Going to the APA meeting?

The annual meeting of the American Psychiatric Association (APA) is in San Francisco this May.  I've attended twice before as I recall, both times when it was here.  I enjoyed it, and even felt it was worth the $1000 we non-members pay to get in, although in my opinion it's not worth doubling that for airfare and lodging to attend in another city.  The presentations were generally of high quality, and so plentiful that I always found something worthwhile to attend.  Up to 50 CME (continuing medical education) hours are available over five days, enough to maintain a California medical license for two years.  This year, in addition to the other presentations, the new DSM-5 will be unveiled and discussed, so we can anticipate hearing a lot that is new and essential for clinical practice.  Bill Clinton will give the keynote speech. Yet it's a hard decision for me to attend this meeting.  The APA and its annual meeting reflect aspects of psychiatry that concern me.  In 2006 the drug industry accounted for about 30 percent of APA's $62.5 million in financing, half through drug advertisements in its journals and meeting exhibits, and the other half sponsoring fellowships, conferences, and industry symposia at the annual meeting.  Every year the annual meeting features a huge exhibit hall of lavish booths courtesy of the pharmaceutical industry.  In past years I watched my fellow psychiatrists line up for branded coffee mugs and similar swag; although voluntary restrictions by the Pharmaceutical Research and Manufacturers of America (PhRMA) in recent years have curtailed this, the APA itself welcomes such giveaways according to this year's information sheet for exhibitors.  This year there are industry sponsored "Product Theater" presentations most days around lunchtime (six sessions total, up to 250 attendees per session), and "Therapeutic Update" meetings at dinnertime (three two-hour sessions) — pure marketing vehicles that are not approved for CME, that lack any pretense of scientific balance or neutrality, and that come with a nice free meal to tickle the limbic systems of the recipients.  In fact, there's a surprisingly wide range of promotional and marketing opportunities at the meeting (pdf here) that the APA sells to industry.  We participants may sign up for the scientific presentations and collegiality, but the APA invites us for the millions of dollars we bring in.

Of course, individual attendees aren't forced to take a seat at a "Therapeutic Update" and may never set foot in the exhibit hall.  So what's the problem?  Can't attendees enjoy an educational experience free of commercial influence?  Unfortunately, with APA selling everything from sponsored wi-fi, to plasma-screen billboard space, to branded do-not-disturb signs at the hotel, the industry flavor will be hard to miss.  Registrants are warned that our names, titles, mailing addresses, and email addresses will be "shared" (i.e., sold) to meeting exhibitors.  Perhaps there's an unpublicized opt-out I'm not aware of.

Whatever one thinks of this blizzard of advertising to a highly selected, captive audience of over 10,000 psychiatrists, it hardly needs to be said that the practice of psychotherapy will have no deep-pocketed sponsorship; healthy nutrition, exercise, lifestyle balance, and introspection will enjoy no "Product Theater" or "Therapeutic Update."  If this year's meeting resembles those I attended in the past, many presenters will mention the importance of psychosocial factors in mental health, and, if one seeks them out, there will be talks by some of the luminaries in trauma research and psychological treatments.  But this will be in the context of blaring signs promoting the newest antidepressant, mood stabilizer, and anti-psychotic — which nowadays may all be the same product — and a zeitgeist of DSM diagnoses leading to pharmaceutical remedies.

Speaking of DSM, the unveiling of DSM-5 ought to be interesting.  DSM diagnosis is an integral part of most mental health (not just psychiatric) practice, as treatment authorization and reimbursement by health plans often hinge on the DSM disorder for which the patient "meets criteria."  Both the process of creating the new DSM-5 and its conclusions have come under repeated attack from a range of reputable critics, including the chair of the DSM-IV Task Force Dr. Allen Frances, Division 32 of the American Psychological Association (the "other" APA), the British Psychological Society, the American Counseling Association, and others.  One common criticism is that diagnostic categories are being loosened (or widened), such that more patents will meet criteria for a mental disorder, and in turn more psychiatric medications will be prescribed.  Dr. Frances charges that the APA treats publication of DSM-5 as a "cash cow," citing the hefty cost ($199 hardcover, $149 paperback) of this instant and inevitable best-seller.  My own feelings about the DSM are mixed, and I'm curious to see how the newest edition turned out, particularly the section on personality disorders.

Despite my concern about undue commercial influence, misplaced priorities, and its controversial diagnostic manual, I plan to go to the APA meeting this year.  There's too much of value to me in all those presentations.  But when I pass the anti-psychiatry protesters at the entrance, I know I will wish for some way to declare myself neither anti-psychiatry nor, despite appearances, in full agreement with the spectacle within.

