videos, educational handouts, and worksheets. Like the interventions tested in the RAISE studies, CSC is based on collaborative treatment planning, a respectful and effective means for establishing a positive therapeutic alliance, and maintaining engagement with individuals and their family members over time.

To prepare states for the implementation of the set-aside, SAMHSA and NIMH are co-hosting national webinars to inform states of the evidence-based components of coordinated specialty care for FEP. In addition, SAMHSA will be providing technical assistance and resources to states as they develop and implement their plan. Some states already have significant investments to help individuals experiencing FEP. We encourage these states to coordinate existing programs with programs supported by the new 5 percent set-aside. We hope that, with this new Block Grant investment, leveraged by services reimbursed by Medicaid or private insurance, every state should be able to begin to develop or enhance early intervention services for FEP.

While SAMHSA’s mission is service and NIMH’s is research, we share the same goal of recovery for those experiencing a first episode of psychosis. Rather than a 17-year delay, this new announcement from SAMHSA uses the latest evidence to implement a much-needed innovation over the next few months across the country. This is a great example of what can happen when two agencies work together, moving research into practice to ensure the best outcomes.

The RAISE Project [Recovery After an Initial Schizophrenia Episode] has two studies. The one in New York and Maryland is RAISE Connection, Clinical Trial NCT01216891. Looking at the History of Changes, it started in October 2010 and was described as:

This study, the RAISE Connection Program, is one of the two independent research studies that NIMH has funded to conduct the NIMH RAISE Project. The Connection Program is being supported in whole or in part with Federal funds from the American Recovery and Reinvestment Act of 2009 and the NIMH, National Institutes of Health, Department of Health and Human Services. The Connection Program aims to compare two early treatment interventions for adolescents and adults experiencing a first episode of psychosis. The study will also examine the costs associated with the treatment interventions…

This study will compare two different approaches to helping people get these treatments and services: a team-based approach versus a facilitated community-based approach. The study will determine if one of the approaches is better than the other in helping individuals go to work or to school, live independently, and have enjoyable relationships with others.

with the responsible party being Jeffrey Lieberman MD. in February 2011, it was no longer recruiting. In June 2011, there were multiple changes. Dr. Lieberman was replaced as the responsible party by Susan Ellis PhD and it looks as if the target enrollment was dropped from 370 to 80, and shortened. The parts quoted above were changed to:

The Connection Program aims to to assess the effectiveness of a Team-based intervention for individuals with a first psychotic episode, observing outcomes over time for our study participants. When tracking outcomes, the Connection Program will make comparisons with what is known about the natural history of untreated first episode of psychosis as well as usual care outcomes from other experimental studies…

This study will adapt and evaluate the impact of a comprehensive and integrated treatment intervention for first episode psychosis to be delivered in real-world practice settings to promote symptomatic recovery, minimize disability, and maximize social, academic, and vocational functioning…

along with several other changes:

It’s listed as recruiting up through the last update in June 2013.

I read Dr. Insel’s blog post as something as a rah-rah-aren’t-we-swift-in-going-from-the-bench-to-the-bedside piece. But I was unclear about what it was that was being moved, so I looked it up on clinicaltrials.gov and looked at the history of changes almost out of habit. RAISE Connection started life as an uncontrolled comparative study, comparing two different intervention approaches in first break schizophrenic patients. Something happened [?], and it became a one-armed study with neither control or comparator, with a new recruitment period and a pared down enrollment. Dr. Insel presents it as a feasibility study.

So I thought I’d take a look at the other RAISE study, RAISE ETP [Early Treatment Program][NCT01321177]. It was registered in January 2011, around the time RAISE Connection was changed. So maybe RAISE Connection morphed into a feasibility study?

The ETP study aims to compare two early treatment interventions for adolescents and adults experiencing a first episode of psychosis. The clinical centers have been randomly allocated to offer one of the two treatment programs. Both treatment interventions are designed to provide a person with treatment soon after he or she experiences the early signs of schizophrenia. Participants will be offered mental health services such as medication and psychosocial therapy. These strategies are all aimed at promoting symptom reduction and improving life functioning. Participation in this study will last between 2 and 3 years.

It was a more ambitious undertaking with 33 sites, a target enrollment of 400, and two treatment arms:

Insofar as I can tell, this second study isn’t completed ["While part of the RAISE study is ongoing…"] and it is listed as Single Blind [Outcomes Assessor]. The point being that the results aren’t known.

To rehash: The two "independent" RAISE studies were funded by the ARRA of 2009. The RAISE Connection study was at two sites [New York and Maryland] and was going to compare two different intervention programs in First Episode Schizophrenia. After a little over a year, the study was radically amended with a change in P.I., duration, enrollment target, and one intervention program dropped – meaning that there was neither control nor comparator. The outcome was to compare results with "…what is known about the natural history of untreated first episode of psychosis as well as usual care outcomes from other experimental studies." The study ended in December 2013 and I can find no published results. The RAISE ETP study was of similar design at 33 sites with a Mental Health Center treatment as usual arm and a Behavioral Integrative Treatment arm [see above].

In Dr. Insel’s version on his blog, the first study [RAISE Connection] is referred to as a feasibility study. The second study [RAISE ETP] is still continuing. So I’m having a difficult time understanding how this is an example of a "research finding and putting that finding into practice." Whatever happened to RAISE Connection removed any research from the field by eliminating any comparator. Even Dr. Insel referred to it as a feasibility exercise. The research study is RAISE ETP which has yet to be completed. They mention no preliminary results. So I just don’t get it.

It seems more like the ARRA money became available and they financed RAISE. Then when the SAMHSA budget allocated funding to "implement evidence-based treatments for first episode psychosis," they wrote up what the RAISE protocols proposed. If it’s "evidence-based," it didn’t get its evidence from RAISE. And whatever the case, the phrase "a research finding and putting that finding into practice" is stretching the facts beyond too thin. An uncontrolled study that misfired? A second uncompleted study? Where’s the research in that? Maybe I misread something, because by my reading, Dr. Insel’s blog is a fabrication. I’d appreciate someone else looking it over…

Mickey @ 1:43 PM

2 Comments

the nature of things…

Posted on Sunday 11 May 2014

Any system that results in benefits is intrinsically vulnerable to being abused. It’s just in the nature of things. Systems are created to deal with a group problem, but when benefits are involved, individuals flock to become members of the group, and it grows. Likewise, those financing the system focus on the abuse rather than the system’s intent. That’s in the nature of things too.

My father, like many first-generation-American-born children, was a devoted patriot. He teared up if someone read, "Give me your tired, your poor, Your huddled masses yearning to breathe free" and was first in line to volunteer when we declared war on the Axis powers. I think he always felt guilty about being pulled out of that line and assigned to a munitions plant because he was a chemist. Yet once a year, he became something of a lunatic when he did his taxes – no sympathy for those huddled masses in April. They were just people who "didn’t want to work." His early heart attack terrified him, and he never returned to work. His campaign to get medical disability filled his mind [and ours] – back to the huddled masses he went [though the April lunacy was unchanged].

I was surprised at the balanced efficiency of the military medical system. But there was one part I hated – Medical Board it was called. I had noticed as a resident at the VA hospital that the patients were service connected for medical conditions that surely had nothing to do with being in the military, but didn’t know how that worked. In the service, I learned. When you retire, you go see all the doctors who write up reports, and then a Medical Board makes that determination. So I had to see all these retiring 40-somethings and write a report. My problem was that just before I was invited into the Air Force, there had been a realistic reform of the system. So these burly soldiers came expecting benefits for their aches and pains along the way, and the Air Force just didn’t do that anymore. "If you were healthy enough to serve, we’re not going to declare you a cripple the day you retire" was the new order of things. The retiring saw that as a personal decision I had made. I learned the meaning of both "shooting the messenger" and "the squeaky wheel gets oiled" in those days.

