The APA annual meeting: a photo essay

As posted previously, last month I attended the American Psychiatric Association's (APA's) annual conference.  Straying from my usual format, I thought I'd post pictures from the meeting and, of course, offer comments. The meeting took place in Moscone Center, a conference center complex located just south of Market Street in downtown San Francisco.  Depicted here are anti-psychiatry protesters who held a rally in front of the main entrance at noon on the first day.  There was also an exhibit of psychiatry's cruelties (psychosurgery, shock treatment, inhumane conditions in asylums, etc) running all five days in a tent across the street from the conference.   The conference was also a block from Yerba Buena Gardens, where I caught a very pleasant Balinese gamelan concert at the same time as the protest rally. This simultaneity — two events scheduled to coincide, forcing a choice — was a constant in the conference as well. The "scientific program" consisted of  numerous overlapping talks, such that attending any presentation meant missing five or more other good ones.  I'm not sure why the APA opted for such frustrating redundancy.  Nor can I explain why predictably popular talks were scheduled into small rooms, with the result that dozens of registrants were turned away once the room filled.  For instance, the crowd for Otto Kernberg's psychoanalytic talk on love and aggression was several times larger than the assigned room.  In this unusual case we were all moved to a cavernous hall at the last moment, where Dr. Kernberg gave a warm and very engaging presentation on the necessity and creative consequences of aggression in romantic love.  (I like how this photo depicts the renowned psychoanalyst Kernberg representing the APA in an era of biological ascendancy.)

The same huge auditorium was to hold the keynote address by Bill Clinton.  However, Mr. Clinton was ill and could not be there in person.  Several hundred (a couple thousand?) conference-goers nonetheless waited over an hour to see him on video.  Mr. Clinton was pleasant, thoughtful, and charismatic, but didn't offer much specifically about psychiatry or mental health.  Mostly he spoke about public health needs in general.

I didn't take many photos in the talks themselves.  Officially it was forbidden, although this rule was routinely ignored by attendees.  The quality of the presentations was high — I mostly chose "mainstream" ones this time, not the many off-beat and generally smaller meetings.  I attended presentations on suicide, personality disorders, PTSD, sexual compulsions, DSM-5 and mood disorders, the controversy over antidepressant efficacy, psychiatrists writing and blogging for the general public, teaching psychotherapy to residents, and assessing the capacity of demented patients to make medical decisions for themselves.  There were dozens of others I would have liked to attend, had they not coincided with the ones I chose.

I skipped the industry-sponsored, free lunch or dinner, non-CME presentations.  But I did wander through the exhibit hall, both to see the "new investigator" scientific posters, and to peruse the brand-new DSM-5. In contrast to the last time I went to this conference, the industry booths seemed less garish and "over the top."  Of course, there were still a lot of them.  Several had raffles where valuable prizes such as an iPad Mini could be won by those who gave the company their contact information.  One booth offered a pocket digest of the new DSM-5, MSRP about $60, to everyone who watched a 12 minute presentation and coughed up a mailing address.  I was tempted... but no.  (It's interesting to ponder how much a single psychiatrist contact is worth to a drug company.  Much more than $60, I'd venture.)

The DSM-5 itself is $200 in hardcover, $150 in paperback — an unabashed moneymaker for the APA.  Despite the incredible controversy it stirred up, my impression is that the changes from DSM-IV-TR are relatively minor.  In particular, the personality disorder section hasn't changed much, although the new edition is no longer multi-axial, i.e., there is no "Axis 2".  Some language has been made more precise, as well as more "biological" in some passages, and some disorders have been expanded to include more that would previously have been considered normal.  Whether this is good or bad depends on one's perspective in several respects; mostly I find it unfortunate.  DSM classifications often matter more to insurers and disability officers than to practicing psychiatrists, who in David Brooks' words are "heroes of uncertainty" (echoing an earlier post of mine, but I'll forgive him for not quoting me).  We deal with individuals, not disease categories.

I will end with a slide from the talk on antidepressant efficacy that summarizes this tension in my field.  As I've discussed previously, randomized controlled trials (RCTs) are the gold standard for scientific rigor in psychiatry; however, a lot of psychiatry is not scientific in this sense.  DSM categories help define the "average" patient with a particular disorder, leaving a lot of wiggle room since the categories are not based on etiology.  RCTs say which treatments best help this "average" patient, represented by the computer composite in the center of this slide.  However, I don't see "average" patients,  I see one of the 12 individuals who contributed to the composite.  Thus, for me, the new DSM was a sideshow at the conference.  The most insightful presentations, whether on PTSD, suicide, or capacity assessment, combined science and the nuanced human communication of meaning.  They recognized that our work is informed by science but goes well beyond it.  Anti-psychiatrists don't like this, insurers don't like this, neuroscientists don't like this, even many psychiatrists don't like this.  But it's true and inevitable for the foreseeable future.  I like it.  As for the APA annual meeting, I'm glad I went, and equally glad I won't feel the need to go back for several years at least.

