“Patient-Centered” Care and the Science of Psychiatry

May 30, 2012

When asked what makes for good patient care in medicine, a typical answer is that it should be “patient-centered.”  Sure, “evidence-based medicine” and expert clinical guidelines are helpful, but they only serve as the scientific foundation upon which we base our individualized treatment decisions.  What’s more important is how a disorder manifests in the patient and the treatments he or she is most likely to respond to (based on genetics, family history, biomarkers, etc).  In psychiatry, there’s the additional need to target treatment to the patient’s unique situation and context—always founded upon our scientific understanding of mental illness.

It’s almost a cliché to say that “no two people with depression [or bipolar or schizophrenia or whatever] are the same.”  But when the “same” disorder manifests differently in different people, isn’t it also possible that the disorders themselves are different?  Not only does such a question have implications for how we treat each individual, it also impacts how we interpret the “evidence,” how we use treatment guidelines, and what our diagnoses mean in the first place.

For starters, every patient wants something different.  What he or she gets is usually what the clinician wants, which, in turn, is determined by the diagnosis and established treatment guidelines:  lifelong medication treatment, referral for therapy, forced inpatient hospitalization, etc.  Obviously, our ultimate goal is to eliminate suffering by relieving one’s symptoms, but shouldn’t the route we take to get there reflect the patient’s desires?  When a patient gets what he or she wants, shouldn’t this count as good patient care, regardless of what the guidelines say?

For instance, some patients just want a quick fix (e.g., a pill, ideally without frequent office visits), because they have only a limited amount of money (or time) they’re willing to use for treatment.  Some patients need to complete “treatment” to satisfy a judge, an employer, or a family member.  Some patients visit the office simply to get a disability form filled out or satisfy some other social-service need.  Some simply want a place to vent, or to hear from a trusted professional that they’re “okay.”  Still others seek intensive, long-term therapy even when it’s not medically justified.  Patients request all sorts of things, which often differ from what the guidelines say they need.

Sometimes these requests are entirely reasonable, cost-effective, and practical.  But we psychiatrists often feel a need to practice evidence- (i.e., science-) based medicine; thus, we take treatment guidelines (and diagnoses) and try to make them apply to our patients, even when we know they want—or need—something else entirely, or won’t be able to follow through on our recommendations.  We prescribe medications even though we know the patient won’t be able to obtain the necessary lab monitoring; or we refer a patient for intensive therapy even though we know their insurance will only cover a handful of visits; we admit a suicidal patient to a locked inpatient ward even though we know the unpredictability of that environment may cause further distress; or we advise a child with ADHD and his family to undergo long-term behavioral therapy in conjunction with stimulants, when we know this resource may be unavailable.

Guidelines and diagnoses are written by committee, and, as such, rarely apply to the specifics of any individual patient.  Thus, a good clinician uses a clinical guideline simply as a tool—a reference point—to provide a foundation for an individual’s care, just as a master chef knows a basic recipe but alters it according to the tastes he wishes to bring out or which ingredients are in season.  A good clinician works outside the available guidelines for many practical reasons, not the least of which is the patient’s own belief system—what he or she thinks is wrong and how to fix it.  The same could be said for diagnoses themselves.  In truth, what’s written in the DSM is a model—a “case study,” if you will—by which real-world patients are observed and compared.  No patient ever fits a single diagnosis to a “T.”

Unfortunately, under the pressures of limited time, scarce resources, and the threat of legal action for a poor outcome, clinicians are more inclined to see patients for what they are than for who they are, and therefore adhere to guidelines even more closely than they’d like.  This corrupts treatment in many ways.  Diagnoses are given out which don’t fit (e.g., “parity” diagnoses must be given in order to maintain reimbursement).  Treatment recommendations are made which are far too costly or complex for some patients to follow.  Services like disability benefits are maintained far beyond the period they’re needed (because diagnoses “stick”).  And tremendous resources are devoted to the ongoing treatment of patients who simply want (and would benefit from) only sporadic check-ins, or who, conversely, can afford ongoing care themselves.