I could tell these stories until the end of time, but I’ll just add couple more. When I left the military and came to a psychiatry residency, I had a stipulation – I wouldn’t rotate at the VA Hospital. I recanted down the road, and it wasn’t about not liking vets. I was one. It was those damned Medical Boards. My residency was during the end of Viet Nam, and we were discovering once again that war can make some people very sick. PTSD can be a showstopper. I saw it in friends and patients. Supervising residents working in the outpatient clinic at the VA, I became something of an expert separating the really ill from the hordes of applicants. I had a resident who thought I was too tight-assed. So he and I put on our jeans and bandanas [I wore a tie-dyed t-shirt and my old fatigue jacket with insignia but not the rank], and off we went to the VA on a field trip. In the huge parking lot, we encountered activists handing out brochures with the diagnostic criteria for PTSD on the front. Inside they told what to say and what not to say. When we got back to the car, there was one under each wiper blade. After that, that resident became the hard-ass and I had to take the other side to undo some of my little lesson. Did I mention, it’s just in the nature of things?

I was drawn to analytic training because the psychoanalysts were the best clinicians. They heard the music I wanted to learn to hear. As would be my fate, my analytic training program spanned the DSM-III [1980], 1976 to 1984. I didn’t use my health insurance for my own analysis though it was covered back then. It didn’t seem right, but I didn’t tell my classmates [or analyst], because it was such a hot topic – insurance coverage for analysis. My otherwise super-reflective teachers and fellow trainees were uniform in explaining why it made perfect sense. Of course it made absolutely no sense, but I wasn’t about to have my pathological egalitarianism analyzed. Like I said, it’s just in the nature of things when benefits are involved.

I live in a place with an indigenous population dating to the country’s founding. The area was long the center of the moonshine trade, and the tradition persists – meth labs, prescription pill abuse. etc. I’ve mentioned that I surrendered the pain pill part of my DEA registration because I got so tired of being ~~hit~~ asked for narcotics. I’m the only person in our clinic that will prescribe Benzodiazepines, and we have a way to be sure that the patients aren’t seeing multiple doctors for prescriptions and are told if patients sell them by the local constabulary. When I explain to patients why I made it impossible for me to prescribe narcotics, they all say exactly the same thing – obviously ill people, the indeterminable, and drug seekers alike. "It’s a shame that people who really need this medication have to suffer because of the bad behavior of others." It is a shame. But it’s in the…

I probably shouldn’t talk about this topic very much, because I actually do have unanalyzable pathological egalitarianism, and the reason is revealed in the second paragraph for all to see. But I can say something about the process. It involves the universal mechanism I call simplification of people. We all know the drill. When angry, the infuriating other becomes a flat character – a mostly bad guy like in the movies. In fact, we love those kind of movies, such a relief from everyday life and the complexity of real human beings to see the world as filled with good guys and bad guys. When I was a kid, the movies were easier – hat color was enough to provide the key in the first scene. Nowadays, we don’t find out for a while that the good doctor is a cannibal, or the cop is a mobster. But a morning watching cartoons with the grandkids shows us that the out front good versus evil paradigm is living and well. Anyone who treats the mentally ill [or looks at their own interior] encounters this dichotomy every day.

So the evil, greedy doctors are just people milking the system for their own gain. Don’t we read about Medicare fraud in the paper every day? Didn’t those greedy analysts bill for endless therapy? See! Or. to reverse the process, those unprincipled Managed Care bean counters are having a field day because mental health coverage is so easy to cut. They’re filling the pockets of their companies at our expense, at the patient’s expense! and we don’t have the biomarkers that other specialties have to fight back. Didn’t I just read that people are killing themselves waiting for appointments at the VA. So it’s Greedy Doctors v Greedy Insurers. Patients out of the picture. Kill the messenger! Squeak! Squeak! It’s a shame that people who really need this medication have to suffer because of the bad behavior of others. It is a shame, but it’s in…

The only way I know to get people out of the simplifying other people mode is encounter. When put in the same room for a long time, waring factions can sometimes be engaged in seeing the complexity of the other – it’s a central principle of couples therapy and diplomacy. A waring couple in a room with a neutral other can sometime recall whatever love means and move towards each other. But don’t try it in a courtroom where benefits are on the table, the simplification of the other gains the upper hand. Why – didn’t I see a case just like mine on 20/20 [or Dateline, or Dr. Phil] just last night?

So my neurotic hangups about the problems of being special are very real. I can’t play the look-at-my-credentials card, even when Sandra asks directly. It’s not in my bag of tricks [2nd paragraph hangover]. I’m willing to compete on the open market only based on what I do. That’s actually not totally sane, but at least I know it. But in terms of the topic on the table, there is one thing that I feel solid about. Managed Care has way overdone it with psychiatry. I dread seeing a truly homicidal or suicidal patient because the resources have disappeared. Hospitalizing someone is now impossible. The same is true with grossly out of control psychotic patients. Psychiatric treatment for severe illness is non-existent except for meds. I wish the people protesting at the APA would give equal time to the Behavioral Health Insurers so people might get the treatment they actually need – "shooting the messenger" and "the squeaky wheel gets oiled" come to mind.

I didn’t consider involving myself with Managed Care, not because of their stingy rates [and they are stingy to the point of being simplifiable down to wanting to destroy psychiatry altogether]. But back in the day, I didn’t do it because they wanted me to do harmful or dangerous things. They created a role for me I didn’t want to fill. That’s not in the nature of things…

Mickey @ 2:34 PM

8 Comments

some thoughts…

Posted on Saturday 10 May 2014

Acceptance of Insurance by Psychiatrists and the Implications for Access to Mental Health Care

by Tara F. Bishop, Matthew J. Press, Salomeh Keyhani, and Harold Alan Pincus

JAMA Psychiatry. 2014 71[2]:176-181.

Importance There have been recent calls for increased access to mental health services, but access may be limited owing to psychiatrist refusal to accept insurance.

Objective To describe recent trends in acceptance of insurance by psychiatrists compared with physicians in other specialties.

Design, Setting, and Participants We used data from a national survey of office-based physicians in the United States to calculate rates of acceptance of private noncapitated insurance, Medicare, and Medicaid by psychiatrists vs physicians in other specialties and to compare characteristics of psychiatrists who accepted insurance and those who did not.

Main Outcomes and Measures Our main outcome variables were physician acceptance of new patients with private noncapitated insurance, Medicare, or Medicaid. Our main independent variables were physician specialty and year groupings [2005-2006, 2007-2008, and 2009-2010].

Results The percentage of psychiatrists who accepted private noncapitated insurance in 2009-2010 was significantly lower than the percentage of physicians in other specialties [55.3% [95% CI, 46.7%-63.8%] vs 88.7% [86.4%-90.7%]; P < .001] and had declined by 17.0% since 2005-2006. Similarly, the percentage of psychiatrists who accepted Medicare in 2009-2010 was significantly lower than that for other physicians [54.8% [95% CI, 46.6%-62.7%] vs 86.1% [84.4%-87.7%]; P < .001] and had declined by 19.5% since 2005-2006. Psychiatrists’ Medicaid acceptance rates in 2009-2010 were also lower than those for other physicians [43.1% [95% CI, 34.9%-51.7%] vs 73.0% [70.3%-75.5%]; P < .001] but had not declined significantly from 2005-2006. Psychiatrists in the Midwest were more likely to accept private noncapitated insurance [85.1%] than those in the Northeast [48.5%], South [43.0%], or West [57.8%] [P = .02].

