{"id":45949,"date":"2014-05-01T17:00:31","date_gmt":"2014-05-01T21:00:31","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=45949"},"modified":"2014-05-01T17:10:25","modified_gmt":"2014-05-01T21:10:25","slug":"my-say","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2014\/05\/01\/my-say\/","title":{"rendered":"my say&#8230;"},"content":{"rendered":"\n<ul><span class=\"small\">        <\/p>\n<li>on Psycritic: <a href=\"http:\/\/www.psycritic.com\/2014\/04\/on-integrated-mental-health-care.html\" target=\"_blank\">On Integrated Mental Health Care<\/a><\/li>\n<li>on Mad in America: <a href=\"http:\/\/www.madinamerica.com\/2014\/04\/end-psychiatry\/\" target=\"_blank\">The End of Psychiatry<\/a><\/li>\n<li>on PsychPractice: <a href=\"http:\/\/psychpracticemd.blogspot.com\/2014\/04\/apa-thetic.html\" target=\"_blank\">APA-thetic<\/a><\/li>\n<li>on Real Psychiatry: <a target=\"_blank\" href=\"http:\/\/real-psychiatry.blogspot.com\/2013\/05\/the-model-of-psychiatric-care-for-future.html\">The Model of Psychiatric Care for the Future<\/a>, <a target=\"_blank\" href=\"http:\/\/real-psychiatry.blogspot.com\/2013\/06\/collaborative-care-model-even-worse.html\">Collaborative Care Model &#8211; Even Worse Than I Imagined<\/a><\/li>\n<p>      <\/span><span class=\"small\">   <\/p>\n<p align=\"justify\"><em>The blogs above are ones I have nothing but respect for. They are all psychiatrists, but have different perspectives and situations. They&#8217;ve all weighed in on various aspects of <strong><font color=\"#200020\">Integrative Care<\/font><\/strong>. 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&#8217;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&#8217;t any clue how he ended up on this bandwagon&#8230; <\/em><\/p>\n<p>   <\/span><span class=\"small\"><em> <\/em>   <\/p>\n<p><em>And then there&#8217;s me&#8230; <\/em><\/p>\n<p>   <\/span><span class=\"small\">      <\/p>\n<li>on 1boringoldman: <a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2014\/04\/29\/the-apa-on-the-move\/\">the APA on the move&hellip;<\/a>, <a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2014\/04\/30\/a-test-soon\/\">tested soon&hellip;<\/a>, <a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2014\/05\/01\/two-versions\/\">two versions&hellip;         <\/a><\/li>\n<p>       <\/span><\/ul>\n<div align=\"justify\">No psychiatrist who is on this side of the doors to an Assisted Living Facility is any stranger to some version of what they&#8217;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 <em>checked off <\/em>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&#8217;t laid eyes on, but that was not a universal practice, just my way of being there. But I didn&#8217;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 &quot;eyeballing&quot; was mostly for their legal backup. For others, I couldn&#8217;t trust what I heard, and so my &quot;eyeballing&quot; was much more detailed, more like a second interview.  <\/div>\n<p align=\"justify\">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 &#8211; all overqualified volunteers. But there was a second clinic, a child and adolescent <em>agency<\/em>, where I not a primary, but more consultant and medication person. I&#8217;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 <em>collaboration<\/em>, so I quit. First, I had to start from zero with every case. I didn&#8217;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&#8217;t willing to do that. I still miss that clinic. The kids were really rewarding to work with.<\/p>\n<p align=\"justify\">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&#8217;ve rearranged that JAMA version [<a href=\"http:\/\/1boringoldman.com\/index.php\/2014\/05\/01\/two-versions\/\" target=\"_blank\">two versions&hellip;<\/a>] to highlight what&#8217;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&#8217;s no such thing as a <em>proxy clinician<\/em>. This isn&#8217;t Integrative Care &#8211; it&#8217;s malpractice. <\/p>\n<p align=\"center\"><img loading=\"lazy\" decoding=\"async\" width=\"475\" height=\"418\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/ico-all-3.gif\" \/><\/p>\n<p align=\"justify\">So I expect that what Dr. Dawson says, this is just a way station on the way to <em>no psychiatrist needed<\/em>, is probably right. Managed Care sees no need for Psychiatrists &#8211; never has, and many of our academicians and thought leaders have done their dead level best to help them with that goal. <\/p>\n<p align=\"justify\">But that&#8217;s just the start of my tirade. I am a Primary Care Physician &#8211; 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&#8217;t bring it off, and I don&#8217;t think I ever could have. That&#8217;s why I did another residency. Mental Illness is different from physical illness and requires a different mindset &#8211; no matter how hard our evidence based, measurement based, neoKraepelinian, key opinion leader, clinical neuroscientists have tried to say otherwise. And here&#8217;s my most recent simple example.<\/p>\n<p align=\"justify\">The adult clinic where I work is truly unique. It&#8217;s for the uninsured without resources. There&#8217;s only one paid employee, everyone else is a volunteer. We&#8217;re all old, retired people including the doctors &#8211; all from the upper ranks of the profession. The pharmacy is run by a former Dean. The escorts are retired rich people. It&#8217;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&#8217;s because I&#8217;m sure I&#8217;ve stopped more medications than I&#8217;ve started. I&#8217;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&#8217;t work, deal with withdrawal and akathisia, and I&#8217;m learning the methods how to slowly get people to change their lifestyle rather than pray for stronger pills &#8211; 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&#8217;t have a clue [and I can&#8217;t teach them]. They think, &quot;person depressed, give antidepressant&quot; and &quot;antidepressant didn&#8217;t work, add yet another&quot; and &quot;anxious, no Xanax these days, use Seroquel.&quot; <\/p>\n<p align=\"justify\">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 &#8211; PHARMA. I&#8217;ll give only one of many examples, this from Eli Lilly and their Zyprexa antipsychiatrist campaign [see <a href=\"http:\/\/1boringoldman.com\/index.php\/2011\/03\/28\/zyprexa-so-whats-wrong-with-martha\/\" target=\"_blank\"><font color=\"#4400aa\">Zyprexa<\/font>: so what&rsquo;s wrong with Martha?&hellip;<\/a>:<\/p>\n<p align=\"center\"><img loading=\"lazy\" decoding=\"async\" width=\"450\" height=\"381\" border=\"1\" src=\"http:\/\/1boringoldman.com\/images\/zyprexa-29.gif\" \/>&nbsp;<\/p>\n<p align=\"justify\">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 &#8211; as above. If they saw it as psychosis, they&#8217;d refer. They prescribe more frequently, more medicines, to more patients, and they don&#8217;t take people off of anything. Lilly&#8217;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.<\/p>\n<div align=\"justify\">Enough. I could blather about this for hours with a million stories, but I&#8217;ve had my say&#8230; <\/div>\n","protected":false},"excerpt":{"rendered":"<p>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 &#8211; Even Worse Than I Imagined The blogs above are ones I have nothing but respect for. They are all psychiatrists, but have [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-45949","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/45949","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=45949"}],"version-history":[{"count":35,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/45949\/revisions"}],"predecessor-version":[{"id":45985,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/45949\/revisions\/45985"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=45949"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=45949"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=45949"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}