Our response to regretted suicide attempts — Sloppy thinking in psychiatry 5

A person is drunk or angry or momentarily distraught.  Or all three.  He or she takes an overdose or cuts a wrist, then reconsiders — or never intended to die in the first place — and either calls 911 or tells someone else who calls 911.  The police come and transport the person to a psychiatric emergency service where a three-day legal hold is placed.  Despite expressing regret for the suicide attempt, the person is admitted for observation and safekeeping. I sometimes question the clinical utility of short-term psychiatric hospitalization for regretted suicide attempts.  Not that it's always wrong, of course, but sometimes it seems to result from sloppy thinking.  The usual rationale is that it's better to be on the safe side.  I.e., if the person's recent words or actions cast doubt on his or her wish to be alive, it's better not to take chances.  This has merit in cases where there's some honest doubt:  Since our statistical success in predicting dangerousness to others and to oneself is quite limited, "false positives" are the price we pay (well, they pay) to keep the "true positives" safe.

But another reason seems even more pervasive though less often stated:  Hospitalization is a predictable and presumably undesired consequence of expressing suicidal feelings.  At one level, legal holds and involuntary hospitalization "train" patients not to express suicidal feelings, lest they spend three or more days in an expensive inpatient unit with its attendant shame, stigma, and many inconvenient rules and expectations.  It may also serve a related function of taking the patient seriously.  Big consequences follow big actions, real or contemplated, and in this way discourage the patient from "upping the ante" with a more serious suicide attempt.

The other side of the coin is that legal holds and hospitalization make us feel better.  We're taking action, not just sitting there.  Clinical management is clear-cut for a change.  We have an interesting little story with heroic overtones to tell our colleagues.  The treatment plan is easy to justify to third-party payors, unlike more subtle interpersonal interventions.  (A few days ago I was on the phone with a managed care reviewer who demanded a "5-axis diagnosis" and behavioral treatment plan for my dynamic psychotherapy patient.  A more pointless exercise I cannot imagine, except that my patient won't receive insurance reimbursement without it.  This level of skeptical scrutiny rarely arises in hospitalizing the suicidal, even though the cost to the payor is far greater and the benefits sometimes less apparent.)  We're hardly ever faulted for choosing to hospitalize.

Of course, this propensity to "hospitalize first and ask questions later" can backfire.  I recall several times in my residency when homeless veterans came to the VA emergency room with bags packed, seeking psychiatric admission.  Their claims of suicidal feelings — or even command hallucinations to commit suicide — were hard to argue with, even though it seemed obvious that the real goal was room and board, not psychiatric care.  Their complaints quickly disappeared once admission was assured.  At the time I noted that civil commitment laws exist to protect the unwilling and undeserving from being hospitalized; none address those who strive to be hospitalized without a valid reason.

A great many suicide attempts and gestures are communicative in nature.  Far from being unambivalent decisions to die, they are cries for help, expressions of rage, tests of whether anyone really cares.  Our responses as mental health professionals are communicative too.  Hospitalization can say, "I'm not playing your game of manipulative suicide threats — I'm calling your bluff."  It can say, "I hear you, and I take your suicide threat very seriously.  It's my job to keep you safe."  It can say, "I blindly follow the rules.  You say suicide, I call 911."  Conversely, choosing not to hospitalize can say, "I'm not playing into your drama of getting me to overreact," or "I'm not taking you seriously, not hearing your pain," or "I defy the conventions of my profession, you cannot count on me to hospitalize you."

It's important to pay attention to the message in one's clinical actions, and also to realize that one's message can be communicated in different ways.  Hospitalization is not the only way to convey serious concern, even if at times it may be the only way to assure physical safety.  If calling the police is an angry reaction to the patient's misbehavior, it should be re-thought.  Nor should it be an unthinking, reflexive response.  The converse is true as well: If inaction is an expression of angry avoidance, denial of the severity of the patient's risk, or a reflexive expression of the practitioner's bold, iconoclastic nature, that too should be re-thought.

Failure to consider the risks and benefits (pros and cons) of hospitalization on a case-by-case basis would be evidence of sloppy thinking in psychiatric practice.  While it may be less common than other forms of sloppy thinking I've posted about, it still happens disappointingly often.  I also wanted to post about it to give readers a place to comment and ask questions about legal holds, as there is ongoing interest and concern on this topic.

Photo courtesy of Petr Kratochvil.