Conclusions and Relevance Acceptance rates for all types of insurance were significantly lower for psychiatrists than for physicians in other specialties. These low rates of acceptance may pose a barrier to access to mental health services.

What’s the Point if Psychiatrists Don’t Accept Insurance, Medicare?

PsychCentral

by John Grohol PsyD

January 11, 2014

Fewer Psychiatrists Seen Taking Health Insurance

New York Times

By ROBERT PEAR

December 11, 2013

Why psychiatrists don’t take insurance

KevinMD

by Dinah Miller, MD of ShrinkRap

January 25, 2014

hat tip to jamzo for the links…

I went into practice around 1986. If patients used insurance, that was fine with me, but for two simple reasons, it never occurred to me to take insurance. First, I would’ve had to have a staff to file it and keep up with it and I didn’t want to pass on those costs. Second, that would’ve required me to be on insurance panels that would’ve prescribed how I practiced, meaning becoming a psychiatrist who primarily prescribed medications – the kind of psychiatrist people rave about in the blog comments, on Mad in America, or on the steps of the APA Meeting in New York. I had no interest in doing that – so I didn’t. One of the reasons Managed Care focused on psychiatry back in the day was that there had been a lot of billing medical insurance for long therapies or hospitalizations, many of which were optional – treatment recommendations based on what the insurance coverage would bear. That was wrong and I didn’t do that either.

The End of Psychiatry

Mad in America

by Sandra Steingard, M.D.

April 20, 2014

[full text online]

In this piece, Sandra suggests that psychiatry can be partitioned into psychotherapy which could be [and has been] taken over by the non-medical disciplines and the medication side that survives could be done by physicians-other. Right now, the bulk of these medicines are prescribed by Primary Care Physicians [badly, I might add]. She, suggests the Neurologists who are the legitimate heirs of matters neuro/brain would be a better choice:

I also think that psychoactive drugs are here to stay. People have sought them out for a long time – well before the advent of modern psychiatry – and that seems unlikely to change. It is imperative that some branch of medicine specializes in understanding these drugs. I wish that branch would be cautious. It’s not that I more faith in neurology than I do in psychiatry to be judicious but that is a problem of modern medicine that is no better or worse in one discipline or another.

And about psychotherapy:

Some of my colleagues [psychiatrists] are concerned because in these new models psychiatrists are not the ones offering psychotherapy. I guess that bothers them more than it does me. And it is not that I am opposed to psychotherapy. I just do not think you need a medical degree to be a good therapist. These models are, among other things, seeking cost effectiveness and almost everyone else in this business costs less than a physician. I also understand that psychotherapy – being labor intensive no matter the practitioner – will always have to fight for time. But this is a problem now and it will be a problem in any system we have.

I did ["…need a medical degree to be a good therapist"]. But that’s not to say that I disagree with her point. But if I want to be a psychotherapist as a physician and am willing to be paid at a similar rate to my non-physician peers [which I was], I see that as my business. As it turned out, a goodly portion of my patients were themselves either therapists or physicians and I generally charged them in the range of what they charged their own patients. I saw that as our business. Psychotherapists aren’t measured by how they got there. They’re measured by their skills in being there.

But I’m not interested in debating the fate of psychiatry, primarily because psychiatry these days is defined as something akin to Insel’s Clinical Neuroscience, something the Neurologists might be interested in taking on if it were a valid way to conceptualize most mental illness. I never believed that for a minute and I doubt the Neurologists will either. There are biological aspects to some mental illness, biological treatments for some mental illness, and probably biological causes for some mental illnesses. But that’s not what got me from Internal Medicine to psychiatry. I never saw biology as a specific requirement for what physicians did. It was the physician’s role to take care of sick people, and I realized that much of the "sickness" I saw in the world was something I couldn’t treat as an Internal Medicine physician. I didn’t know how. I knew how to give pills and gave it my best shot, but it just wasn’t the right thing to do. I knew how to be nice, and sympathetic, and that sometimes helped – but treating significant mental illness involves a whole lot more than a Beatles song ["all you need is love"].

I really doubt that the Neurologists are going to be very interested in taking on modern psychopharmacology. It’s just not what they do, and they sure aren’t likely to believe a lot of the more recent psychopharmacology or clinical neuroscience literature [just like a lot of psychiatrists like me don’t]. I really doubt that Primary Care Physicians will ever do it right, and the notion that what they do will be improved by having a Care Manager consult a Psychiatrist who hasn’t seen the patient is a totally ludicrous suggestion. The patients I’m most concerned about are the ones in Jaspers’ Major Psychosis category. They need physicians well schooled in those illnesses who use biological interventions skillfully. They need psychosocial care delivered by people who are well schooled in those illnesses who use other interventions skillfully. And they don’t need to live under bridges or in prisons.

The psychiatrists I’m most concerned about are those that focus on the Major Psychiatric Syndromes currently treated primarily with biological interventions who aren’t in the PHARMA/KOL sphere of influence – people who both use and research these treatment modalities in ways I consider legitimate and helpful. They were the people I consulted when I saw patients where I needed help, and they were not always that easy to find. They are the babies that will get thrown out with the bathwater in the current backlash against psychopharmacology. They’re the doctors I want to see my wife if she develops Melancholia or my daughter if she has a psychotic break. And I’m not going to find them looking over a list on a Managed Care panel under either Psychiatry or Neurology these days…

Mickey @ 12:28 PM

30 Comments

back in the fold …

Posted on Thursday 8 May 2014

Following Emil Kraepelin’s description of Dementia Praecox as a progressive deteriorating disease, Swiss psychiatrist Eugen Bleuler reported on his experience with these patients at the Burghölzli Sanatorium in his book, Dementia Praecox, or the Group of Schizophrenias, published in 1911. He described a variable not so pessimistic course of illness and posited a particular personality type, the Schizoid Personality, that antedated the outbreak of illness. While this premorbid personality is frequently apparent in retrospect, prediction going the other way [who will develop psychosis?] hasn’t been easily achieved. Back during the DSM-5 Task Force deliberations, there was much ado about the Attenuated Psychosis Syndrome [nee Psychosis Risk Syndrome] – new names for a century old concept.

There were two questions on the table:

Could the patients who were going to become psychotic be identified with any accuracy?

If they could, what would we do about it?

Patrick McGorry and his associates in Australia had been researching this for some time, and had convinced the Australian government to fund a massive intervention program. I summarized his research and the details at some length in the series of posts below:

1. from n equals one…

2. from n equals one…

3. from n equals one…

3. when n=a few needs n=a few more…

it just didn’t work…

an old n=1 type…

The gist of things is that their predictions are fair at first, but when they try to go large, they are less accurate [less to not at all]. About that time, it became apparent that PHARMA was pulling out of CNS drug development for real [summer of 2011]. And if that weren’t enough, the DSM-5 Task Force had to announce that their grand plan to produce a biologically based diagnostic system hadn’t worked out. The reaction was something like a primal scream and the people in charge scrambled to do something akin to damage control. So early detection of Schizophrenia was touted by the moguls as on the near horizon [class action in the air…, psychiatry inc…]. It was as if they felt obligated to have some future shiny object to replace those drugs that were going to come out of the pipeline just around the corner, and early detection and prevention of Schizophrenia was one of the oft-mentioned candidates.

