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.

Review of HealthTap

As posted below, I joined HealthTap a month ago, impressed with its vision of bringing real medical expertise to the public in a Yahoo Answers type format.  Since then I've participated actively.  As of today, I've answered 40 questions, and I've been thanked by 30 members — it's tempting to call them patients, but they're not.  Other physicians have agreed with my answers 60 times; I've agreed with some of theirs as well.  HealthTap claims I've helped over 4000 people; I have no idea how they calculate that.  I've earned 3600 points and 13 rather trivial "awards" by virtue of my activities, granting me "Level 7" status as a "Leading Medical Expert."  I haven't yet used the mobile app or social networking links (i.e., to Facebook, LinkedIn, or Twitter), nor have I written "tips" or "health guides," collections of answers and tips under a defined theme.  I also haven't done much with the networking feature: I "follow" one other psychiatrist, and eight physicians follow me, which basically means they find out immediately if I post something (and their dedicated readers see it as well, like a Facebook "wall").  Today, HealthTap reposted my piece on support and insight in therapy to their blog. All in all, it's been fun.  The awards, points, and "levels" are a bit silly, but they add some zing.  Answering questions in 400 characters isn't as hard as I expected, and part of the fun is deciding what to say in so few words.  It's also interesting to read what other MDs write, especially in fields other than mine.  And it does feel nice to volunteer simple answers to real questions people have.

HealthTap democritizes medical knowledge, and brings the public closer to instant "ask your doctor" convenience than other health sites I've seen.  But looming over the enterprise is the reality that we are not "your" doctor.  The terms of service and legal disclaimers underscore that no doctor-patient relationship exists via the site, and that medical answers are intended to be generic, not for an individual.  But patients, I mean members, mostly ask first-person questions that address their personal medical concerns.  That's the whole idea.  And very often we doctors reply that there are many possible diagnoses or etiologies to consider, but that only an in-person medical evaluation can sort them out.

While HealthTap is an inspired effort, in my opinion it is hampered by the wrong model.  It tries to be a social networking site, when in reality it's a knowledgebase.  Social networks derive value from interconnected communications among members; think Twitter and Facebook.  But people don't chat about health issues on HealthTap, nor do they befriend others.  They seek answers to questions.  HealthTap's social network model encourages asking the same questions over and over, since quick access to doctors is emphasized, not the fact that thousands of questions have already been answered.  For example, in my one month on the site several members have asked how to treat anxiety.  It's a good generic question, but it's already been answered a number of times — at least as well as one can answer such a broad question in 400 characters.

HealthTap encourages doctors to create a Virtual Practice to "enhance your reputation, get new patients, and improve practice efficiency."  I don't quite see the utility, but perhaps this works better for other specialties.  I can imagine a family physician pointing real patients to his or her HealthTap page for tips or guidelines about common complaints.

I think HealthTap would serve its members better by embracing the knowledgebase model.  Make prior questions and associated answers more easily searchable, and give searching priority over asking anew.  If a user's specific question is not found, it could be submitted to HealthTap staff for vetting.  Duplicate or incoherent questions could be rejected, grammar and spelling cleaned up, and meaningful tags added to facilitate retrieval later.  To encourage participation, doctors could still be recognized for answering quickly or often, or with answers colleagues agree with.  Thanks could still be offered by members for helpful answers, and everyone could still log into personalized pages as they do now.

HealthTap is reportedly popular and growing rapidly.  HealthTap Express, the mobile app, is the #1 Staff Pick on Android Market.  As long as people seek health information online, and as long as doctors volunteer to provide it, HealthTap's future seems bright.  But it could be so much more if its architecture better matched its primary purpose.  Social networks are great for social networking.  Knowledgebases are great for organizing, storing, and retrieving knowledge.  The doctor-patient relationship, a small social network, cannot exist on HealthTap, but a great deal of medical knowledge already does.  Its organization and accessibility could be greatly enhanced without sacrificing the responsiveness and personalization that brings smiles to the HealthTap team and its members.

Movie review: "A dangerous method"

Tonight I was invited to an advance screening of "A Dangerous Method," a film about the early days of psychoanalysis.  It stars Keira Knightley, Michael Fassbender, and Viggo Mortensen, and will be in wide release by Sony Pictures Classics this month.  The invitation was extended to Psychology Today bloggers, among others, in the hope we'll publicize the release.  Since I was gifted with a free viewing, I invite readers to consider this review with my potential conflict of interest in mind. Overall, I was pleasantly surprised by the film, which has received mixed but mostly positive reviews so far.  It humanizes both Freud and Jung, and introduces us to Sabina Spielrein, a real-life patient of Jung who later became a renowned psychoanalyst herself.  Jung's reputed sexual affair with Spielrein is treated as fact in the movie, and serves as the main dramatic focus.  Some reviewers feel Knightley overacted the part of Spielrein.  I thought it was pitched about right: a troubled young woman having illicit sex with her therapist would naturally be agitated and volatile.  I did find Spielrein's willingness, from the first session, to participate in newfangled psychoanalysis to be a bit optimistic.  Also, her suggestion at one point that "there is man in every woman, and woman in every man" too-neatly implies that she gave Jung his idea of the anima and animus.  Nonetheless, Spielrein is very well played.