Movie review: "Escape Fire: The Fight to Rescue American Healthcare"

The independent documentary Escape Fire: The Fight to Rescue American Healthcare by Matthew Heineman and Susan Froemke is a thoughtful indictment of the status quo.  Instead of focusing on political polarization, the pros and cons of Obamacare for instance, the film mainly documents the absurdity and waste of what we have now.  Instead of a system to promote health, Americans have a "disease management system" that spends almost twice as much as any other country — and nearly as much on prescription medicines as the rest of the world combined — yet we are 50th in life expectancy, and almost 75% of healthcare costs are spent on preventable diseases that are the major causes of disability and death in our society.  Economic incentives maintain this status quo.  High-tech interventions are reimbursed generously, yet reimbursement for face-to-face primary care often does not even cover the cost to deliver it.  As a result, fewer new physicians enter primary care, and doctor visits become shorter and shorter.  Meanwhile, unnecessary medical and surgical procedures are prevalent despite their risks, and cost thousands of lives each year. Escape Fire uses a firefighting metaphor to make its main point.  In forest fires, sometimes a smaller fire is set in order to deprive the main fire of fuel, creating a firebreak.  Such firebreaks can allow firefighters to escape the area — thus an "escape fire."  The filmmakers use this metaphor to say that the status quo in health care isn't working, and that we may need counter-intuitive and non-traditional solutions to save the system.  I confess that I find this metaphor somewhat ill-chosen: The remedies suggested in the film do not "fight fire with fire."  And there is no escaping our need to address health care.

The film spends much time on the military, in part as a microcosm of the problems facing our larger society.  Soldiers' use of prescription drugs has tripled in the past five years.  A large section of Escape Fire, including fascinating footage inside a C-17 Medevac plane as it crosses the Atlantic, follows Sergeant Robert Yates returning from Afghanistan.  Severely injured in a battle that killed most of his platoon, he suffers chronic pain and PTSD.  Sgt. Yates was given a shopping bag full of pills, but later replaces them with stress- and pain-management techniques he learns as part of an innovative Army program.

Although the film never mentions psychiatry as a medical specialty, mental health issues loom large in both military and civilian health care.  Again and again, patients are depicted in primary care offices reviewing their antidepressant medications, or breaking down in tears.  The current system, devoted to disease management, offers poor care to such patients.  They need time, not reimbursed procedures.  As medical journalist Shannon Brownlee notes on camera: "Health care should have a lot more care in it."

The film proposes several escape fires, i.e., solutions, to rescue American health care.  In 2005 Safeway began to provide financial incentives for employees who engage in healthier behavior, and thereby lowered its health care costs by more than 40%.  (That's how the film puts it.  Actually, from 2005 to 2009 Safeway's health care costs remained flat for the 30,000 employees enrolled in the program, while most companies' costs rose by 40% over the same period.)  This was the one example of a monied interest realigning financial incentives to promote health.  The film would have been stronger with more such examples — I hope there are some.

The military provides a solution of a different type.  Often innovation gains a foothold there before achieving acceptance in civilian society.  Just as America's armed forces were on the vanguard of racial integration and later gender equality, perhaps they can lead the way on health care too.  The Army Surgeon General established a Pain Management Task Force to look at alternatives to narcotics, and now the Army is using acupuncture and meditation to decrease narcotic use in the wounded.  Sgt. Yates, the self-proclaimed "redneck hillbilly" who didn't believe in Eastern Medicine, "decided to give it a shot," and it worked.

I found the profile of Dr. Erin Martin the least hopeful in the near term.  Initially shown as a primary care doctor in a low-fee clinic, Dr. Martin had high ideals, but was demoralized by too many patients and too little time.  She was dissatisfied and frustrated by a system that made her job nearly impossible.  Her escape fire was literally to escape: She quit the clinic, became a fellow in Dr. Andrew Weil’s Integrative Medicine program, and found a practice that supported her patient, humane approach.  The film endorses this as the escape fire for primary care — but of course those clinic patients still need a doctor.

Dr. Martin's path is similar to the one I took myself.  Early in my career I worked for two years in a public mental health clinic.  The patients were in great need, but the system was frustrating and the work demoralizing.  Providing comprehensive, humane mental health care in such a system is an uphill battle at best, and in some respects nearly impossible.  I have much admiration for those who work in such settings.  However, like Dr. Martin, I chose to leave and practice in a way that makes more sense to me.  While the makers of Escape Fire would likely endorse my choice, public mental health clinics still need doctors too.  Moreover, it will be a long time before the American health care system rewards Dr. Martin and others who aim to avoid commodity care.  Indeed, the system is accelerating in the opposite direction.  Those of us who build this particular escape fire in essence work outside the larger system.

As I wrote at the outset, Escape Fire is a thoughtful indictment of the status quo.  The film has been reviewed positively, and it strikes a nice balance between worrisome facts and emotional interest, ending on a hopeful note.  We should have no illusions about easy solutions though.  Healthier lifestyle choices are hard to pursue when fast food is cheap and tasty; a shift to preventative care from disease management would represent a fundamental sea change and a realignment of billions of health care dollars.  For a start, at least, we can agree that American health care is burning, and that new solutions are desperately needed.