The entire situation calls into question the value of treatment guidelines, as well as the validity of psychiatric diagnoses.  Our patients’ unique characteristics, needs, and preferences—i.e., what helps patients to become “well”—vary far more widely than the symptoms upon which official treatment guidelines were developed.  Similarly, what motivates a person to seek treatment differs so widely from person to person, implying vastly different etiologies.

To provide optimal care to a patient, care must indeed be “patient-centered.”  But truly patient-centered care must not only sidestep the DSM and established treatment guidelines, but also, frequently, ignore diagnoses and guidelines altogether.  What does this say about the validity, relevance, and applicability of the diagnoses and guidelines at our disposal?  And what does this say about psychiatry as a science?

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Addiction Psychiatry and The New Medicine

May 21, 2012

I have always believed that addictive disorders can teach us valuable lessons about other psychiatric conditions and about human behavior in general.  Addictions obviously involve behavior patterns, learning and memory processes, social influences, disturbed emotions, and environmental complexities.  Successful treatment of addiction requires attention to all of these facets of the disorder, and the addict often describes the recovery process not simply as being relieved of an illness, but as enduring a transformative, life-changing experience.

“Addiction psychiatry” is the area of psychiatry devoted to the treatment of these complicated disorders.  Certain trends in addiction psychiatry, however, seem to mirror larger trends in psychiatry as  whole.  Their impact on the future treatment of addictive behavior has yet to be determined, so it would be good to evaluate these trends to determine whether we’re headed in a direction we truly want to go.

Neurobiology:  Addiction psychiatry—like the rest of psychiatry—is slowly abandoning the patient and is becoming a largely neuroscientific enterprise.  While it is absolutely true that neurobiology has something to do with the addict’s repetitive, self-destructive behavior, and “brain reward pathways” are clearly involved, these do not tell the whole story.  Addicts refer to “people, places, and things” as the triggers for drug and alcohol use, not “dopamine, nucleus accumbens, and frontal cortex.”  This isn’t an argument against the need to study the biology of addiction, but to keep due focus on other factors which may affect one’s biology.  Virtually the same thing could also be said for most of what we treat in psychiatry; a multitude of factors might explain the presence of symptoms, but we’ve adopted a bias to think strictly in terms of brain pathways.

Medications:  Researchers in the addiction field (not to mention drug companies) devote much of their effort to disxover medications to treat addictions.  While they may stumble upon some useful adjunctive therapies, a “magic bullet” for addiction will probably never be found.  Moreover, I fear that the promise of medication-based treatments may foster a different sort of “dependence” among patients.  At this year’s APA Annual Meeting, for instance, I frequently heard the phrase “addictions are like other psychiatric disorders and therefore require lifelong treatment” (a statement which, by the way, is probably incorrect on TWO counts).  They weren’t talking about lifelong attendance at AA meetings or relapse prevention strategies, but rather to the need to take Suboxone or methadone (or the next “miracle drug”) indefinitely to achieve successful recovery.  Thus, as with other psychiatric disorders– many of which might only need short-term interventions but usually result in chronic pharmacological management—the long-term management of addiction may not reside in the maintenance of a strong recovery program but in the taking of a pill.

New Providers:  Once a relatively unpopular subspecialty, addiction psychiatry is now a burgeoning field, thanks to this new focus on neurobiology and medication management—areas in which psychiatrists consider themselves well versed.  For example, a psychiatrist can become an “addiction psychiatrist” by receiving “Suboxone certification” (i.e., taking an 8-hour online course to obtain a special DEA license to prescribe buprenorphine, an opioid agonist).  I have nothing against Suboxone: patients who take daily Suboxone are far less likely to use opioids, more likely to remain in treatment, and less likely to suffer the consequences of opioid abuse.  In fact, one might argue that the effectiveness of Suboxone—and methadone, for that matter—for opioid dependence is far greater than that of SSRIs in the treatment of depression.  Many Suboxone prescribers, however, have little exposure to the psychosocial aspects—and hard work—involved in fully treating (or overcoming) an addiction, and a pill is simply a substitute for opioids (which itself can be abused).  Nevertheless, prescribing a medication at monthly intervals—sometimes with little discussion about progress toward other recovery goals—resembles everything else we do in psychiatry; it’s no wonder that we’re drawn to it.

