Who is mentally ill?

My fellow psychiatrist and blogger Dinah Miller raised this simple yet profound question on Shrink Rap the other day.  Who is rightfully labeled mentally ill?  Is it anyone with a psychiatric diagnosis, past or present?  Anyone with currently active psychiatric symptoms?  Anyone receiving psychiatric treatment?  Dr. Miller observes that "the mentally ill" is an oft-cited demographic.  It carries much social weight — negative in the form of discriminatory practices related to employment, driving, and gun ownership, and positive in the form of entitlements, disability status, and the like. With so much riding on this label, knowing exactly how and to whom it applies seems crucial. "But there is no agreed upon definition of who is mentally ill, and the Diagnostic and Statistical Manual (DSM) lists hundreds of disorders, limiting its utility as the determinant of who is mentally ill and therefore eligible for discrimination, stigmatization, or special benefits....  I'm a psychiatrist, and I confess, I have no idea who these 'mentally ill' are."

She includes a brief survey that she hopes everyone — mental health professionals, patients, and neither/both — will fill out.  At this point, if you'd like to complete her survey before I bias you with my own thoughts, go ahead and do that, then come back here.

Ok, here is my view of "the mentally ill."  It's a term I've never felt comfortable with, and thus rarely use, owing to what I view as imprecision.  Certain groups define mental illness to suit their purposes.  For example, the National Alliance on Mental Illness (NAMI) declares that "mental illness is a medical condition," and then provides a list of selected mental disorders they believe qualify as "mental illness."  This in turn leads to the rather incredible claim that "one in four adults... experiences mental illness in a given year. "  However, NAMI's definition does not reflect common usage, nor does it comport with the way "illness" is used in the rest of medicine.  More commonly, mental illness is a conceptually slippery, undefined euphemism that makes it easier to talk about restricting the rights of a subpopulation, or conferring benefits on them, without being too specific about whose rights are affected and why.

Definitions can be descriptive or prescriptive.  The former is how a word or phrase is actually used, the latter how it is properly used.  In actual use, "mentally ill" seems most often to mean manifesting a severe, observable psychiatric condition that renders the person unable to live normally.  Florid psychosis, mania, and severe obsessive-compulsive symptoms are clear examples.  However, contrary to NAMI, even fairly severe depression is equivocal, and neurotic anxiety, mild depression, and most personality disorders are clear non-examples. Typical discourse around rights and entitlements conflates current mental illness with high likelihood of having mental illness in the near future.  So a person can be temporarily free of impairment and yet still be subject to the restrictions and entitlements of someone in the throes of impairment.

As mentioned, this is not how "illness" is used in the rest of medicine.  (I'm about to get prescriptive here.)  Medical anthropologists long ago differentiated disease (or diagnosis) from illness.  The former may be asymptomatic and completely unknown to the patient.  Examples include the "silent killer" hypertension and an asymptomatic brain tumor.  In contrast, illness is a subjective state of feeling medically unwell, plus the psychological, social, and cultural consequences of this state.  Those suffering a cold, "the flu," or nausea feel ill, even if the exact underlying disease is not well characterized.  Illness leads to a socially defined "sick role": the ill person is relieved of his or her usual duties, accepts help from caregivers, is more needy and less autonomous than usual, etc.  If "mental illness" were used the way "illness" is used in the rest of medicine, ego-syntonic conditions, e.g., most mania, would be termed disorders but not illnesses.  Conversely, mild to moderate depression and anxiety would be unequivocal mental or emotional illnesses, even lacking a specific diagnosis.

Since "mentally ill" obscures as much as it clarifies, perhaps no one should be labeled this way.  Indeed, only in psychiatry can a person be declared ill by someone else.  In the rest of medicine, it's self-descriptive.   In my view, "the mentally ill" harbors too many unstated implications and vaguely shared assumptions regarding whom we are talking about.  Legal restrictions and entitlements should be based on more concrete standards — and actually, they are.  "Mental illness" is more of a rhetorical flourish, a bit of hand-waving when it's difficult or inconvenient to pin down specifics.