So Dr. Lieberman’s video above is just one of many videos and articles he’s produced over his presidential year on the topic. I can’t find that there’s any more solid evidence that they are closer to accurate predictions or promising interventions than they were in the summer of 2011 when they jumped on this bandwagon. Which brings me to this article in the PsychiatricNews:

Recalling Chestnut Lodge: Seeking the Human Behind the Psychosis

PsychiatricNews

by Mark Moran

April 18, 2014

[full text on-line]

The psychoanalytic method and highly individualized treatment approach at Chestnut Lodge pointed toward the contemporary focus on early detection and intervention…

One of Kraepelin’s methods of parsing the psychoses was to look at the form of the psychotic communications rather than their specific content. Visual Hallucinations – Delerium. Delusions and Auditory Hallucinations of persecution – Dementia Praecox. Delusions of Grandeur – Mania. etc. The irrational deadness of the mental productions in Melancholia. These qualities became the hallmarks of his diagnostic groups. So I was making diagnoses by form, and trying to stabilize the patients quickly to make room those that followed. But I spent my days listening to a content that was as unique as the ripples in a stream. And as a new resident, I found the content of these communications fascinating, and read and reread the writings of a specific group – the psychiatrists at the Chestnut Lodge, where all patients had been treated with psychotherapy no matter how disturbed long before the arrival of the neuroleptics. Harry Stack Sullivan, Frieda Fromme Reichman, Otto Will, Harold Searles, etc. – they published case studies that were exactly what I wanted to read. I don’t know if it helped my patients that I was learning to speak schizophren·eze – but it sure helped me maintain my connection with their humanity in those days, and the contribution to my overall learning how to listen was invaluable. So I was delighted to read this article in the PsychiatricNews, though it surprised me.

During the 1980 revolution in psychiatry, Chestnut Lodge stood as a symbolic bastion of psychoanalytic treatment – on the other side from the wave of psychopharmacologic treatment. The patient, Dr. Osteroff, was admitted to Chestnut Lodge in 1979 and treated for seven months with intensive psychotherapy, diagnosed as having a personality disorder. His condition worsened over that hospitalization, and he was transferred to another facility where he rapidly responded to medication. The details are here:

respecting our limits…

comment: Dr. Carroll

a loud creaking noise…

faded from the rolls…

There wasn’t much argument that the patient was misdiagnosed and the case mishandled. But it became a cause célèbre dragging on through the 1980s as a referendum between the psychological and biological treatments of mental illness, and was argued in the pages of The American Journal of Psychiatry between neoKraepelinian Gerald Klerman and psychoanalyst Alan Stone as the right to effective treatment. Chestnut Lodge fell into decline in this new era and burned as it sat idle awaiting being turned into condos. So while I was delighted to see the Lodge described in such positive terms, I wondered why it was suddenly revived as I knew it and particularly with the subtitle, Seeking the Human Behind the Psychosis. The answer is in the article:

And yet ironically, it was also the years of analytic work with patients with psychosis at the Lodge that had helped point McGlashan in the direction of early detection and intervention in the “prodromal” phases of the disorder — a movement that is now the leading edge of schizophrenia research. For it was the rich case histories of countless patients at the Lodge that provided the clearest evidence that in almost every case, signs of trouble had been apparent sometimes years before an acute psychotic episode. “That’s what really taught me that there is this psychosis risk period, that it’s very distinctive and that it’s lengthy,” McGlashan said. “I decided that that’s where we have to intervene. And when I left the Lodge [in 1990] that became the focus of all my work.”

Another aumnus of the Lodge, Robert Heinssen, helped change the approach there in it’s latter days, and now directs the Division of Services and Intervention Research at the National Institute of Mental Health:

Today, Heinssen is the National Institute of Mental Health’s science officer for the North American Prodrome Longitudinal Study, a nine-site consortium of clinical research programs dedicated to the early detection and prevention of psychotic disorders and other forms of serious mental illness. McGlashan has been a leading investigator in the ongoing Early Treatment and Intervention in Psychosis (TIPS) study in Scandinavia, and developed the Scale of Prodromal Symptoms, which is used to assess at-risk individuals for inclusion in early-intervention programs.

The Bullard family sold the Chestnut Lodge property in the 1990s, and the hospital closed in 2001. The property changed hands several times before a developer purchased it with the intention of converting the property into condominiums; but on the morning of June 7, 2007, the main building burned to the ground under mysterious circumstances. Its ruins — the old cottage where Fromm-Reichman lived still stands — persist as a monument to an extraordinary and heroic effort to understand the individual behind the psychotic disorder, an individual with a history and a human story that might have taken a different turn.

“There were some phenomenal teachers and therapists there,” Heinssen said. “To the uninitiated, people with psychosis can appear alien, and it is no surprise that they get pushed away. There is something extraordinarily unsettling about interacting with someone who experiences a different reality. But at the Lodge there were many heroic doctors and nurses who sought to find the human being behind the disease. They taught me to look beyond psychotic symptoms and to connect with the real person who has a soul and value and worth.”

They helped teach me that too. While I’m glad to see the Lodge back in the fold and am glad the work on psychosis prodrome is underway and appears to be in good hands, there’s still something that bothers me. That video by Dr. Lieberman is a cheerleading session; it exaggerates the state of the art; and it reminds me of all those endless inflated claims from the age of PHARMA [hopefully passing]. Real scientists aren’t salesmen. They don’t say "research has shown…" unless it’s in the bank. But we have a layer of gentlemen scientists who talk the talk, but don’t walk the walk, and I include Dr. Lieberman in that group. So in spite of being pleased to see this article that speaks of people and a place that was so important to me when I started psychiatry and encountered psychosis, I can’t help but think that the article is in PsychiatricNews as part of some kind of APA shiny object campaign…

Mickey @ 4:15 PM

7 Comments

1913…

Posted on Tuesday 6 May 2014

DSM-5 and the Research Domain Criteria: 100 Years After Jaspers’ General Psychopathology

by Jose de Leon, M.D.

American Journal of Psychiatry. 2014 171:492-494.

In 1913, 30-year-old German psychiatrist Karl Jaspers published the first edition of General Psychopathology, in which he summarized current psychiatric knowledge and included his ideas regarding the methodological and scientific issues then facing psychiatry. In the words of his biographer, Jaspers thought the discipline of psychiatry “was crying out for a systematic clarification of current thinking” and that “to make real progress psychiatrists must learn to think,” but his book was not well received by more senior German psychiatrists. Jaspers subsequently became better known as a philosopher. In 1922, when writing the third edition, Jaspers was no longer in direct contact with psychiatry and asked for suggestions from Kurt Schneider, an excellent young psychiatrist, who then probably updated the later editions of the book.

The first English translation of General Psychopathology, more than 900 pages long, was published in 1963, reflecting the seventh German edition. Jaspers’ book defined psychiatry as a hybrid scientific discipline that must combine the methods of the natural and the social sciences which, respectively, provide an explanation of psychiatric diseases that follows the medical model and an understanding of psychiatric abnormalities that are variations of human living. General Psychopathology has had a continuous influence on psychiatry in the United Kingdom, including psychiatric research and resident training, but has had very limited direct impact on U.S. psychiatry. General Psychopathology’s English translator described a visit to a Philadelphia psychiatry department, where the chairman told him, “Nobody reads it, but it is obligatory to have it seen on your shelf.” The American Journal of Psychiatry has published only two articles on Jaspers. In 1967, Havens commented on the publication of the General Psychopathology translation and hoped that U.S. psychiatrists would be open to Jaspers, who “provides a systematic rationale for eclecticism.” In 1986, Schwartz and Wiggins used Jaspers’ “explaining” and “understanding” concepts in the context of Engel’s biopsychosocial model.