Psychiatry as behavioral neuroscience — Sloppy thinking in psychiatry 3

This third installment in my series on sloppy thinking in psychiatry addresses something a little more subtle than "chemical imbalance" or polypharmacy.  It is the growing vision, well represented by this recent editorial in Current Psychiatry, that the only salvation for the field lies in embracing the language and practice of neuroscience.  With "chemical imbalance" discredited, attention has turned to functional brain imaging and genetics as our last and best hope to retain a shred of dignity as a medical specialty.  Dr. Nasrallah's editorial goes further than most, arguing that we need a new name for psychiatry:  Psyche is an "archaic concept" that "has outlived its usefulness and needs to be shed."  Likewise, our "brilliant future anchored in cutting-edge neuroscience" will be hastened by renaming the major mental illnesses, calling psychotherapy “verbal neurotherapy," and by embracing the language of "brain repair."  But it's not all a matter of terminology: "The disastrously dysfunctional public mental health bureaucracy must be abandoned and transformed into 'brain institutes,' in all states, similar to cancer centers or cardiovascular institutes, where state-of-the-art clinical care, training, and research are integrated." I share the sentiment, really I do.  Wouldn't it be great to see shiny Brain Institutes cropping up all over, replacing those sad, underfunded public mental health clinics?  Wouldn't we hold our heads higher if our business cards promised "verbal neurotherapy" and "brain repair"?  We could call ourselves medical doctors without a hint of doubt or insecurity, sit proudly at the hospital cafeteria table  with the other doctors — you know, the surgeons and cardiologists and such — and charge higher fees as a premier medical specialty instead of our current status as mental health "primary care."  There's a lot to recommend this vision; where do I sign up?

Unfortunately, there is nowhere to sign up.  This is a pipe dream.  Psychiatry isn't clinging to archaic language about the psyche out of nostalgia.  It's the best we have.  "Verbal neurotherapy," while technically a valid description of psychotherapy, is absurd hand-waving.  By the same token, taking a vacation is "locational neurotherapy."  We aren't going to gain anyone's respect by dressing up our current practices in pseudoscientific jargon.

Nor are we withholding "behavioral neuroscience" from our patients now.  In addition to the verbal neurotherapy, i.e., psychotherapy, that forms the mainstay of my practice, I also offer pharmaceutical neurotherapy, advice regarding nutritional and exercise neurotherapies, discussion of various occupational and relational neurotherapies — I even suggest an occasional locational neurotherapy.  I simply lack the hubris, or perhaps it's the marketing genius, to call it that.

When scientists develop safe, effective psychiatric treatments based on neuroplasticity and neuroprotection I'll happily offer them to patients (or refer patients to centers where such treatments are available).  When my Election Day ballot includes a measure to upgrade public mental health facilities to state-of-the-art Brain Institutes, you can count on my vote.  I'm not holding my breath.

Kidding aside, there is nothing sloppy or ill-advised about incorporating neuroscience into psychiatry.  Nor is it a new idea.  From prehistoric trepanning to Freud's 1895 "Project for a Scientific Psychology" (pdf of a 2004 review), from the introduction of neuroleptics in the 1950s (modern commentary here) to the "decade of the brain" in the 1990s, psychiatry has nearly always paid homage to the neural underpinnings of behavior.  The only obvious exception was the heyday of psychoanalysis, from about 1950 to 1980.  Otherwise, we use the best neuroscience we have at the time.  The real problem, of course, is that we ask more of our neuroscience than it can deliver.  Trepanning probably didn't help, Freud abandoned his "project," neuroleptics caused major side-effects and failed to allow patients to return to the community, and the "decade of the brain" turned many psychiatrists into drug-doling technicians.  Science keeps improving, and I'm sure we'll see good things emerge in the coming years.  However, progress will occur at its own pace, and no amount of wishing or envisioning will make it happen any faster.

It is sloppy thinking to imagine that behavioral neuroscience is something new and revolutionary.  The real revolution in psychiatry, if it ever happens, will be the integration of careful neuroscience, psychology, sociology, and other disciplines to elucidate and benefit our lived experience.  This integration will incorporate, not supplant, our higher level understandings of psychology and psychodynamics.  When psychiatry is ripe for the "creative destruction" of polarized thinking and choosing sides, it will be stronger than the sum of its parts, and will have finally reinvented itself  into something we can unequivocally be proud of.

And yet again, photo courtesy of Petr Kratochvil.

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.