Friday, April 18, 2014

On Integrated Mental Health Care

The American Psychiatric Association sure seems to be pushing hard for integrated (a.k.a. "collaborative") care these days. They even commissioned a report on how integrated care would save the system billions, which the Psych Practice blog recently dissected. APA president Dr. Jeffrey Lieberman, who is nearing the end of his term, recently published this piece in Psychiatric News. The attitude is one of "change is coming, so we'd best prepare." In this post, I'd like to take a critical look at various aspects of integrated care, based on my own (admittedly limited) experience.

First, why is integrated care a good idea? Where I work now, many psychiatrists do not accept insurance, and it can take patients months to get in to see a psychiatrist. When they do see a psychiatrist, the psychiatrist and referring physician are often too busy to communicate with one another. In some places, primary care doctors are forced to handle psychiatric patients with severe illnesses like schizophrenia, as highlighted in this post by Dr. Maria Yang. With children, pediatricians with very little psychiatric training often end up counseling parents about behavioral issues and prescribing medications, due partly to the severe shortage of child and adolescent psychiatrists.

Just as the American health care system is not just one system, but a patchwork mostly local systems, integrated/collaborative mental health care is not one thing; it can be done in many different ways. Several years ago, I experienced integrated care first-hand when I worked as a consulting psychiatrist in several primary care clinics that mainly provided care for underserved populations. Not surprisingly, most patients I saw were over 40 and had multiple medical problems. Most were referred to me because of depression or anxiety, though a significant number had a personality disorder, bipolar disorder, or schizophrenia. I got to spend an hour for each new patient visit and 30 minutes for each follow-up. In some of the clinics, I was told I should try to refer the patient back to their primary care physician (PCP) after 6 visits with me, though they were generally flexible about that.

I have to say, it was overall a good experience for me. I got to focus on providing patient care and did not have to deal with insurance companies or pharmacy benefit managers, since the clinics mostly used a generic formulary for medications. I was also glad that I helped not only the patient, but fellow physicians as well. The primary care doctors were uniformly and sincerely appreciative of having a psychiatrist that they could quickly refer patients to, or quickly consult with on a "curbside" basis. The patients tended to show up consistently for their appointments and liked having more time to talk with me compared to their brief PCP appointments. In one of the clinics, where the patients were mostly refugees and immigrants, few of them would have sought out a therapist or psychiatrist on their own, but they were more comfortable going to their doctor's office to meet with me. This all seems to concur with the APA's view of things.

That being said, my experience with integrated care was far from perfect. I thought that the vast majority of patients I saw would have benefitted from psychotherapy, yet very few of the clinics employed therapists, and none had access to more intensive treatments like dialectical behavior therapy. Even in the clinics that did have therapists (usually LCSWs), they were usually full and could not readily see new referrals. Because of the therapist shortage, I often ended up prescribing a medication by default. And of course, other forms of integrated care may be much more compromised than what I experienced. For example, managed care organizations seem to focus much more on cost containment, screening using rating scales, and then using medications to get those numbers down. To quote Sandra Steingard's comment last month on the 1Boring Old Man blog:
I was at a conference where a psychiatrist enthusiastically described her experience with collaborative care. Every morning, the treatment team would get together (the “huddle”). She gave an example of why this was so helpful. One day, someone mentioned that someone’s PHQ-9 had gone up by a few points (this is a nine item screening for depression). The presenter said something like, "So we agreed to increase the fluoxetine from 20 to 40 mg and we were all set to go!"
I also get quite concerned when I read things like Dr. Lieberman's article, which reflects the thinking of the APA leadership. From his closing paragraphs:
The difference between challenge and opportunity is often one of perception. Psychiatrists can view health care reform as leading to an inevitable change from the status quo and worrisome loss of autonomy. Alternatively, they can recognize that psychiatrists are well positioned to participate in and direct new health care initiatives—to become leaders of change, rather than siloed providers outside the mainstream of modern health care. We are the most highly trained, knowledgeable, and best positioned of all health care specialists to determine and provide (or at least oversee) the care of people with mental disorders. We are also mental health advocates who can identify gaps in service, educate others on the role of psychiatry, and offer concrete ways to better serve those within our communities.