At 100 years, we might speculate on what Jaspers would think about the current differences in diagnostic strategy between the National Institute of Mental Health’s Research Domain Criteria [RDoC] and DSM-5. The RDoC appears reminiscent of Karl Wernicke’s attempt to consider all mental disorders as brain disorders, and DSM-5 follows Emil Kraepelin’s dictum that all psychiatric disorders follow the medical model of disease. Jaspers had strong critiques of both Wernicke and Kraepelin.

This time last year, I read an article by Dr. Mario Maj in World Psychiatry, Mental disorders as “brain diseases” and Jaspers’ legacy [see an anniversary…]. I didn’t even know that Karl Jaspers was a psychiatrist before then. I knew him as a philosopher. But I found the article immediately compelling, because it said what I’ve always thought [and still think]. I even drew one of my little diagrams to illustrate Jaspers simplified:

There were the Brain Diseases [Cerebral Illnesses], the Psychiatric Diseases [Major Psychoses], and the mental illnesses associated with life and experience [Personality Disorders]. When psychiatry changed in 1980 with the DSM-III, I didn’t [get it or change]. I thought of these three categories with different mindsets. So when psychiatry began to conflate the circles, I left the academy. I didn’t think I was a dinosaur or reactionary, but I was certainly told that. That’s ancient history, but when I read Maj’s paper, I was glad to see it said by someone of Jaspers’ stature. Then six months ago, I read Dr. Leon’s paper A post-DSM-III wake-up call to European psychiatry [see back at you, EU…]. There was Jaspers again with another favorite, Kurt Schneider. So I’m pleased to see Dr. Leon’s thoughts in a mainstream American journal:

According to Insel et al., “the RDoC framework conceptualizes mental illness as brain disorders. In contrast to neurological disorders with identifiable lesions, mental disorders can be addressed as disorders of brain circuits.” At the beginning of the 20th century, Wernicke, already famous for describing the sensory speech center, also wrote a textbook including a pathophysiological model of the relationship between brain and behavior, which became one of the most important competitors of Kraepelin’s textbook. According to Jaspers, Wernicke believed that all mental illnesses are “cerebral illnesses in the sense that they can be wholly comprehended in terms of cerebral processes”. If Wernicke had not died young, we psychiatrists might be living in a “Wernickian world” instead of a “Kraepelinian world”. Although Jaspers acknowledges that Wernicke’s pathophysiological model applied well to aphasia and other neurological disorders, Jaspers thought Wernicke erred in extending it to all psychiatric disorders. Jaspers contrasted Wernicke and Sigmund Freud, who were both disciples of the same Viennese mentor, Theodor Meynert, saying that they were positioned at opposite extremes in psychiatry. In Jaspers’ view, Wernicke thought that “explaining” was the only methodology needed in psychiatry. On the other hand, Freud thought that “understanding” was the only methodology needed in psychiatry. The RDoC’s focus on brain disorders implies a view similar to Wernicke’s that explaining is the only methodology needed in psychiatry.

The diagnostic scheme for psychiatric disorders developed by the Department of Psychiatry at Washington University, which led to DSM-III, DSM-IV, and DSM-5, is a Kraepelinian nosological model where mental disorders follow the medical model of disease as a set of identifiable symptoms. Jaspers was critical of Kraepelin’s idealization of the medical model of general paralysis of the insane [neurosyphilis] as a model for psychiatric disorders, with each disorder having a unique cause, set of symptoms, course, outcome, and neuropathology. In General Psychopathology, Jaspers proposed that some psychiatric disorders follow the traditional medical model, principally those that were called organic mental disorders in DSM-III. Jaspers called them “known somatic illnesses with psychic disturbances” [“Group I”]. Other psychiatric disorders, he proposed, were not medical disorders but variations of normality; Jaspers called these disorders of personality, including “abnormal reactions, neurosis and neurotic syndromes, as well as abnormal personalities and their developments” [“Group III”]. Situated between them were the psychoses [“Group II”], which, according to Jaspers, could be distinguished from normality but were not clearly separated from each other—e.g., intermediate cases between schizophrenia and manic-depressive illnesses. Jaspers felt that Kraepelin’s denial of the heterogeneous nature of mental disorders failed to capture some psychiatric disorders correctly.

Jaspers’ critiques a century ago of Wernicke’s brain pathophysiological model and Kraepelin’s medical model might thus be applied contemporarily to RDoC and DSM-5. We still struggle 100 years later with the issues that Jaspers raised: psychiatry is a hybrid scientific discipline that must include in its research enterprise patients’ beliefs and culture, influences not captured by traditional scientific reductionism, and psychiatry encompasses heterogeneous disorders, not just those that follow the traditional medical model.

I don’t know much more to say about that last bit except, "Absolutely!" I think I might have found the DSM-III changes in psychiatry more palatable if they’d shrunk the specialty to the two left-hand circles where they fit. But that’s not what happened. Instead they expanded the domain of what was once called Biological Psychiatry to encompass all of mental illness.

When I discovered Jaspers a year ago, I revisited the history of that era. These days, we talk a lot about ideologies, biases, and conflicts of interest, but by the standards of a century ago in Europe, we’re rookies in dealing with outside forces. I’d made my peace with Freud in analytic training and teaching the "Freud Course" in our Psychoanalytic Institute – what he got right, where he was dead wrong, how his persona influenced his work, and the impact of the anti-semitism of those times on so many things in his life. While I can join in eruditely with those who never tire of criticizing many of his theories, his clinical acumen and his contributions to listening and understanding were unequaled in my experience, and I wouldn’t have missed the chance to study Freud’s thinking for anything.

But I knew next to nothing about Kraepelin. As I read about him, his views on mental diseases and his sociopolitical views merged and were a major surprise to me [see all ears…, an open question…, see also Dr. Noll’s comments to those posts]. He was as complicated as Freud and very much a man of his times. His theories were all about a "congenitally inferior predisposition," "hereditary degeneration," and "genetic influences" result from "alcohol and syphilis." Candidly, he was into eugenics and had he lived long enough, I fear he would gotten caught up in the craziness that swept German under Hitler. That’s a harsh thing to say and I’m no expert, but it’s not said lightly. A couple of the softer quotes [from Shepherd, see also all ears…, an open question…]:

On the origins of hysteria: [Kraepelin] wrote about ‘morbid’ constitution, ‘defective heredity’ and certain environmental conditions. He considered the possibility of uterine disturbances but said the role played by ‘the female sexual organs … is not clear’. In the eighth edition of Psychiatrie [1909–15], he considered at length [70 pages] the origins of paranoia: was it an outgrowth of ‘the hard blows life delivers to everyone’ or was it owing to innate degeneracy where ‘morbid germs … were already present in the disposition’ as in a genetic disease like Huntington’s chorea? Kraepelin opted for degeneracy.