In contrast, I found Fassbender's portrayal of Jung more vague and wooden.  The film suggests he was a psychic who could foretell the future in dreams and premonitions.  His feelings toward Spielrein seem confused, not merely ambivalent or conflicted.  And he refers to countertransference years before Freud published the term, although it could be argued the two historical figures may have discussed it between themselves earlier.

The decline and fall of Freud and Jung's collaboration is the secondary theme, and here I was particularly impressed with the believable way Freud was portrayed.  A pioneer, pragmatist, and controlling intellectual, he knew his treatment approach was controversial and sought to rein in Jung's more expansive and spiritual predilections, which the elder Freud saw as giving ammunition to his enemies.  Instead of the usual stereotype as a gruff, unyielding father figure preoccupied with sex, Mortensen plays Freud as somewhat authoritarian, but fundamentally smart, affable, and very concerned about the future of his psychoanalytic movement.  Their famous 1909 falling-out on the deck of a ship sailing to America is played with a soft touch: Freud refuses to let Jung analyze his dream for fear of losing his authority (something Jung later recounted as due to Freud's secrecy over his affair with his sister-in-law Minna Bernays).  In the film, Jung is hurt by this non-reciprocity, and goes on afterward to develop his own theories of the psyche.

The film is beautifully photographed, and has a number of nice touches.  The opening and closing credits are shown over a close-up of handwritten correspondence, the main way Freud and Jung communicated with each other.  In one scene Jung conducts a word-association test using physiologic data collection — an accurate depiction of some of his research at Burghölzli, the psychiatric clinic of Zurich University, where he worked from 1900–1908.  I even liked how the film showed the evolution from horse drawn carriages to automobiles, which of course happened in the same time period.

The American physician-psychologist William James was Freud's contemporary and wrote: "I can make nothing in my own case of his dream theories, and obviously 'symbolism' is a most dangerous method."  The film "A Dangerous Method" is not nearly so dismissive of psychoanalysis.  Yet, in its depiction of the dueling dream interpretations of Freud and Jung, and the complex relationship between Jung and Spielrein,  it deftly highlights how symbolism is indeed a dangerous method of transacting human relationships.

The lure of rapture

Fundamentalist Christian minister Harold Camping of Oakland, California, has widely publicized that today is the day of the Rapture, when according to some interpretations of the New Testament true believers ascend to heaven to escape impending misery and turmoil on Earth.  I am writing in the afternoon, and can't guarantee just yet that Camping is mistaken.  But let's assume he is: He was wrong before, and he is just the latest in a long string of mistaken end-times prophets.  I promise to post a prompt, heartfelt apologetic retraction if he turns out to be right — and if the internet and I survive the initial cataclysm. I have a few reflections on end-time prophesies, starting with the admission that I've always found them oddly alluring. As a child, I knew I would be alive in the year 2000.  In my young mind this futuristic date glittered with flying cars, modular glass homes, one-piece unisex jumpsuits that somehow didn't look absurd, and one or more Moon colonies.  But in addition, I had repeatedly heard predictions that Christ's Second Coming would coincide with the new millennium.  Although there is plenty of theological controversy on this point even within Christianity, and even though I was not raised to believe anything of the sort, it always struck me as exciting that  such a grand moment might actually take place in my lifetime.

With the year 2000 come and gone, most end-time attention has since moved to 2012, when, among other things, the Mayan calendar supposedly runs out of dates.  Even so, I wonder whether Mr. Camping, who is 89 years old, is consciously or unconsciously motivated by the possibility that this greatest of historical events might occur in his remaining natural lifetime.  Perhaps it is human nature both to hope and to believe that we live in a unique time.  A touch of narcissism perhaps?

Psychologists and others have wondered, and occasionally studied, how believers deal with mistaken prophesy.  What will Camping and his followers do or say tomorrow?  Leon Festinger's classic 1956 study "When Prophesy Fails" suggests that rather than recanting his beliefs, Camping is apt to rationalize his failed prophesy.  For example, he may realize his calculations were off, or declare a divine 11th hour reprieve for the world.  Of course, some followers, perhaps the majority, are apt to feel disillusioned and humiliated.  The "Great Disappointment" of 1844 offers the historical precedent of a similar failed prophesy.

There is a non-religious definition of rapture: "n. the state of being carried away with joy, love, etc.; ecstasy."  In a larger sense, we all seek to connect with something bigger than ourselves.  For many, it is religion and its connection with God.  Others find connection and larger purpose in humanitarian or political work.  Playing music or team sports with others can satisfy this need to some extent, as can being part of the crowd at a concert or other event.  Even mobs and riots satisfy this need, albeit in destructive ways.  The lure to belong, to share experiences with others, to have a larger purpose, to be "in a groove" seems innate.  I once saw a greeting card that read, "People who never get carried away... should be."