There is a historic and exciting opportunity for psychiatrists to influence the future of medical care and occupy our rightful position in the field of medicine. Our nation is still at the beginning of the reform process, and we have the ability to influence its direction, but not if we choose to sit on the sidelines. It is important for psychiatrists to stay involved, not only in practice settings, but as APA members at the local and district branch levels. Step up and make your thoughts known to health care and government leaders; most are willing to listen if we offer ideas and solutions.
Is the focus on improving patient care, or something else? I believe that most psychiatrists are secure with their professional identities, and it is the more biologically-oriented psychiatrists who feel that we must claim our rightful place amongst other medical professionals. It's clear that they fear that psychiatrists would just opt out of the system entirely and remain in solo practice or collaborate mostly with independent psychologists and therapists. This would open the door for people like prescribing psychologists or nurse practitioners to fill the unmet need of psychiatric prescribers in medical settings. So on some level, this is a political battle as the APA fights to retain the mantle of mental health leadership. Why else do you think they have prominent politicians like Bill Clinton and Joe Biden opening the APA annual meetings?

In my mind, the biggest unmet need in mental health right now for the insured population is increasing the numbers of providers of effective therapies like CBT, DBT, PCIT, and so on. Of course, the APA does not address this at all. Instead, what the biological psychiatrists tend to emphasize is that primary care doctors don't diagnose enough, don't use the right dosage of medication, and patients do not stay on medications for long enough. Thus, the relentless push for diagnostic inflation, mass screening so cases are not missed, medication algorithms so that doses are optimized, and tracking patients like they're widgets in a factory. If psychiatry changes in accord with this vision, it would profoundly alter who enters this profession (if it continues to exist at all). Most psychiatrists I know went into this field because of a desire to treat the whole person rather than just symptoms, not to "or at least oversee" treatment provided by someone else. This type of system would favor those whose interests lie primarily in numbers, charts, "huddling" with a team. Is this really what anyone other than the APA wants business interests of managed care want the future psychiatrist to be?

This post was edited to more accurately reflect what I meant to say. Thanks, Dr. Dawson!

Monday, April 14, 2014

Book Review: Slow Getting Up

Over the weekend, I read Nate Jackson's Slow Getting Up: A Story of NFL Survival from the Bottom of the Pile in almost one sitting, a rare thing these days with my attention span getting ever shorter. Jackson was an unlikely success story, someone who beat the odds by making it to the NFL and playing for six seasons despite not being drafted after playing for a Division III college.

Jackson very vividly captures the bravado of the professional athlete: the pride in his extraordinary physical prowess, the adrenaline rush of stepping onto the field, the agony of being in the purgatory of NFL Europe, the fear of appearing weak, the drunken cash-burning Vegas partying, the frenzied testosterone-fueled cracking of helmets.

The book is wickedly funny in parts, such as when Jackson described having to be at practice early because he was part of the special teams unit:
Forty-five minutes later the rest of the team shows up. Starters don't come to special teams meetings. They're happy not to play during the ritual sacrifice of kickoffs and punts, but maybe they're also a bit envious. We're a tight-knit group. We know things the other guys don't. We know about fifty-yard dead-spring head-on collisions. We know about snot bubbles. We look at the game differently. [p. 101]
The gallows humor pervades much of the book, but the most jarring passages are when Jackson quotes from his own extensive medical record. The dry technical language belies the horrible ravaging that his body has suffered. From one of his later injuries:
MRI findings:

High-grade complete tear and stripping of proximal left adductor longus and brevis, with distal retraction and about 5cm tear defect gap with intervening edema and hemorrhage. Strain of the adjacent pectineus and obturator externus and gracilis muscles and attachments.