Patients:  Like many patients who seek psychiatric help, addicts might start to see “recovery” as a simple matter of making an appointment with a doctor and getting a prescription.  To be sure, many patients have used drugs like Suboxone or methadone to help them overcome deadly addictions, just as some individuals with major depression owe their lives to SSRIs or ECT.  But others have been genuinely hurt by these drugs.  Patients who have successfully discontinued Suboxone often say that it was the most difficult drug to stop—worse than any other opioid they had abused in the past.  Patients should always be reminded of the potential risks and dangers of treatment.  More importantly, we providers have an obligation to make patients aware of other ways of achieving sobriety and when to use them.  Strategies that don’t rely so heavily on the medical model might require a lot more work, but the payoffs may be much greater.

——

Addictions involve complex biological, psychological, and social dimensions that differ from person to person.  The response of the psychiatric profession has been to devote more research to the neurobiology of addictions and the development of anti-addiction drugs, potentially at the expense of exploring other aspects that may be more promising.  As expected, psychiatrists, pharmaceutical companies, third-party payers, and the general public are quickly buying into this model.

Psychiatry finds itself in a Catch-22.  On the one hand, psychiatry is often criticized for not being “medical,” and focusing on the biology of addiction is a good way to adhere to the medical model (and, perhaps, lead us to better pharmacotherapies).  On the other hand, psychiatric disorders—and especially addictions—are multifactorial in nature, and successful treatment often requires a comprehensive approach.  Fortunately, it may not yet be too late for psychiatry to retreat from a full-scale embrace of the medical model.  Putting the patient first sometimes means stepping away from the science.  And as difficult and non-intuitive as that may be, sometimes that’s where the healthiest recovery can be found.


“Trainwrecks”

May 15, 2012

One of the highlights of the American Psychiatric Association (APA) Annual Meeting is the Exhibit Hall.  Here, under bright lights and fancy multimedia displays, sponsors get to show off their new wares.  If anyone wonders whether modern psychiatry isn’t all about psychopharmacology, one visit to the APA Exhibit Hall would set them straight.  Far and away, the biggest and glitziest displays are those of Big Pharma, promising satisfaction and success—and legions of grateful patients—for prescribing their products.

At the 2012 Annual Meeting last week, I checked out most of the Pharma exhibits, mainly just to see what was in the pipeline.  (Not much, it turns out.)  I didn’t partake in any of the refreshments—lest I be reported to the Feds as the recipient of a $2 cappuccino or a $4 smoothie—but still felt somewhat like an awestruck Charlie Bucket in Willie Wonka’s miraculous Chocolate Factory.

One memorable exchange was at the Nuedexta booth.  Nuedexta, as readers of this blog may recall from a 2011 post, is a combination of dextromethorphan and quinidine, sold by Avanir Pharmaceuticals and approved for the treatment of “pseudobulbar affect,” or PBA.  PBA is a neurological condition, found in patients with multiple sclerosis or stroke, and characterized by uncontrollable laughing and crying.  While PBA can be a devastating condition, treatment options do exist.  In my blog post I wrote that “a number of medications, including SSRIs like citalopram, and tricyclic antidepressants (TCAs), are effective in managing the symptoms of PBA.”  One year later, Nuedexta still has not been approved by the FDA for any other indication than PBA.

In my discussion with the Avanir salesman, I asked the same question I posed to the Avanir rep one year ago:  “If I had a patient in whom I suspected PBA, I’d probably refer him to his neurologist for management of that condition—so why, as a psychiatrist, would I use this medication?”  The rep’s answer, delivered in that cool, convincing way that can only emerge from the salesman’s anima, was a disturbing insight into the practice of psychiatry in the 21st century:

“Well, you probably have some patients who are real trainwrecks, with ten things going on.  Chances are, there might be some PBA in there, so why not try some Nuedexta and see if it makes a difference?”

