Skin In The Game

April 8, 2012

We’ve all heard the saying “you get what you pay for.”  But in medicine, where the laws of economics don’t work like they do everywhere else, this maxim is essentially meaningless.  Thanks to our national health-insurance mess, some people pay very little (or nothing) out-of-pocket for a wide range of services, while others have to fork over huge sums of money for even the most basic of care.

Good arguments have been made for health insurance to become more like automobile or homeowners insurance.  Car insurance doesn’t cover oil changes and replacement tires, but it does pay for collisions and mishaps that may result if you don’t perform routine maintenance.  Homeowners insurance doesn’t pay the plumber, but might reimburse you for a flood that results from a blown valve on your water heater.

In medicine, we’ve never really seen this type of arrangement, apart from the occasional high-deductible plans and health savings accounts.  If you have a typical employer-sponsored health plan, not only do you pay little or nothing for your basic, routine care, but your insurance company has probably added even more services (massage, discounted gym memberships, “healthy eating” classes) in the name of preventive medicine and wellness.  (It’s almost as if your auto insurance paid for exactly what you’d do if you wanted to hang on to your car for 500,000 miles.)  When faced with this smorgasbord of free options, it’s easy to ignore the true underlying cost.  One way to reverse this trend is to ask for patients to put some “skin in the game.”

This might happen in Medicaid, the insurance plan for low-income persons.  California Governor Jerry Brown, for instance, proposed that patients receiving Medi-Cal (the California version of Medicaid) should pay higher co-pay amounts for care which is currently free (or nearly so).  A $5 co-payment for an office visit, or a $50 co-pay for an emergency room visit might sound hefty, but it’s a bargain—even for a poor family—if it means the difference between life and death… or even just sickness and health.

Unfortunately, California’s proposal was shot down in February by the Obama administration on legal grounds: the co-pays “are neither temporary nor targeted at a specific population.”  There are other legitimate questions, too, about its feasibility.  Would people forgo routine checkups or neglect to fill prescriptions to save a few dollars, only to cost the system more money down the road?  Would doctors and hospitals even bother to bill people (or send accounts to collections) for such low sums?  Is it fair to charge people money for what some people think is a right and should be free to all?

Without commenting on the moral and political arguments for or against this plan, I believe that this is a proposal worth testing—and psychiatry may be precisely the specialty in which it may have the greatest promise.

Psychiatric illnesses are unique among medical conditions.  Effective treatment involves more than just taking a pill or subjecting oneself to a biological intervention.  It involves the patient wanting to get better and believing in the path he or she is taking to achieve that outcome (even if it violates what the provider thinks is best).  Call it placebo effect, call it “transference,” call it insight, call it what you will—the psychological aspect of the patient’s “buying in” (pardon the pun) to treatment is an important part of successful psychiatric care, just as important—perhaps more so—as the biological effect of the drugs we prescribe.

Like it or not, part of that “wanting” and “believing” also involves “paying.”  Payment needn’t be extreme, but it should be enough to be noticeable.  Because only when someone has “skin in the game” does he or she feel motivated to change.  (Incidentally, this doesn’t have to be money, it could be one’s time, as well:  agreeing to attend an hour of weekly psychotherapy, going to self-help groups 2 or 3 times a week, or simply driving or taking the bus to the doctor’s office can mean a great deal for one’s recovery.)  It’s more than symbolic; it can mean a lot.

In my own life, I’ll admit, I took medical care for granted.  I was fortunate enough to be a healthy child, and had parents with good jobs that provided excellent health insurance.  It wasn’t until my mid-20s that I actually had to pay for medical care—even my co-payments seemed shocking, since I had never really had to pay anything before then.  Over the years, as I struggled with my own mental health needs (which were, unfortunately, not covered by my insurance), I had to pay ever-larger amounts out of my own pocket.  I honestly believe that this was a major contributor to my successful recovery—for starters, I wanted to get to a point where it didn’t make such a huge bite out of my bank account!

The absence of a “buy-in” is most stark precisely where Governor Brown wants to change it:  in Medicaid patients.  In the community clinics where I have worked, patients can visit the office with zero co-payment (and no penalties for no-shows).  This includes medication and therapy visits.  Prescriptions are often free as well; some patients take 4 or 5 (or more) medications—at zero out-of-pocket cost—which can set the government back hundreds of dollars a month.  At the same time, patients with no health insurance (or even with insurance, like me) can’t access the same drugs because of their prohibitive price tag or byzantine insurance restrictions.  It’s nowhere near a level playing field.

To make matters worse, patients on Medicaid generally tend to be more medically ill and, almost by definition, face significant environmental stressors that detrimentally affect their physical and mental well-being.  In these patients, we give psychiatric diagnoses far too liberally (often simply to give patients the opportunity to keep coming to see us, not because we truly believe there’s a diagnosable “mental illness”), and allow them to keep coming in—for free—to get various forms filled out and to refill medications that cost a fortune and don’t treat anything, perpetuating their dependence on an already overburdened health care system.  In fact, these patients would be much better served if we expected (and helped) them to obtain—and yes, even pay for—counseling or social-work assistance to overcome their environmental stressors, or measures to promote physical and mental wellness.