Moderate proximal hamstring tendinosis and/or strain and scarring are seen, with longitudinal thinning and possible tearing of the proximal deep margins at the ischial tuberosity attachments bilaterally. [p. 185]
From my viewpoint, Jackson's interactions with the team doctors take on a surreal quality. They ostensibly warn him of the risks and benefits of procedures such as steroid or NSAID injections, but it's a foregone conclusion that he would do whatever might get him back onto the field the fastest. Of course, the doctors were serving the team more than the players: one passage describes how Jackson's injuries were first reported to the team's management and the coach before he himself found out what was going on. The long-term health of the player did not factor much into the equation.

Ultimately, what I got out of the book is that the NFL is a profit-generating industry, which like all others, seeks to maximize its profits. It treats the players as replaceable cogs in a machine, parts that can easily be replaced when broken. Sure, coaches and general managers are frequently hired and fired as well, but it is the bodies and minds of the players that pay the ultimate price for our entertainment. Yet at the same time, players enter into this arrangement willingly (at least in the beginning), attracted by the money, the glory, the desire to be compete with the best in the world.

And that brings me to perhaps why I wrote this post today. There was an article in The Daily Beast making the rounds: How Being a Doctor Became the Most Miserable Profession. The article highlights a litany of woes, including the high suicide rate amongst doctors, the fact that 9 out of 10 doctors would discourage others from joining the profession, and how doctors have to see so many patients now that "the average face-to-face clinic visit lasts about 12 minutes."

Just as the NFL uses its players for profit maximization with little regard for their well-being, the healthcare system uses doctors in the same way. I tend to believe that what keeps most doctors in the profession is not the quest for money or status, but a sense of duty, of wanting to help patients and not abandon them. So in this way, doctors might actually be worse off than NFL players. There's no collective bargaining agreement. Doctors – in the U.S., at least – don't go on strike. The associations that are supposed to represent doctors often seem to collude with the business forces of medicine rather than look out for the interests of practicing clinicians. Doctors are not so easily replaced, and since there's already a big doctor shortage in the U.S., we've been sucking up physicians from the rest of the world's supply.

Compared to primary care, psychiatrists have it relatively good. Many are still in solo private practices, not on insurance panels and seeing a manageable number of patients per day. Others work in public-sector roles. Yet with every passing year, the system creeps closer to requiring psychiatrists to participate, ostensibly to help contain costs with measures like integrated care. What can be done to change it for the better? The current path is clearly not sustainable. Cost containment is clearly being targeted at the wrong level. How about containing costs here, or here? Now that would be a great start!

Monday, March 31, 2014

Losing the White Coat Part 2: Residency

This is part 2 of a series on the evolution of my approach to psychiatry. Part 1 was about my medical school experience, and A Most Influential Professor described a key experience I had in college.

I went into psychiatry because I was fascinated by the variety of human emotions, behavior, and psychopathology, and I wanted to explore the plethora of influences (cultural, social, psychological, and biological) on those aspects of humanity. My medical school emphasized the biological approach, so I decided to continue my training elsewhere for residency.

At my residency program, while there was more of an emphasis on psychotherapy compared to my medical school, the biological psychiatrists still reigned supreme. The university had some well known psychotherapists, but they tended to have titles such as "emeritus professor" or "clinical professor," meaning that they were not around very much. And I doubt they would have felt welcome, with the residents' main jobs being completing paperwork and adjusting medications during the majority of their rotations, rather than running groups or conducting therapy.

It was easy to see who the big money-makers of the department were: the researchers who focused on the neural basis of mental disorders while providing biological treatments in their clinical practice. There was a bipolar disorder expert, who once had a patient on 10 different medications, to the point that it was impossible to tell what was the patient's "disease" and what were the side effects. There was the schizophrenia expert who headed the locked inpatient unit, who frequently gave talks to psychiatrists in the community advertising the newest antipsychotic medications. She claimed that because she was on the speaker bureau for all the big pharma companies, she was unbiased in her assessment of the medications. And then there was the renowned depression expert, who once told us, "Even if the medications are no more effective than placebo, it doesn't mean that you shouldn't treat the patients." Make of that what you will.