Third-party payment for psychotherapy: (2) Medical necessity

In my last post I outlined some complexities of third party payment for office psychiatry, and especially for psychotherapy.  As my example I used Medicare, the only third party payer I bill.  Some of the problems include complex billing (i.e., collecting from multiple parties), partial reimbursement, unrealistic documentation requirements, loss of patient confidentiality, and a misplaced emphasis on medication "evaluation and management" over psychotherapy.  There are also challenges specific to dynamic psychotherapy, such as obscuring the transference.  But I saved the most fundamental issue for this post: Does third party payment for psychotherapy make sense in general? This may seem a puzzling question, coming from me.  I not only value deeply what psychotherapy offers, I make my living from it.  Shouldn't it go without saying that psychotherapy should be paid for somehow, no matter where the money comes from?  My experience with public and private health insurers tells me otherwise.

"Medical necessity" is the linchpin, and frankly the problem.  The more a therapeutic encounter fits a medical model and is arguably "necessary" in that framework, the more readily it is covered by health insurance.  Psychotherapists of all stripes tiptoe uncomfortably around this issue.  Medication management fits the medical model very well, so psychiatrists who incorporate this into their psychotherapy sessions enjoy outsized reimbursement (or their patients do).  Talking about anything else, no matter how central to the patient's presentation, does not fit the medical model nearly as well.  Nonetheless, psychotherapists who offer a step-by-step approach aimed concretely at relief of symptoms emulate medical evaluation and treatment much more than those who employ open-ended, exploratory approaches to tackle dysfunctional family dynamics, chronic self-sabotage, and many other concerns for which people seek psychotherapy (and later report benefit; see Consumer Reports, November 1995, Mental health: Does therapy help? pp. 734-739, and this analysis of the Consumer Reports survey by Martin Seligman).  Note that the crucial variable for coverage is not what helps more, or relieves more agonizing misery.  It's what seems more "medical."

Using “medical necessity” as the criterion to treat human misery that often isn’t medical at all leads to much inconsistency and even cruelty.  As mentioned in my last post, insurers demand that I code my "procedure" (i.e., the session) depending on what we talked about.  If we spend the hour discussing medications, even if this focus can easily be understood as a symbolic, unconscious appeal by the patient for care-taking or some other emotional need, it's worth far more to the insurer than if we spend the same hour explicitly discussing the patient's experiences and reactions to actual caretakers.  (As added irony, the latter discussion can obviate the former in future sessions, a detail lost on insurers and most everyone else.)  Since private insurance partly reimburses many of my non-Medicare patients based on how their sessions are coded, an agitated, marginally employed, chronically suicidal patient with severe personality issues is reimbursed far less over time than a high-functioning, stably-employed patient with a medication obsession.  This makes no sense and is blatantly unfair.

The truth is, I'm the same expert — and put bluntly, worth the same amount of money — no matter what I'm discussing with the patient.  That is, as long as I have the integrity to focus on the patient's central issues, not to provide or bill for unneeded services, not to offer hand-waving in lieu of explanation, not to mindlessly prescribe medication after medication, not to casually chat and call it psychotherapy, and so forth.  In other words, I need to be a good doctor instead of a sloppy or unethical one.  I need to know when to be "medical" and when not to be.

Traditional dynamic psychotherapy fits the medical model especially poorly.  It is not primarily focused on symptom relief.  The treatment is not tailored to diagnostic categories.  It follows no step-by-step sequence.  Even expert practitioners often cannot estimate treatment duration.  After many decades of published studies the evidence base for treatment efficacy still triggers heated debates.  Arguing "medical necessity" for such treatment is at best unnatural, at worst contrived or even misleading.  (It's even more absurd to argue the medical necessity of one specific session in an ongoing treatment; to me, this is like asking whether the 10th note in a piano concerto is "musically necessary.")  Those of us who recognize the value of dynamic work and have seen patients change in important, fundamental ways are kept busy trying to pound this square peg into a round hole.  But CBT doesn't avoid this problem either: it's more like a square peg with rounded corners.