In the end, the solution seems like common sense.  When you own something—whether a home, an automobile, a major appliance, whatever—you tend to invest much more time and money in it than if you were just renting or borrowing.  The same could be said for your own health.  I don’t think it’s unreasonable to ask people to pony up an investment—even a small one—in their psychological and physical well-being.  Not only does it make good fiscal sense, but the psychological effect of taking responsibility for one’s own health may result in even greater future returns on that investment.  For everyone.

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Two Psychiatries

March 12, 2012

A common—and ever-increasing—complaint of physicians is that so many variables interfere with our ability to diagnose and treat disease:  many patients have little or no access to preventive services; lots of people are uninsured; insurance plans routinely deny necessary care; drug formularies are needlessly restrictive; paperwork never ends; and the list goes on and on.  Beneath the frustration (and, perhaps, part of the source of it) is the fact that medical illness, for the most part, has absolutely nothing to do with these external burdens or socioeconomic inequalities.  Whether a patient is rich or poor, black or white, insured or uninsured—a disease is a disease, and everyone deserves the same care.

I’m not so sure whether the same can be said for psychiatry.  Over the last four years, I’ve spent at least part of my time working in community mental health (and have written about it here and here).  Before that, though—and for the majority of my training—I worked in a private, academic hospital setting.  I saw patients who had good health insurance, or who could pay for health care out of pocket.  I encountered very few restrictions in terms of access to medications or other services (including multiple types of psychotherapy, partial hospitalization programs, ECT, rTMS, clinical trials of new treatments, etc).  I was fortunate enough to see patients in specialty referral clinics, where I saw fascinating “textbook” cases of individuals who had failed to respond to years of intensive treatment.  It was exciting, stimulating, thought-provoking, and—for lack of a better word—academic.  (Perhaps it’s not surprising that this the environment in which textbooks, and the DSM, are written.)

When I started working in community psychiatry, I tried to approach patients with the same curiosity and to employ the same diagnostic strategies and treatment approach.  It didn’t take long for me to learn, however, that these patients had few of the resources I had taken for granted elsewhere.  For instance, psychotherapy was difficult to arrange, and I was not reimbursed for doing it myself.  Access to medications depended upon capricious, unpredictable (and illogical) formularies.  Patients found it difficult to get to regular appointments or to come up with the co-payment, not to mention pay the electric bill or deal with crime in their neighborhood.  It was often hard to obtain a coherent and reliable history, and records obtained from elsewhere were often spotty and unhelpful.

It all made for a very challenging place in which to practice what I (self-righteously) called “true” psychiatry.  But maybe community psychiatry needs to be redefined.  Maybe the social stressors encountered by community psych patients—not the least of which is substandard access to “quality” medical and psychiatric services—result in an entirely different type of mental distress, and demand an entirely different type of intervention.

(I should point out that I did see, at times, examples of the same sort of mental illness I saw in the private hospital, and which did respond to the same interventions that the textbooks predicted.  While this reaffirmed my hope in the validity of [at least some] mental illnesses, this was a small fraction of the patients I saw.)

Should we alter our perceptions and definitions of illness—and of “psychiatry” itself—in public mental health?  Given the obstacles found in community psychiatry settings (absurdly brief appointment times; limited psychotherapy; poor prescription drug coverage; high rates of nonadherence and substance abuse; reliance on ERs for non-emergency care, often resulting in complicated medication regimens, like dangerous combinations of narcotics and benzodiazepines), should we take an entirely different approach?  Does it even make sense to diagnose the same disorders—not to mention put someone on “disability” for these disorders—when there are so many confounding factors involved?

One of my colleagues suggested: just give everyone an “adjustment disorder” diagnosis until you figure everything out.  Good idea, but you won’t get paid for diagnosing “adjustment disorder.”  So a more “severe” diagnosis must be given, followed closely thereafter by a medication (because many systems won’t let a psychiatrist continue seeing a patient unless a drug is prescribed).  Thus, in a matter of one or two office visits (totaling less than an hour in most cases), a Medicaid or uninsured patient might end up with a major Axis I diagnosis and medication(s), while the dozens of stressors that may have contributed to the office visit in the first place go unattended.

Can this change?  I sure hope so.  I firmly believe that everyone deserves access to mental health care.  (I must also point out that questionable diagnoses and inappropriate medication regimens can be found in any demographic.)  But we psychiatrists who work in community settings must not delude ourselves into thinking that what’s written in the textbooks or tested on our Board exams always holds true for the patients we see.  It’s almost as if we’re practicing a “different psychiatry,” one that requires its own diagnostic system, different criteria for “disability” determinations, a different philosophy of “psychotherapy,” and where medications should be used much more conservatively.  (It might also help to perform clinical trials with subjects representative of those in community psychiatry, but due to their complexity, this is highly unlikely).