The commodification of psychiatry

Several recent articles, blogs, and even my participation in HealthTap (discussed in my last two posts) have led me to think about how psychiatry, and mental health treatment generally, are increasingly viewed as commodities.  In the language of economics, a commodity is a physical good, such as food, grain, or metal, which is interchangeable with any other product of the same type.  Commodities are carefully specified, e.g., "Wheat, No.1 Hard Red Winter, ordinary protein, FOB Gulf of Mexico," but the supplier is immaterial.  Everything one needs to know about a commodity is in the specification.  Based on that alone, a smart buyer seeks the lowest price. Much has been written lately about the psychiatric "med check," a 10 to 20 minute encounter every few months for patients who take psychiatric medications.  A New York Times profile of one such high-volume practice generated notoriety for this approach, well deserved in my view.  Even the profiled doctor had reservations, but succumbed to the lure of higher income as compared to the traditional model of one patient per hour.

Although psychiatric medication management can be done well, the "med check" is often critiqued as an assembly-line approach that treats collections of symptoms, not people.  The assembly-line metaphor highlights the commodification of both parties.  On an assembly-line, each "part" moving down the line can be treated as any other. Likewise, each worker is interchangeable with any other having the same qualifications.  In commodity psychiatry, any fully specified "Major depression, single episode, moderate severity" can be treated as any other.  Mental health workers of a given specification (psychiatrist, nurse, counselor) are interchangeable as well.  The only thing left is to let the marketplace (or government) set the price of this commodity transaction.

While commodity treatment is easiest to recognize in the stereotypical "med check," it is rampant in the rest of the field as well.  Suicidal patients should immediately be sent to the ER, yes?  Because all patients who declare themselves suicidal are the same, just like "Wheat, No.1 Hard Red Winter, ordinary protein, FOB Gulf of Mexico."  Well, no.  In supervising residents and talking with colleagues, I'm amazed how often patients cool their heels, and spend thousands of dollars, in three-day inpatient stays triggered by a threat of suicide.  I claim no magical gift for curing depression or suicidal urges, and I've had my share of patients who scream, "I'm heading for the Golden Gate Bridge right now!"  Nonetheless, I can't recall the last time I hospitalized anyone for suicide risk, and I've never had a patient die by suicide.  Why?  Because it means something when someone threatens suicide, and that meaning varies from person to person.  "Suicidality" isn't a commodity specification, and it should not be treated as such.

Nor is psychotherapy immune from commodification.  "You have social anxiety?  We offer a 16 session cognitive-behavioral treatment for that." As though people who are anxious in social situations are interchangeable — and as though any practitioner who conducts a brand-name 16 session intervention is the same as any other who offers that brand.  The specification is all that matters, the supplier is immaterial.  Perhaps the ultimate example of therapy as commodity is when there is no therapist at all, as in this recent article about a smartphone app designed to decrease social anxiety.  Here, however, the app really is a commodity: Every copy of the app works the same, and it treats all users exactly the same as well.

With an ever-expanding diagnostic manual, and with a pharmaceutical, electronic, or scripted cure for every ill, psychiatry speeds toward a future where it no longer matters who has symptoms, it only matters what the symptoms are.  Likewise, practitioners are interchangeable and thus should be chosen for the lowest cost, just as a buyer spends the least possible on a certain grade of wheat.  It makes no sense to pay for an expensive psychiatrist or psychologist to perform psychotherapy, when psychotherapy is a commodity that can be supplied by people who charge less, or perhaps by a computer program, website, or smartphone app.

To be sure, there are areas of medicine well-served by rote protocol.  Thankfully, no one stops to "customize" CPR during a cardiac arrest.  But in most health care scenarios, treating patients as commodities is dubious.  And in the subtle realm of emotional health it's tragic.  As I wrote in my post about nomothetic versus idiographic thinking in psychiatry, western medicine derives its considerable power from lumping patients into a disease category, and then applying statistically proven treatment to members of that category.  For example, in psychiatry we are not forced to approach a new case of bipolar disorder in complete ignorance; among other things, we know lithium is apt to relieve the signs and symptoms.  But if we stop there, at the nomothetic level of knowledge, we are treating the bipolar disorder, not the patient.  The "supplier," the person suffering the disorder, is immaterial.  We are doing commodity psychiatry.