However, the experience that opened my eyes most to the flaws of a purely biological approach to psychiatry was what I saw happening with Dr. Z, one of the psychiatrists on the electroconvulsive therapy (ECT) service. He gave great lectures, drawing up pretty diagrams of the circuits in the brain believed to underly mood and depression. Unlike most psychiatrists, he often walked around in scrubs, and he had a confident charm to go along with a cheerful disposition. Perhaps appropriately so, since he offered a treatment unparalleled in its effectiveness for patients with severe psychotic depression and bipolar disorder.

The problem, though, was that the bipolar disorder diagnosis (and its attendant "treatment resistant depression") became so loosely applied that practically anyone with mood swings was being diagnosed with "bipolar II," and Dr. Z fully embraced this trend. His evaluations for whether a patient was a good candidate for ECT were thorough, to a point. There was meticulous documentation of the medications that the patient has tried and the inadequate response to them. Mostly ignored, however, were details about what the patient's life was actually like and what factors may have been influencing their symptoms. Thus, plenty of patients who clearly had borderline personality disorder (BPD) were deemed "excellent candidates" for ECT; none of the depression medications that they had tried ever did lasting good, since their moods would turn depressed or irritable in response to interpersonal stress, regardless of what meds they were taking.

I remember hearing two stories in particular about his patients (details altered to protect anonymity). One day, a patient of Dr. Z's arrived in clinic holding a knife to her chest after her boyfriend broke up with her. She told the astounded clinic receptionist that she would stab herself if she did not see Dr. Z right away. Dr. Z was not in, and the patient ended up walking into the office of another psychiatrist, who managed to calmly talk her down while security was notified. Another time, a patient was dragged kicking and screaming into the ER after swallowing a handful of pills during an argument with her husband. She was heard yelling, "I'll only talk to Dr. Z! Where is he? I know he's coming because he loves me!" Dr. Z clearly had a profound effect on his BPD patients, even if the benefits of ECT for those patients was very temporary.

Recently, I read Dr. David Allen's post on the difference between the symptoms of major depression and the depression often seen in BPD. But even back then something felt off to me about doing ECT on patients who had "treatment resistant depression" because of a personality disorder, which brings me back to the title of this post. At the institutions where I trained, the psychiatrists who wore the white physician's coats, not surprisingly, tended to be the more biologically-oriented ones. Thus, in my mind the white coat became associated with their view of psychiatry, one that I did not share.

Thankfully, my mind was already set on being a child psychiatrist. At least in the world of child psychiatry, despite the influence of biological psychiatrists like Harvard's Biederman, many (I don't dare to claim "most," given the direction things seem to be heading) child psychiatrists still consider the influence of things like family, parenting, and developmental trauma on behavior, rather than just focusing on figuring out the black box of the brain.

Saturday, March 22, 2014

There's a Pill for That…Or Not

A few days ago, I read an article by Los Angeles-based psychiatrist Joseph Pierre titled "A Mad World" (thanks to Vaughn Bell over at Mindhacks for the link). Right off the bat, I was suspicious of the SEO link-baiting done by the Aeon editors: the title that appears on the web browser's title bar is not "A Mad World," but is "Do psychiatrists think everyone is crazy?", and the URL of the article ends in "have-psychiatrists-lost-perspective-on-mental-illness." Of course, Dr. Pierre likely had no control over how the publication chose to market his article; more on this later.