On individuals with distinctly hysterical traits: …among the leaders of current and past upheavals one also finds a surprising number of people who in one way or another fall outside the bounds of normality. In this latter category he concludes dreamers and poets, swindlers and Jews: The active participation of the Jewish race in political upheavals has something to do with this [morbidity]. The frequency of psychopathic predisposition in Jews could have played a role, although it is their harping criticism, their rhetorical and theatrical abilities, and their doggedness and determination which are most important.

and as to psychological causation:

Karl Jaspers was also affected by the sociocultural forces in Germany during those years. He left practice after his 1913 book, General Psychopathology, and taught psychology. At age 38, he moved to philosophy where he is now better known. In 1937, he was removed from his academic position and his books were banned because of his "Jewish taint" [his wife was Jewish]. While Jaspers’ comment, "psychiatry is a hybrid scientific discipline that must include in its research enterprise patients’ beliefs and culture," was about mental illness itself, it could equally be about the students of psychiatric illnesses like Kraepelin, and his "beliefs and culture." Or for that matter, Jaspers’ own concerns [from an anniversary…]:

As a philosopher, Jaspers, like many of his contemporaries, worried about the human encounter with technology, science, and collective institutions – seeing them as barriers to personal freedom. He urged a Transcendence of the limits of rational objectivism to achieve what he called Existenz – an authentic subjectivity. Like so many, his career was suspended during the Nazi era when he and his Jewish wife spent the war in fear of the very kinds of technology and ideology he had written about. After the war, he resumed teaching, writing about the German responsibility for the atrocities of the Third Reich [Die Shuldfrage]. Where Jaspers’ Allgemeine Psychopathologie criticized Kraepelin for an over-reliance on a medical model, he would later criticize Freud for over-generalizing about human experience from a limited field of observation.

And Dr. Leon suggests that, "At 100 years, we might speculate on what Jaspers would think about the current differences in diagnostic strategy between the National Institute of Mental Health’s Research Domain Criteria [RDoC] and DSM-5" but then implies the answer his own rhetorical question – Jaspers would’ve liked neither [I would add because they are both based on the same as yet unproven ~~opinion~~ premise].

In the sanatoriums and asylums of a century ago, the majority of patients had brain syphilis, alcoholic dementias, or the brain disease [Group I, cerebral illness]. The minority had what Jaspers called Group II [Major Psychoses]. I had known of Kraepelin as the one who separated out the diseases in Jaspers Group II [Dementia Praecox AKA Schizophrenia and Manic Depressive Illness]. Freud was not a psychiatrist and knew little of such patients. He wrote about one case [from the patient’s autobiography]. His cases were outpatients with a different set of symptoms and "illnesses." He couldn’t connect with psychotic patients and said so. Jaspers was writing about both groups of patients, and demarcated them with clear boundaries, as in my diagram [so ~~did~~ do I].

When the DSM-III came along, we suddenly had a new group – the neoKraepelinians – who following Kraepelin generalized the medical model which had kind of worked for the Major Psychoses to all mental illnesses – classifying based on symptoms. They included the neurotic patients, the behavioral syndromes, everything. It didn’t work for the psychoanalysts, the psychotherapists, the psychologists, the social workers, the counselors, etc. It did work for the insurance carriers, the medicare architects, the hospitals, the FDA, PHARMA, etc. because they had pigeon-holes to put people into [DRGs in medical parlance]. The medical justification was Kreapelin AKA neoKraepelin who apparently thought all mental illness was biological degeneracy of some kind and who had some weird ideas about how heredity worked. After reading more about Kraepelin, I find myself thinking that the neoKraepelinian Emil Kraepelin was a creation of the St. Louis psychiatry group – not the historical figure I’ve read about more recently. And I’m thinking now that the real Kraepein’s opinions about Jaspers Group III were more socio/political prejudice than medical/psychiatric observation.

Whatever the case, Karl Jaspers’ 1913 reflections on mental illness were written in reaction against that medicalization of all mental illness one hundred years ago, and are particularly appropriate to our struggles with the same issues right here, right now. Leon wonders how Jaspers would react to the DSM-5 and RDoC. I wonder how he would react if he read the psychiatric news and the bulletins coming from the APA in New York right now. I expect he’d have plenty to say, but it would sound very much like what he said in 1913…

Mickey @ 9:16 PM

12 Comments

as I knew it…

Posted on Sunday 4 May 2014

April is the cruellest month, breeding
Lilacs out of the dead land, mixing
Memory and desire, stirring
Dull roots with spring rain…

The Wasteland [1922] T.S. Eliot

Every year, I joke that rather than being a post-World War I lament about the burdens of hope, what Eliot was really writing about was Spring Pollen – that he was a fellow sufferer of seasonal allergies. But this year, it was more poignant, more like Walt Whitman in his 1865 eulogy to Abraham Lincoln:

When lilacs last in the dooryard bloomed,
And the great star early drooped in the western sky in the night,
I mourned, and yet shall mourn with ever-returning spring…

In the week after Easter, I lost my two best friends of some forty years duration [in memory…]. We retired around the same time and moved to the mountains to grow old together, living within a couple of miles of each other. Beside being lifelong playmates, the two of them had more to do with shaping my values than any medical mentor, though they had nothing to do with medicine. Andy was a minister who, early on, left organized religion and lived it’s tenets rather than talking about them. Al was a decorated photojournalist who, among other things, chronicled the dark realities of the South and was instrumental in showing them to the world. This blog began life as 3oldmen.com to keep up with our other shared friends elsewhere, but Andy and Al weren’t the writing kind. When I turned to writing about more weighty matters, my daughter rebranded it 1boringoldman.com to protest.

But this is not a eulogy, it’s about my recent encounters with Medicine and its current practices during my friends’ illnesses. The doctors were excellent except for the Emergency Room where some were okay and a couple were truly horrible. The best I can say is that I didn’t hit one of them [which says more about my restraint than his just due]. Which brings me to what I want to talk about. There were two main forces at work in our hospitals and medical systems that are diametric antipodes – struggling with each other in every single medical encounter.

At multiple points along the way, each of them needed to be in the hospital for diagnostic reasons, but apparently that’s a poor use of hospitals these days so we had to haul these two very ill men all over hell and half of Georgia [literally] to get the tests needed for diagnosis as itinerant outpatients. And there were numerous examples of ‘we can’t do this test [we need] until we do this other one [that we already know the result of]’. The tentacles of managed care utilization review spreadsheets were everywhere, usually unnecessarily obstructive, and drove us all nuts – concretely interfering with decent care. Consults that could’ve been done in a few minutes took days to schedule and coordinate with others doctors. The impact of the forces of restraint in medical spending were certainly apparent every day, everywhere.

On the other side of the coin, the waste and unnecessary expensive medical tests took my breath away. It was worst in Emergency Rooms where CAT Scans and MRIs were ordered as if you had to have one or more just to prove you’d been there. It felt like a mixture of fee churning, CYA, and defensive medicine – more like the primary purpose of an ER was to generate revenue rather than tend to the sick. That was true in the hospitals as well. There are rigid protocols for everything perverted to drive up costs rather than contain them [their original purpose]. I’ve been mostly blessed with health, so my stint on the "consumer side" of modern healthcare was more up-close than it has ever been, and left me with a bad taste in my mouth – both the outside influence of managed care restrictions and rules and the outrageous waste, expense, and excesses of the hospital corporations/PHARMA/etc. I felt something between shame and rage much too often in this last month for my liking. There are other things that need feeling when you’re losing your friends.