Faced with the struggle to show medical necessity, it's tempting to wonder whether psychotherapists should refuse to play this game.  However, opting out isn't easy.  Even if I chose not to be a Medicare provider — I admitted my mixed feelings about this last time — self-pay patients with private insurance would still seek maximal reimbursement for seeing me.  I can hardly blame them.  I see no way out of participating, at least indirectly, in this misapplied standard of medical necessity.

It's hard enough to assure that all Americans have access to basic health care.  Assuring that all have access to mental health care is one step harder, even when that care accrues only to the seriously mentally ill and fits the medical model very well.  It will be a very long time indeed before America deems it worthwhile to offer psychotherapy to the so-called worried well: those who have all their faculties but are miserable due to inner conflicts, self-defeating beliefs, or a traumatic past.  If that day ever comes, it will be when medical necessity is supplanted by a more fitting standard, one that judges mental distress and its treatment on their own merits, and not by borrowing legitimacy from medicine.

Third-party payment for psychotherapy: (1) "Do you take Medicare?"

From late 1996 to early 2007 I was medical director of a low-fee mental health clinic where psychiatry residents and psychology interns receive training.  Since the clinic accepted Medicare for payment, I did as well.  I signed on as a Medicare "preferred provider" and have remained on the panel ever since, even though I left the clinic for full-time private practice nearly seven years ago. I never joined private insurance panels for several reasons.  As an inveterate do-it-yourselfer, I've always handled my own billing and bookkeeping.  This is considerably harder when multiple health plans are billed, co-payments collected, and so on.  I like the straightforward way I provide a service, and the person receiving the service pays me directly.  Somehow it feels more honest than contracting with health plans to funnel referrals my way.  Private health plans also pay less than usual-and-customary fees and require doctors to share patients' private details with corporate reviewers to document "medical necessity."  Moreover, since dynamic psychotherapy has always been a big part of my practice — increasingly so over time — I'm sensitive to arguments that third-party payment complicates transference and countertransference, obscures acting-out around payment, and detrimentally takes payment out of the treatment frame.  Last but not least, as I'll discuss mainly in my next post, insurers base reimbursement on a medical model that fits poorly with dynamic work.

The upshot is that I have a cash-only (or "self pay") practice, with the exception of my Medicare patients.  Until this year, Medicare "allowed" 65% or so of my full fee.  (Medicare sets an allowed fee for a given service, and then pays 50-80% of that.  I can collect the rest, up to the allowed amount, from a secondary insurer or from the patient.  This works more or less automatically for secondary insurers, and rather awkwardly when I try to collect from patients.)  In 2013 the CPT codes for psychiatric office visits were revamped.  This made billing more complicated, and introduced odd, often illogical variations in Medicare and private insurance reimbursement — sometimes paying more than before, sometimes less.

As one of the few private-practice, office-based psychiatrists in San Francisco still on the Medicare panel, I've become a magnet for these patients.  A local medical center with which I have no affiliation used to refer several callers to me every week, until I sent a letter asking them to please not kill me with their kindness.  Medicare callers request to see me for medications only, even after I explain this is not the nature of my practice.  It's more tricky when patients claim to want therapy to get a foot in the door, and then once in my office and now my medico-legal responsibility, confess that they only wanted medication refills all along.  Some callers ask to be added to a non-existent waiting list, or to call me every month or two to see if I change my mind about accepting them as patients.  Clearly, the demand is there, the economic incentive is not.

Medicare and other third-party payers have a valid need to assure their money isn't wasted.  Sometimes my claims are rejected, as when I received a notice this week that one patient's diagnosis (Depression Not Otherwise Specified, 311) "is inconsistent with the procedures" I billed (three weekly sessions of moderate-complexity medication management, 99213, combined with 50-minute therapy sessions, 90836).  It's tempting to protest this, as there's absolutely nothing inconsistent about treating atypical depression with medication and psychotherapy.  I could take the time to marshal my arguments, compose a letter, and reveal personal details about my patient to present my case.  But it's far easier to resubmit the claim with a slightly upcoded diagnosis, e.g., Major Depression, recurrent, mild severity, 296.31, and get paid.  This uncomfortably clashes with my usual tendency to downcode slightly to protect my patient's confidentiality.  (Since pressures to upcode and downcode routinely distort the documentation of diagnoses in clinical practice, I'm skeptical of all research that uses these diagnoses to derive conclusions about psychiatric practices, disorder incidence, and the like.  Garbage in, garbage out.)