He does make some good points about how mainstream psychiatrists are not as bound by the DSM as some may think:
The truth is that while psychiatric diagnosis is helpful in understanding what ails a patient and formulating a treatment plan, psychiatrists don’t waste a lot of time fretting over whether a patient can be neatly categorised in DSM, or even whether or not that patient truly has a mental disorder at all. A patient comes in with a complaint of suffering, and the clinician tries to relieve that suffering independent of such exacting distinctions. If anything, such details become most important for insurance billing, where clinicians might err on the side of making a diagnosis to obtain reimbursement for a patient who might not otherwise be able to receive care.
However, reading through the piece gave me a very uneasy feeling. After thinking about it some, I think my discomfort comes from the author's uncritical acceptance of American consumerism, as illustrated by sections like this one:
Though many object to psychiatry’s perceived encroachment into normality, we rarely hear such complaints about the rest of medicine. Few lament that nearly all of us, at some point in our lives, seek care from a physician and take all manner of medications, most without need of a prescription, for one physical ailment or another.
Now, I love being a consumer as much as most other Americans. The convenience of being able to do just about anything ("There's an app for that") on a handheld device is incredible. But what happens when you mix healthcare and consumerism? You get commercials telling viewers to "ask your doctor about" lots of different conditions, whether it's chronic dry eye, low T, or whatever. We already live in a county where the costs of healthcare far outweigh the benefit in terms of life expectancy, so isn't the over-medicalization of normality worth lamenting, even if most people don't? And certainly when it comes to healthcare, the consumer is not always right, though doctors often give in and end up doing things like prescribing antibiotics for viral illnesses.

And then there was this passage, straight out of a pharma executive's wet-dream:
Pharmacotherapy for healthier individuals is likely to increase in the future as safer medications are developed, just as happened after selective serotonin re-uptake inhibitors (SSRIs) supplanted tricyclic antidepressants (TCAs) during the 1990s. In turn, the shift to medicating the healthier end of the continuum paves a path towards not only maximising wellness but enhancing normal functioning through ‘cosmetic’ intervention. Ultimately, availability of medications that enhance brain function or make us feel better than normal will be driven by consumer demand, not the Machiavellian plans of psychiatrists.
SSRI's have been around for over 25 years, and where are the safer medications? Has he not been reading the headlines? He continues with:
The legal use of drugs to alter our moods is already nearly ubiquitous. We take Ritalin, modafinil (Provigil), or just our daily cup of caffeine to help us focus, stay awake, and make that deadline at work; then we reach for our diazepam (Valium), alcohol, or marijuana to unwind at the end of the day. If a kind of anabolic steroid for the brain were created, say a pill that could increase IQ by an average of 10 points with a minimum of side effects, is there any question that the public would clamour for it?
Suppose we have a pill that could take away pain but has no side effects whatsoever, including constipation, sedation, deadliness in overdose, etc. Isn't it obvious that an emergent effect (whether or not you call it a "side effect" or not) is that people would be hooked on this pill, and it would have enormous street value? Perhaps I'm just old-fashioned, but I get the sense that side effects (e.g. passing out drunk, getting jittery from caffeine, becoming duller from chronic cannabis use) are nature's way of keeping us from going overboard with too much of a good thing.

Dr. Pierre states toward the end:
In the final analysis, psychiatrists don’t think that everyone is crazy, nor are we necessarily guilty of pathologising normal existence and foisting medications upon the populace as pawns of the drug companies. Instead, we are just doing what we can to relieve the suffering of those coming for help, rather than turning those people away.
Drug dealers can make the same argument, that they're just there to meet a consumer demand, relieve suffering, and increase happiness. Of course, with drug dealers it's easy to see that their products have very short-term benefits but cause long-term harm. While not nearly as extreme, I believe that if all we're doing is relieving suffering without helping patients recognize and change what led to the suffering, we are not truly helping them in the long run; we're just turning them into repeat customers. And suffering itself is not always a bad thing. In the field of child psychiatry & psychology, for example, we are increasingly recognizing how parents' efforts to protect their children from any suffering can lead to those kids having trouble being on their own or dealing with stress later in life.