I tried to keep what was going on in my life out of what I was writing about Integrative or Collaborative Care, but on rereading, I think I failed at that. What I read sounded like perverse systems theory drivel with people jockeying for position. Even though I was a reluctant soldier, the best system of medical care I ever worked in by far was the US military on an overseas base. Part of that was because it was a healthy population. Part of it was because there were very few, if any, sociological problems – by definition, everybody was employable and employed, pretty much on the same level. But another piece was that it was genuinely Collaborative Care, Integrative Care, whatever you want to call it when there is a team of medical personnel working together. We were all in a centralized location, knew each other, ate lunch together, were paid the same, etc. If you needed some help, it was just down the hall. I was an Internist then, but the Psychiatrists were an integral piece of that system.

The second best systems were the two megalithic City/County Charity Hospitals where I did my training [one now closed]. They were always on the brink of bankruptcy, underfunded, chaotic, and staffed largely by sleep deprived trainees. The patients were indigent and with a ton of pathology, but the healthcare was good, including psychiatry – collaborative. I would include the charity clinic where I now work in that group, though services are limited.

The worst, also by far, is the system I’ve dealt with the last months with my friends, private systems with the best doctors and the most medical resources. It’s because the regulatory forces, the intrusion of the managed care carriers, the phobia about hospitalization, and the carpetbagger profiteers have made one hell of a mess of things. I’ve left out the details because I expect most of you have stories of your own. I always said I didn’t want to age into one of those old guys who longed for "the good old days," but this particular April, I was mourning more than the final days of my friends. I mourned the loss of Medicine as I knew it…

Mickey @ 4:00 PM

10 Comments

not directly seeing the patients…

Posted on Friday 2 May 2014

Health Reform, Research Pave Way for Collaborative Care for Mental Illness

by Bridget M. Kuehn MSJ

JAMA, June 19, 2013 309[23]:2425-2426.

JAMA: What is collaborative care?

Dr. Katon: It involves a care manager, who is a nurse or other collaborative care professional, who sees the patients and provides enhanced education and tracks their outcomes. The care manager uses a case registry to monitor all the patients being treated for mental illness in the practice. If a practice physician starts a patient on an antidepressant, the care manager monitors the patient’s response. The care manager’s job is to make sure patients don’t fall through the cracks. The care manager receives weekly supervision from a psychiatrist, who, based on the patient’s experience with the medication and initial clinical response, may recommend medication changes. The care manager communicates the psychiatrist’s recommendation to the primary physician.

JAMA: What kind of training do clinicians need to implement this model?

Dr. Katon: It’s a new role for psychiatrists because they are not directly seeing the patients. Most psychiatrists are used to working directly with the patient vs being responsible for a population of patients. It’s a team approach.They must learn the concepts of measuring care outcomes and utilizing stepped-care approaches where increases in intensity of care are driven by outcomes. The American Psychiatric Association offered a course in collaborative care at its annual meeting. The Academy of Psychosomatic Medicine also has training in this model of care.

This article I’ve been quoting is actually an interview of Psychiatrist Wayne Katon, MD, Professor of psychiatry at the University of Washington in Seattle, who has worked to "develop and test models for integrating mental health care into primary care practice for the past 30 years." While my comments are critical, I mean him no malice. It sounds as if he’s trying to be helpful by improving the quality of psychiatric care being delivered by primary care physicians. Good for him. As I said in my last post, they sure need the help.

When I read the criticisms of psychiatrists in the comments on this and other blogs, the psychiatrists being raled about were unfamiliar to me. They are people who see patients for brief sessions and prescribe medications based on symptoms. At first, I thought the critics were exaggerating, but that’s not right. They are seeing psychiatrists shaped by the APA/DSM-III/Academic/PHARMA/Managed-Care view of psychiatry. Psychiatrists willing to sign on to their panels. And their complaints ["bio-bio-bio"] are perfectly legitimate. It’s the psychiatry third party payers have been willing to pay for ["medication management"]. If referred for any kind of therapy, it would be to other mental health types who have agreed to be on "the plan." That split arose with the arrival of Managed Care. The Carriers paid psychiatrists well to do "medication management" only and opened up insurance reimbursement to non physicians because they charged less and would agree to the kind of control the carriers were interested in. So the psychiatrist/therapist split became the standard for the last twenty plus years.

Certainly by the time I went into practice [late 1980s], that writing was on the wall. I thought about returning to Internal Medicine, but that’s not where my heart was. So I opened my office and worked hard for twenty years. I decided that insurance wasn’t any of my business, so I gave out bills with a DSM Code and a CPT code and left the rest to my patients, refusing requests to call for approval or join anything. I was blessed with a decent reputation from my academic years and a wife who, like me. came from a modest background and aspired to nothing more than that. So I worked long hours, adjusted fees for people that I thought I could help and couldn’t afford treatment, and was way busier than I needed to be.

I refer to those years as being in a cocoon or cloistered, because I didn’t know how much things were changing. But at the time, it didn’t feel that way. My close associates were doing the same thing and it just felt like my life. The point here is that the psychiatrists being criticized made a lot more money than I ever did, and they did what they were being paid to do. They are now what people see in their minds when they say "psychiatrist." There was a flowering of psychologists, social workers, etc. in private practice being paid by the Managed Care people to do time limited therapy/counseling and glad for the work. Since I wasn’t on any plans or panels, I never saw people whose carriers controlled things so tightly. My patients who used insurance did their own dealings with their carriers.

My intuition is that that this system is going to come to something of an end. This Integrative Care business sounds like a move to reduce or eliminate the involvement of both the psychiatrists and the therapists. Notice that the only mention of therapy is, "May offer brief psychotherapy" for the "care managers" [two versions…]. So essentially "covered" mental health care means medication from primary care followed along using tests like the PHQ-9.

Managed Care has no interest in covering mental illness and never has – cutting reimbursement wherever possible. Having essentially created the psychiatrist everyone complains about as the standard, they are now moving to cut even that, as above. The psychiatrists are going to be reimbursed for reviewing charts with a care manager and that’s it. I expect they’d like to get non-physician mental health types to be "care managers." Why the APA would be actually promoting such nonsense is beyond me. The Academic/Pharmaceutical complex seems to be morphing into the Academic/Managed Care complex quickly.

The new criticism is that psychiatrists will be doing their "bio-bio-bio" thing without even seeing the patients at all. As you can surmise from the quotes above, about the only thing psychiatrists who agree to do this Integrative Care can do is talk about medications with a care manager with a list of medicated patients and a fist-full of test results. The end of this story is that decent mental health care isn’t going to be "covered" at all. In truth, it hasn’t been "covered" for a very long time. I’m glad I saw where all of this was headed such a long time ago and didn’t even think about entering that arena. That’s why so many of us aren’t in the AMA, or the APA, or on any of the Managed Care panels.

Personally, what’s happening here bothers me a lot, just as it did thirty years ago [and in-between], but I have no idea where it’s headed or what to do about it. This blog isn’t about that. It’s about insuring that the science part is legit, and it hasn’t been…

Mickey @ 2:50 PM

39 Comments

my say…

Posted on Thursday 1 May 2014

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

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…

on 1boringoldman: the APA on the move…, tested soon…, two versions…

No psychiatrist who is on this side of the doors to an Assisted Living Facility is any stranger to some version of what they’re calling Collaborative or Integrative Care these days. It was a central feature of the Community Mental Health Movement of the 1960s. We all spent our time in Mental Health Clinics or Crisis Intervention Centers where patients were seen by a variety of clinicians, and we checked off their work. I expect some of the authors above work in those situations themselves now. For me, I actually ran a Crisis Service for a good while. I never signed off on a case I hadn’t laid eyes on, but that was not a universal practice, just my way of being there. But I didn’t object to the system itself. In those days in the CIS, I knew every clinician well. I had some that were impeccable, and my "eyeballing" was mostly for their legal backup. For others, I couldn’t trust what I heard, and so my "eyeballing" was much more detailed, more like a second interview.