Upcoding and downcoding in such cases is not criminal mischief, but an attempt to fit traditional, mainstream psychiatry into a procrustean bed of medical-model diagnosis and procedure coding.  Public and private insurers alike sacrifice ecological validity for documentation that appears, but really isn't, "evidence based."  To take one example, as of this year we must code medication "evaluation and management" separately from the provision of psychotherapy, even if in practice these are done simultaneously and inseparably.  A 50-minute psychotherapy session (90836) that includes brief attention to medication (99212) is reimbursed at a much lower rate than the same 50-minute session with more time devoted to meds (99213 or 99214).  This makes little sense when in many cases the psychotherapy is far more clinically significant than the medications being discussed.  (You'll note that I think of the psychotherapy code first, but actually it is an add-on to the primary medication "E & M" code.)  If medications are not mentioned or evaluated at all, there is yet another code to use for psychotherapy (90834), with an "allowed fee" of $89 for 50 minutes, well below what any psychiatrist or psychologist actually charges.  If this isn't bewildering enough, some of my colleagues are now doing 52-minute sessions, an insignificant increase in duration that qualifies for a different code with much higher reimbursement.

Since cash-only practice excludes all but the affluent, I view my taking Medicare as a modest concession to avoid elitism.  I also support a single-payer health care system, also known as "Medicare for all," so participating in Medicare feels like practicing what I preach.  At the same time, it's easy to see why most of my office-based colleagues opt out of Medicare: lower pay for more paperwork, rules that don't make sense, and various factors that make dynamic psychotherapy harder to conduct and be paid for.  So far I still answer yes, albeit hesitantly, when asked whether I take Medicare.  In my next post I'll expand these ideas into private insurance for outpatient psychiatry, including whether dynamic psychotherapy resembles a medical intervention enough to fit a "medical necessity" model.

Online commentary: marketplace of ideas or shouting match?

A central disruptive technology of our online world is the breaking down of unidirectional communication.  In years past, newspapers and other media published articles without immediate feedback from readers.  True, a few readers might telephone the editor's desk, and the paper might print a select handful of "letters to the editor" in the next issue.  But by and large: "Freedom of the press is guaranteed only to those who own one" (A.J. Liebling, The New Yorker, May 14, 1960).  The average person didn't own a printing press. Now, thanks to blogs, online forums, e-books and the like, anyone can publish.  There is freedom of the press for the masses, but not necessarily an audience.  The ubiquitous comments section in online media thus has a special place in the publishing ecosystem.  Eyeballs are attracted to the professional publication, meanwhile public commentary hangs on its coattails, gaining readership it would not otherwise enjoy.

My local newspaper, the San Francisco Chronicle, has a free online version.  The prolific public commentary is loosely moderated: some comments are deleted for personal attacks, obscenity, and the like.  Nonetheless, an air of bravado, vigilantism, and snap judgment weaves through page after page of commentary.  For example, an unfolding story about a fatal knifing following a baseball game attracts scores of comments with each new revelation.  Readers decide the young men are "thugs," argue over who likely started the fight, declare sports fans crazy and San Francisco as way too soft on crime.  Some proclaim with certainty that self-defense justifies wielding a knife, others just as adamantly that it never does.  There are 145 such comments today, adding to those from yesterday.

Does freedom to express an offhand opinion, and the privilege of having it seen by thousands of others, contribute to public discourse?  On the one hand, a freewheeling marketplace of ideas arguably allows the best to prevail.  Unfettered competition among different ideas, like competing products in a marketplace (or competing species in biological evolution) leads to survival of the fittest.  Neighbors discussing issues of mutual concern over the proverbial backyard fence — isn't this a cornerstone of democracy?