I don't advocate turning people away, but I often emphasize to patients that feeling better is going to take significant time and effort on their part, and is not something I can just give them, which may not be what a good consumer wants to hear. Which brings me back to my first paragraph. I not only pointed out the methods Aeon used to market the article to consumers, but I also mentioned that Dr. Pierre works in L.A. This is not a coincidence, as L.A. is one of the epicenters of American consumerism. This article is emblematic of how consumerism operates and is a defense of it, by someone who may be too immersed in a consumerist culture to see its follies.

Sunday, March 16, 2014

Insel's Techno-Utopia

In a recent post, 1BOM likened the key opinion leaders (KOLs) in psychiatry who gathered at two glitzy meetings to fashion commentators at the Oscars:
It was Dr. Schatzberg’s comment at the end, "More needs to be done now if we are to have new treatments in the next decade..." It sounded to me like those dress designers thinking about what new innovations they could muster for the coming year. It has to be something new – novel, innovative, a new look, a new material, a new something to drape the pretty ladies with on the red carpet next year. […]

The psychopharmacology era from 1987 to the recent past has been like that. The next wonderful new antidepressant has to be more desirable than the last one. The novel way of accessorizing [sequencing, combining, augmenting] has to be value added. Without a pipeline producing something new periodically, the shine wears off of the old drugs and their foibles begin to show. So we need a new design, a new line [as they say in the garment industry], something to keep the momentum flowing. But our KOLs haven’t been like the dress designers, they’ve been more like the Red Carpet commentators who talk about other peoples’ designs – giving talks like recent advances in …, or neurobiology of ..., or writing review articles, or signing on to the industrial clinical trials – more groupies than stars. That must be why they’re so frantic. Commentators with nothing to comment about.
I think that's an interesting analogy, but for me it doesn't quite hit the nail on the head. To me, a more apt analogy is along ideological lines. Lately I've been reading Steven Pinker's The Better Angels of Our Nature, a very detailed and data-driven book about why violence has declined over time. I was struck by the following passages about the roles of utopian ideologies in promoting violence:
Institutionalized torture in Christendom was not just an unthinking habit; it had a moral rationale. If you really believe that failing to accept Jesus as one's savior is a ticket to fiery damnation, then torturing a person until he acknowledges this truth is doing him the biggest favor of his life; better a few hours now than an eternity later. And silencing a person before he can corrupt others, or making an example of him to deter the rest, is a responsible public health measure. [p. 16-17]
[…]
Revolutionary and Napoleonic France, Bell has shown, were consumed by a combination of French nationalism and utopian ideology. The ideology, like the versions of Christianity that came before it and the fascism and communism that would follow it, was messianic, apocalyptic, expansionist, and certain of its own rectitude. And it viewed its opponents as irredeemably evil: as existential threats that had to be eliminated in pursuit of a holy cause. [p. 239]
Of course, none of these KOLs are like Napoleon, Stalin, Mao, etc. Thank the deity of your choice that they do not have that much power, and that we live in a much more peaceful time. These days, scathing editorials questioning a person's integrity are as dirty as the KOLs get.

But just like those utopian movements, much of academic psychiatry (especially the KOL segment) is driven by an ideology: the tenets of biopsychiatry, which the 1 Boring Old Man blog has described in detail. This ideology is assumed to be correct, and because its believers think that this system will result in a huge amount of good (i.e. "NIMH envisions a world in which mental illnesses are prevented and cured"), then people who seem to oppose this ideology are at best deeply misguided, at worst causing irrevocable harm. Furthermore, anything short of this grand vision is deemed not worth pursuing.

In my mind, this is the best explanation for why things like Paxil study 329, or the Markingson case, or problematic conflicts of interest, or millions of mentally ill being locked up in jails and prisons, get ignored by the leaders of academic psychiatry. They're seen as relatively insignificant bumps in the road in the grand utopian scheme. Last year, I wrote a somewhat tongue-in-cheek post about what if the NIMH succeeds in its utopian vision. With the recent news that the NIMH will only fund treatment studies that also examine biological etiology, things are much more serious than I thought.