It is really no surprise that doomsayers capture headlines and our attention.  Whether we expect to rise to heaven today with God's Chosen, or join others in ridiculing the gullible — or blog to readers on the internet — we all can be part of a grand spectacle.  It makes this sunny Saturday more special than it would otherwise be, and ourselves a bit more connected to feelings, purposes, and forces greater than ourselves.

Carlat on mindless psychiatrists

My fellow psychiatrist and blogger Dr. Daniel Carlat has an article in this weekend's New York Times Magazine.  "Mind Over Meds" is a memoir of Dr. Carlat's growing realization that psychiatry can't be done well in 15-20 minute medication visits, that talking to patients as people is important too. I'm generally a fan of Dr. Carlat.  His blog is one of the few listed on my blogroll (the short list of links over there on the right of this page).  He writes well, and I share his skeptical attitude toward overzealous promotion of psychiatric drugs to our profession and the public.  "Mind Over Meds" is a good article: Carlat reviews the swing from the "brainless" psychiatry of early 20th-century psychoanalysts, to the "mindless" psychiatry of today, where symptoms are treated with medications and the patient may be lost in the process.

This is all on target, and I appreciate how Dr. Carlat is willing repeatedly to make it personal and write about revisions in his own thinking — as he did in this prior NY Times Magazine article, also well worth reading.  The gist is that psychiatry has painted itself into a corner by limiting itself largely to psychopharmacology, i.e., medications, and ceding psychotherapy — understanding the patient as a person — to other mental health professionals.

Unfortunately, "Mind Over Meds" goes off the rails in two ways.  The less important is a passage that I have to believe is just badly worded, as it seems to denigrate psychologists and other non-psychiatric therapists:

Like the majority of psychiatrists in the United States, I prescribe the medications, and I refer to a professional lower in the mental-health hierarchy, like a social worker or a psychologist, to do the therapy. The unspoken implication is that therapy is menial work — tedious and poorly paid.

A couple of early commenters have already chided Dr. Carlat for this "mental health hierarchy" language.  Discussing whether mental health professionals constitute a hierarchy is beyond my scope here, but I believe Dr. Carlat is well aware that the expertise of many psychologists (for example) to do psychotherapy surpasses his own.  In fact, he has recently taken a contrarian position in favor of granting psychologists prescribing privileges.  I doubt he meant this talk of hierarchy as a putdown, but he should have been more clear.

The bigger gaffe is that the article ultimately calls for psychiatrists to do "some sort of psychotherapy... when our patients need more from us than just medication."  Dr. Carlat seems to be satisfied with a little support here, a few extra minutes of listening there.  However, that isn't psychotherapy except in the most meaningless, hand-waving sense.  That is just listening to one's patients, something every doctor should do, from dermatologists to orthopedic surgeons.  I hate to say it, but it's no wonder health plans won't pay for that.  It used to be part of the job, not something extra.

Psychiatrists have a lot more going on than mere doctor-patient rapport — or at least we used to.  Even psychiatrists who choose not to conduct psychodynamic therapy still learned, or should have learned, about psychodynamics, an intellectual and historical cornerstone of our field.  A psychiatrist's work needs to be psychodynamically informed even if he or she only prescribes medication.  As the most obvious example, a dynamic understanding may shed light on a patient's medication non-compliance and help to address it.  Even better, a dynamic understanding of the patient may obviate the need for medications at all.  (To those who argue that psychodynamics has been supplanted by cognitive-behavioral therapies, I note that Dr. Aaron Beck, the founder of cognitive therapy, was a psychoanalyst first.  Even cognitive therapy works better if it is conducted by a psychodynamically informed therapist.)

Dr. Carlat should have gone farther.  Psychiatry needs to retake the position that we strive to understand and heal the mind from the molecule on up  (a position taken by Freud, among many others).  It is true that this encompasses a dauntingly wide spectrum, from psychopharmacology to psychological treatment, and beyond that to social and cultural influences.  As physicians we are the only mental health discipline with the training to appreciate the whole span; other professions, like clinical psychology, may have more in-depth knowledge and treatment skills regarding a particular part of this spectrum.  Of course, any given psychiatrist may choose not to practice at all of these levels — probably cannot, given the sweeping range.  But it is the essence of psychiatry to know about the full spectrum, and either offer whatever treatment is needed at any level, or refer the patient to a professional who can provide it.

It is necessary but not sufficient to see a patient behind the symptoms, to listen.  It is also incumbent on psychiatrists to conduct real psychotherapy, dynamic or otherwise, when sitting with a patient for 50 minutes and charging for it.  Ceding "real" therapy to others has diminished our field and has turned most psychiatrists into technicians.  "Mind Over Meds" is the right title for a much deeper topic.