Popular Science takes a different view.  The 141 year old publication this week announced it is ending online comments on its articles.  They say a barrage of commentary that rejects well-established science, e.g., evolution and global climate change, creates controversy where none legitimately exists.  They claim this serves neither science nor the society that depends on it.  The announcement cites a Mother Jones piece that profiles and interviews a climate-change denying "troll"; notably, the 370 comments following that article run the gamut from thoughtful points about climate change to a heated debate about "mens' rights activists" and "femi-nazis" that has nothing to do with the original post.

Meanwhile, back at the San Francisco Chronicle website, a column appeared last week about a young man with apparent psychiatric issues who "is proof that something isn't working with the mental health care system."  He was picked up five times in recent months for bizarre, minor crimes — punching cars, climbing street signs, stripping naked in public, etc.  Each time he was detained on a 72-hour psychiatric hold, after which he was released.  Most recently he was atop a 40 foot ledge for nine hours, screaming and threatening passersby and police, all of which tied up dozens of first-responders, snarled traffic, and cost the city a lot of money.  As a result he is now in the County Jail medical ward, booked on an array of felony and misdemeanor charges.

The 97 comments that follow this column largely decry this man's repeated, rapid release from psychiatric custody.  Here are a few excerpts:

• We need to get the laws in this country changed to make it possible to put people like this in longer-term hospitalization. • Seriously what about some sanity, if your getting picked up repeatedly by the cops you need to be on long term hold. • So basically some lucky person has to be injured or killed by this guy before anything will be done. • Bring back psych hospitals. The pendulum has swung too far to an extreme in allowing the mentally ill to put themselves, and society, at risk on the streets. The social experiment has failed.

A few ideas quickly occurred to me.  We don't apply psychiatric holds based on how much "trouble" people stir up.  He's apparently not holdable — if he were, he would have been held.  Maybe he clears quickly, as would be the case with a medical cause of bizarre behavior, or drug intoxication.  He's detained on criminal charges now, so he won't be released in 72 hours this time unless he posts bail.  But the main thing that occurred to me is how this commentary so glaringly contrasts with that on the psychiatry blogs I read.  In these latter, narrow-focus forums, the predominant tone of the commentary is anti-psychiatric.  No one argues for longer-term hospitalization or says the pendulum has swung too far in favor of patients' rights.

Obviously, this is a matter of readership.  For better or worse, Chronicle readers feel safer with psychiatrists than they do with the man in the news story, and they aren't terribly sensitive about protecting the latter's liberty.  Anti-psychiatrists, in contrast, are a small but vocal minority who disproportionately flock to psychiatry blogs, just as those who reject science flock to the comment boards at Popular Science.  Some of the blogs at Psychology Today also attract devoted critics, some of whom hotly object to the tone with which a sensitive topic has been discussed.  (My blog is apparently not controversial enough to attract such vitriol.)  Should psychiatrist bloggers and those at Psychology Today follow the lead of Popular Science?  Should we disallow commentary, claiming that it creates controversy where none legitimately exists, and that this false controversy serves neither our professional work nor the society that depends on it?

In my view, the answer is captured by a variation of the Yerkes-Dodson law.  That is, too little agreement is just as bad as too much.  An echo chamber of unanimity brings conversation to a halt, as does a cage fight where everything offered is criticized in a hostile way.  Discourse proceeds best when all parties and views are treated with respect, and when a substantial shared basis for discussion exists.  In my opinion, commentary should be permitted on online forums.  However, comments that reject the basic tenets of the discussion — the legitimacy of science in a science forum, mental health treatment in a psychiatry or psychology forum — should be disallowed.  Speakers have a right to express such views, of course, just not by usurping the forums and readership of their opponents.  Likewise, off-topic comments, whether commercial spam, political diatribes, or pet peeves, do not add to thoughtful discourse.  Nor does overt contempt or name-calling.  This means comment moderation is needed, which adds effort and expense to operating an online media outlet.  But the situation as it is now does not serve public discourse very well.  Freedom of speech is not the freedom to grab the microphone from the speaker's hand and use it to shout to a crowd who came to hear someone else.

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.