The alternative is not to abandon the hard-won knowledge of western medicine and nomothetic research.  It is to acknowledge that every person sharing a diagnostic category is unique — that no individual experiences major depression or bipolar disorder in quite the same way as anyone else.  Understanding and enhancing each patient's unique experiential reality is the essence of psychiatric practice, and mental health care generally.  Since these nuanced goals cannot be accomplished without considering the "supplier" — the person with the disorder, as well as the person offering care — the commodity model will forever shortchange psychiatrists and their patients.

Efficacy of dynamic psychotherapy

The following post is an adaptation of an argument I presented on Sacramento Street Psychiatry, my blog on the Psychology Today website.  As usual, I welcome your comments. Western medicine's great strides are largely due to understanding etiology (the biological basis of disease), defining a nosology (a system of categorizing diseases), and testing treatments aimed at these nosological entities, not at individual patients. Take 100 healthy volunteers, swab their throats with Streptococcus, and perhaps 88 will soon develop strep throat. Both our knowledge of bacterial infections (etiology) as well as repeated empirical observation of similar cases leads us to conclude that Streptococcus causes a recognizable condition called strep throat (nosology). Once patients are diagnosed with strep throat — once their conditions become exemplars of this disease category — experiments can be done to show which treatments relieve the condition. Western medicine is the accretion of such knowledge.

Hypotheses about disease categories, and about treatments aimed at these categories, can be tested using randomized controlled trials (RCTs), our most powerful statistical method to assess the effect of independent variables. As in the rest of medicine, evidence supporting the efficacy of psychopharmacology, as well as manualized psychotherapies such as CBT, depends on sorting patients into nosological categories such as "major depression," applying different treatments to comparison groups, and finding statistically significant group mean differences.  In psychology such a research approach is called nomothetic; the goal is to identify general laws of behavior.

However, another kind of knowledge is important too. Why didn't the other 12 subjects get strep throat? Is it the same reason for all 12, or is the answer different for each of them? Looking at what makes people unique, as opposed to members of a category, is called idiographic research in psychology. This is the nature of psychodynamic theory and treatment, and why it resists the usual RCT approach to research. Patients who present for such treatment rarely fit neatly into a category such as "depressed." They vaguely say their lives aren't working well for them, or that their relationships are unsatisfying in a particular way. They lack meaning and purpose in life.  They get a "funny feeling" when dealing with competition. Their boss triggers authority issues.  They can't trust their spouse's fidelity. And on and on.  Such complaints are not exemplars of a nosological category. We may not know what causes schizophrenia or bipolar disorder — we have no etiological understanding of any psychiatric disorder, one reason they are called "disorders" and not "diseases" — but at least these labels reflect a coherent nosology.  Not so with the presenting complaints of most psychotherapy patients.

Psychodynamic therapists and psychoanalysts find little of value in the nomothetic approach. DSM-IV and similar nosology sheds no light on the particular patient in the office, with his unique history, dreams, fears, hopes, etc. The psychoanalytic/dynamic perspective is to understand the uniqueness of that specific patient, and to promote unique helpful changes that may have no relevance to any other patient seen in the practice.

This is not to discount the importance of the nomothetic approach where it applies. If a patient's condition is exemplary of a nosological category, it should be treated that way.  Doing so allows us to use powerful research tools to separate bias and wishful thinking from real treatment effects.  If a patient presents with major depression, bipolar disorder, or schizophrenia, nomothetic research can and should guide treatment. In such cases, psychodynamic therapy must stand or fall on the same RCT basis as other treatments.  The evidence base for manualized psychotherapies such as CBT, IPT, and a few others is stronger than for dynamic psychotherapy. If someone is seeking relief of major depression, pure and simple, I am happy to refer them to a CBT therapist, and have done so on a number of occasions.  It would be nice to be able to claim strong evidence for the efficacy of prescription antidepressants as well, but unfortunately this is less clear.

CBT and other manualized therapies for specific conditions are much easier to study than dynamic therapy for ill-defined complaints. So it's really no surprise there are more such studies.  Idiographic research methods, e.g., pre and post measures in single-case designs, have been used to study dynamic psychotherapy, both whether it works and how. But nomothetic researchers consider this "weak science": There are no control groups — no groups at all, actually.

The bottom line is that dynamic psychotherapy has different goals than CBT or medication.  It doesn't aim to treat a nosological category such as major depression.  Since it isn't based on a nomothetic treatment model, RCTs are the wrong assessment tools to use.  Idiographic research methods may be statistically weaker than their nomothetic counterparts, but they are the best that this domain of inquiry allows.  (Seligman argues that naturalistic surveys have their place too.)  Dynamic psychotherapy is based on a rich theoretical foundation that has been scrutinized and refined for the past century. But ultimately it comes down to the individual and the unique mix of discomforting feelings and troubling thoughts that led him or her to reach out for help.