I nodded, thanked him, and politely excused myself.  (I also promptly tweeted about the exchange.)  I don’t know if his words comprised an official Nuedexta sales pitch, but the ease with which he shared it (no wink-wink, nudge-nudge here) suggested that it has proven successful in the past.  Quite frankly, it’s also somewhat ugly.

First of all, I refuse to refer to any of my patients as “trainwrecks.”  Doctors and medical students sometimes use this term to refer to patients with multiple problems and who, as a result, are difficult to care for.  We’ve all used it, myself included.  But the more I empathize with my patients and try to understand their unique needs and wishes, the more I realize how condescending it is.  (Some might refer to me as a “trainwreck,” too, given certain aspects of my past.)  Furthermore, many of the patients with this label have probably—and unfortunately—earned it as a direct result of psychiatric “treatment.”

Secondly, as any good scientist will tell you, the way to figure out the inner workings of a complicated system is to take it apart and analyze its core features.  If a person presents an unclear diagnostic picture, clouded by a half-dozen medications and no clear treatment goals, the best approach is to take things away and see what remains, not to add something else to the mix and “see if it makes a difference.”

Third, the words of the Avanir rep demonstrate precisely what is wrong with our modern era of biological psychopharmacology.  Because the syndromes and “disorders” we treat are so vague, and because many symptoms can be found in multiple conditions—not to mention everyday life—virtually anything a patient reports could be construed as an indication for a drug, with a neurobiological mechanism to “explain” it.  This is, of course, exactly what I predicted for Nuedexta when I referred to it as a “pipeline in a pill” (a phrase that originally came from Avanir’s CEO).  But the same could be said for just about any drug a psychiatrist prescribes for an “emotional” or “behavioral” problem.  When ordinary complaints can be explained by tenuous biological pathways, it becomes far easier to rationalize the use of a drug, regardless of whether data exist to support it.

Finally, the strategy of “throw a medication into the mix and see if it works” is far too commonplace in psychiatry.  It is completely mindless and ignores any understanding of the underlying biology (if there is such a thing) of the illnesses we treat.  And yet it has become an accepted treatment paradigm.  Consider, for instance, the use of atypical antipsychotics in the treatment of depression.  Not only have the manufacturers of Abilify and Seroquel XR never explained how a dopamine partial agonist or antagonist (respectively) might help treat depression, but look at the way they use the results of STAR*D to help promote their products.  STAR*D, as you might recall, was a large-scale, multi-step study comparing multiple antidepressants which found that no single antidepressant was any better than any other.  (All were pretty poor, actually.)  The antipsychotic manufacturers want us to use their products not because they performed well in STAR*D (they weren’t even in STAR*D!!!) but because nothing else seemed to work very well.

If the most convincing argument we can make for a drug therapy is “well, nothing else has worked, so let’s try it,” this doesn’t bode well for the future of our field.  This strategy is mindless and sloppy, not to mention potentially dangerous.  It opens the floodgates for expensive and relatively unproven treatments which, in all fairness, may work in some patients, but add to the iatrogenic burden—and diagnostic confusion—of others.  It also permits Pharma (and the APA’s key opinion leaders) to maintain the false promise of a neurochemical solution for the human, personal suffering of those who seek our help.

This, in my opinion, is the real “trainwreck” that awaits modern psychiatry.  And only psychiatrists can keep us on the tracks.


Is The Joke On Me?

May 12, 2012

I recently returned from the American Psychiatric Association (APA) Annual Meeting in Philadelphia.  I had the pleasure of participating on a panel discussing “psychiatrists and the new media” with the bloggers/authors from Shrink Rap, and Bob Hsiung of dr-bob.org.  The panel discussion was a success.  Some other parts of the conference, however, left me with a sense of doubt and unease.  I enjoy being a psychiatrist, but whenever I attend these psychiatric meetings, I sometimes find myself questioning the nature of what I do.  At times I wonder whether everyone else knows something I don’t.  Sometimes I even ask myself:  is the joke on me?