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.

Enough. I could blather about this for hours with a million stories, but I’ve had my say…

Mickey @ 5:00 PM

15 Comments

two versions…

Posted on Thursday 1 May 2014

I’ve tried to steer clear of the guild side of psychiatry in this blog and focus on the misinformation generated on the psychopharmacologic side of the world. But reading about this push for Integrative Care coming from the APA has sort of put it in my face. Unless I’m grossly misreading things, the APA is currently actively participating in removing the medical specialty of psychiatry from the clinical care of patients. Here’s the APA Infographic subtext again:


• Makes initial diagnosis and prescribes medications • Modifies treatment based on patient preferences,needs, and psychiatrist recommendations		• Identifies goals, needs, and preferences for treatment • Participates in regular screening


• Monitors all patients in practice • Provides education • Tracks treatment response • May offer brief psychotherapy • Assures patient engagement		• Provides team leadership • Reviews caseload regularly • Educates and consults • Sees patients who are not making improvements

George Dawson of Real Psychiatry was onto Integrative Care earlier than most of us [see The Model of Psychiatric Care for the Future, Collaborative Care Model – Even Worse Than I Imagined], certainly before I was [see his recent comments here, here, and here]. In the second post […Even Worse Than I Imagined], he mentions a JAMA article with an earlier version of the Integrative Care model:

Health Reform, Research Pave Way for Collaborative Care for Mental Illness

by Bridget M. Kuehn, MSJ

JAMA, June 19, 2013 309[23]:2425-2426.

The difference in these versions is fairly obvious. Here’s my image from the Infographic with the difference highlighted in red:

The psychiatrist never sees the patient or the primary care physician in the JAMA version. Here’s what Dr. Dawson has to say about that:

As predicted in my original post, the psychiatrist here is so marginalized they are close to falling off the page. And let’s talk about what is really happening here. This is all about a patient coming in and being given a PHQ-9 depression screening inventory. For those of you not familiar with this instrument you can click on it here. It generally takes most patients anywhere from 1 – 3 minutes to check off the boxes. Conceivably that could lead to a diagnosis of depression in a few more minutes in the primary care clinic. At that point the patient enters the antidepressant algorithm and they are they are officially being treated. The care manager reports the PHQ-9 scores of those who do not improve to the "supervising" psychiatrist and gets a recommendation to modify treatment.

This is the model that the APA has apparently signed off on and of course it is ideal for the Affordable Care Act. It is the ultimate in affordability. The psychiatrist doesn’t even see the patient – so in whatever grand billing scheme the ACA comes up with – they won’t even submit a billing statement. The government and the insurance industry have finally achieved what they could only come close to in the past – psychiatrists working for free. Of course we will probably have to endure a decade or so of rhetoric on cost effectiveness and efficiency, etc. before anyone will admit that. Keep in mind what the original government backed model for treating depression was over 20 years ago and you will end up shaking your head like I do every day. Quality has left the building.

I have more than two cents to add here, but knowing the attention span of the average expectable blog reader, I’m going to let this sit for a bit and gather my thoughts before diving in. But the hiatus doesn’t mean I don’t have an opinion…

Mickey @ 1:28 PM

6 Comments

the Age of Meta…

Posted on Wednesday 30 April 2014

Efficacy of Pharmacotherapy and Psychotherapy for Adult Psychiatric Disorders
A Systematic Overview of Meta-analyses

by Maximilian Huhn; Magdolna Tardy; Loukia Maria Spineli;Werner Kissling; Hans Förstl; Gabriele Pitschel-Walz; Claudia Leucht; Myrto Samara; Markus Dold; John M. Davis; and Stefan Leucht.

JAMA Psychiatry. Published online April 30, 2014.

IMPORTANCE There is debate about the effectiveness of psychiatric treatments and whether pharmacotherapy or psychotherapy should be primarily used.

OBJECTIVES To perform a systematic overview on the efficacy of pharmacotherapies and psychotherapies for major psychiatric disorders and to compare the quality of pharmacotherapy and psychotherapy trials.

EVIDENCE REVIEW We searched MEDLINE, EMBASE, PsycINFO, and the Cochrane Library [April 2012, with no time or language limit] for systematic reviews on pharmacotherapy or psychotherapy vs placebo, pharmacotherapy vs psychotherapy, and their combination vs either modality alone. Two reviewers independently selected the meta-analyses and extracted efficacy effect sizes.We assessed the quality of the individual trials included in the pharmacotherapy and psychotherapy meta-analyses with the Cochrane risk of bias tool.

FINDINGS The search yielded 45 233 results.We included 61 meta-analyses on 21 psychiatric disorders, which contained 852 individual trials and 137 126 participants. The mean effect size of the meta-analyses was medium [mean, 0.50; 95%CI, 0.41-0.59]. Effect sizes of psychotherapies vs placebo tended to be higher than those of medication, but direct comparisons, albeit usually based on few trials, did not reveal consistent differences. Individual pharmacotherapy trials were more likely to have large sample sizes, blinding, control groups, and intention-to-treat analyses. In contrast, psychotherapy trials had lower dropout rates and provided follow-up data. In psychotherapy studies, wait-list designs showed larger effects than did comparisons with placebo.

CONCLUSIONS AND RELEVANCE Many pharmacotherapies and psychotherapies are effective, but there is a lot of room for improvement. Because of the multiple differences in the methods used in pharmacotherapy and psychotherapy trials, indirect comparisons of their effect sizes compared with placebo or no treatment are problematic.Well-designed direct comparisons, which are scarce, need public funding. Because patients often benefit from both forms of therapy, research should also focus on how both modalities can be best combined to maximize synergy rather than debate the use of one treatment over the other.

…

Maybe it’s the influence of the Systematic Reviews from the Cochrane Collaboration, but it seems like every time you turn around, there’s a new meta-analysis. The RIAT Project is looking at older questionable studies. And AllTrials is pushing for the raw data for the Clinical Trials for all the drugs still in use. It’s an appropriate time for looking back over the the literature of the last twenty years and figuring out what it all meant – trying to separate out the wheat from the chaff. The APA is about to meet in New York barreling ahead with a new initiative – Integrative Care – in response to the Affordable Care Act. This time last year, they were launching the DSM-5 and still talking about psychiatry as Clinical Neuroscience. Now it’s psychiatry as a consultative specialty backing up primary care. But I’m still in a "What the hell was all that about?" frame of mind.

This study was a huge undertaking and the methodology deserves a thorough look-see in the coming days, but just scanning their results, it looks like an important resource in addressing these recent confusing years. The scale at the bottom [standardized mean difference] is the difference between the means of two groups divided by the standard deviation of the pool of participants. Expressing the effect sizes in this way allows studies using differing measurement instruments to be compared. If the horizontal lines [95% Confidence Limits] don’t cross 0, the difference is significant. In general, an SMD of 0.2 is small, 0.5 moderate, and 0.8 is large. The authors caution that the methodologies of the drug and therapy studies are different enough to invalidate direct comparisons of magnitude between the two.

So here is a sample of their results for perusal – some of which are something of a surprise [MDD. OCD, BPO, GAD]…

Mickey @ 11:05 PM

8 Comments

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