Here’s an example of what I mean.  On Sunday, David Kupfer of the University of Pittsburgh (and task force chair of the forthcoming DSM-5) gave a talk on “Rethinking Bipolar Disorder.”  The room—a cavernous hall at the Pennsylvania Convention Center—was packed.  Every chair was filled, while scores of attendees stood in the back or sat on the floor, listening with rapt attention.  The talk itself was a discussion of “where we need to go” in the management of bipolar disorder in the future.  Dr Kupfer described a new view of bipolar disorder as a chronic, multifactorial disorder involving not just mood lability and extremes of behavior, but also endocrine, inflammatory, neurophysiologic, and metabolic processes that deserve our attention as well.  He emphasized the fact that in between mood episodes, and even before they develop, there are a range of “dysfunctional symptom domains”—involving emotions, cognition, sleep, physical symptoms, and others—that we psychiatrists should be aware of.  He also introduced a potential way to “stage” development of bipolar disorder (similar to the way doctors stage tumors), suggesting that people at early stages might benefit from prophylactic psychiatric intervention.

Basically, the take-home message (for me, at least) was that in the future, psychiatrists will be responsible for treating other manifestations of bipolar disorder than those we currently attend to.  We will also need to look for subthreshold symptoms in people who might have a “prodrome” of bipolar disorder.

A sympathetic observer might say that Kupfer is simply asking us to practice good medicine, caring for the entire person rather than one’s symptoms, and prevent development or recurrence of bipolar illness.  On the other hand, a cynic might look at these pronouncements as a sort of disease-mongering, encouraging us to uncover signs of “disease” where they might not exist.  But both of these conclusions overlook a much more fundamental question that, to me, remains unanswered.  What exactly is bipolar disorder anyway?

I realize that’s an extraordinarily embarrassing question for a psychiatrist to ask.  And in all fairness, I do know what bipolar disorder is (or, at least, what the textbooks and the DSM-IV say it is).  I have seen examples of manic episodes in my own practice, and in my personal life, and have seen how they respond to medications, psychotherapy, or the passage of time.  But those are the minority.  Over the years (although my career is still relatively young), I have also seen dozens, if not hundreds, of people given the diagnosis of “bipolar disorder” without a clear history of a manic episode—the defining feature of bipolar disorder, according to the DSM.

As I looked around the room at everyone concentrating on Dr Kupfer’s every word, I wondered to myself, am I the only one with this dilemma?  Are my patients “special” or “unique”?  Maybe I’m a bad psychiatrist; maybe I don’t ask the right questions.  Or maybe everyone else is playing a joke on me.   That’s unlikely; others do see the same sorts of patients I do (I know this for a fact, from my own discussions with other psychiatrists).  But nobody seems to have the same crisis of confidence that I do.  It makes me wonder whether we have reached a point in psychiatry when psychiatrists can listen to a talk like this one (or see patients each day) and accept diagnostic categories, without paying any attention to the fact that they our nosology says virtually nothing at all about the unique nature of each person’s suffering.  It seems that we accept the words of our authority figures without asking the fundamental question of whether they have any basis in reality.  Or maybe I’m just missing out on the joke.

As far as I’m concerned, no two “bipolar” patients are alike, and no two “bipolar” patients have the same treatment goals.  The same can be said for almost everything else we treat, from “depression” to “borderline personality disorder” to addiction.  In my opinion, lumping all those people together and assuming they’re all alike for the purposes of a talk (or, even worse, for a clinical trial) makes it difficult—and quite foolish—to draw any conclusions about that group of individuals.

What we need to do is to figure out whether what we call “bipolar disorder” is a true disorder in the first place, rather than accept it uncritically and start looking for yet additional symptom domains or biomarkers as new targets of treatment.  To accept the assumption that everyone currently with the “bipolar” label indeed has the same disorder (or any disorder at all) makes a mockery of the diagnostic process and destroys the meaning of the word.  Some would argue this has already happened.

But then again, maybe I’m the only one who sees it this way.  No one at Kupfer’s talk seemed to demonstrate any bewilderment or concern that we might be heading towards a new era of disease management without really knowing what “disease” we’re treating in the first place.  If this is the case, I sure would appreciate it if someone would let me in on the joke.


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