Fortunately, a new emphasis on the concept of “recovery” is taking hold in many community mental health settings.  This involves patient empowerment, self-direction, and peer support, rather than a narrow focus on diagnosis and treatment.  For better or for worse, such an approach relies less on the psychiatrist and more on peers and the patient him- or herself.  It also just seems much more rational, emphasizing what patients want and what helps them to succeed.

Whether psychiatrists—and community mental health as a whole—are able to follow this trend remains to be seen.  Unless we do, however, I fear that we may continue to mislead ourselves into believing that we’re doing good, when in fact we’re perpetuating a cycle of invalid diagnoses, potentially harmful treatment, and, worst of all, over-reliance on a system designed for a distinctly different type of “care” than what these individuals need and deserve.


The Curious Psychology of “Disability”

December 28, 2011

I’ll start this post with a brief clinical vignette:

I have been seeing Frank, a 44 year-old man, on a regular basis for about six months.  He first came to our community clinic with generalized, nonspecific complaints of “anxiety,” feeling “uncomfortable” in public, and getting “angry all the time,” especially toward people who disagreed with him.  His complaints never truly met official criteria for a DSM-IV disorder, but he was clearly dissatisfied with much in his life and he agreed to continue attending biweekly appointments.  Frank once requested Xanax, by name, but I did not prescribe any medication; I never felt it was appropriate for his symptoms, and besides, he responded well to a combined cognitive-interpersonal approach exploring his regret over past activities as a gang member (and related incarcerations), feelings of being a poor father to his four daughters, and efforts to improve his fragile self-esteem.  Even though Frank still has not met criteria for a specific disorder (he currently holds the imprecise and imperfect label of “anxiety NOS”), he has shown significant improvement and a desire to identify and reverse some of his self-defeating behaviors.

Some of the details (including his name) have been changed to preserve Frank’s privacy.  However, I think the general story still gets across:  a man with low self-worth, guilty feelings, and self-denigration from his overidentification with past misdeeds, came to me for help.  We’ve made progress, despite a lack of medications, and the lack of a clear DSM-IV (or, most likely, DSM-5) diagnosis.  Not dramatic, not earth-shattering, but a success nonetheless.  Right?

Not so fast.

Shortly after our appointment last week, I received a request for Frank’s records from the Social Security Administration, along with a letter from a local law firm he hired to help him obtain benefits.  He had apparently applied for SSI disability and the reviewers needed to see my notes.

I should not have been surprised by this request.  After all, our clinic receives several of these requests each day.  In most cases, I don’t do anything; our clinic staff prints out the records, sends them to SSA, and the evaluation process proceeds generally without any further input from us (for a detailed description of the disability evaluation process, see this article).  But for some reason, this particular request was uniquely heartbreaking.  It made me wonder about the impact of the “disability” label on a man like Frank.

Before I go further, let me emphasize that I’m looking at Frank’s case from the viewpoint of a psychiatrist, a doctor, a healer.  I’m aware that Frank’s family is under some significant financial strain—as are many of my patients in this clinic (a topic about which I’ve written before)—and some sort of welfare or financial support, such as SSI disability income, would make his life somewhat easier.  It might even alleviate some of his anxiety.

However, in six months I have already seen a gradual improvement in Frank’s symptoms, an increase in his motivation to recover, and greater compassion for himself and others.  I do not see him as “disabled”; instead, I believe that with a little more effort, he may be able to handle his own affairs with competence, obtain some form of gainful employment, and raise his daughters as a capable father.  He, too, recognizes this and has expressed gratitude for the progress we have made.

There is no way, at this time, for me to know Frank’s motives for applying for disability.  Perhaps he simply saw it as a way to earn some supplementary income.  Perhaps he believes he truly is disabled (although I don’t think he would say this—and if he did, I wish he’d share it with me!).  I also have no evidence to suggest that Frank is trying to “game the system.”  He may be following the suggestions of a family member, a friend, or even another healthcare provider.  All of the above are worthwhile topics to discuss at our next appointment.

But once those records are sent, the evaluation process is out of my hands.  And even if Frank’s request is denied, I wonder about the psychological effect of the “disability” label on Frank’s desire to maintain the gains he has made.  Labels can mean a lot.  Psychiatric diagnoses, for instance, often needlessly and unfairly label people and lead to unnecessary treatment (and it doesn’t look like DSM-5 will offer much improvement).  Likewise, labels like “chronic,” “incurable,” and “disabled” can also have a detrimental impact, a sentiment expressed emphatically in the literature on “recovery” from mental illness.  The recovery movement, in fact, preaches that mental health services should promote self-direction, empowerment, and patient choice.  If, instead, we convey pessimism, hopelessness, and the stigma of “disability,” we may undermine those goals.

As a healer, I believe that my greatest responsibility and most difficult (although most rewarding) task is to instill hope and optimism in my patients.  Even though not all of them will be entirely “symptom-free” and able to function competently in every situation life hands them, and some may require life-long medication and/or psychosocial support (and, perhaps, disability income), I categorically refuse to believe that most are “disabled” in the sense that they will never be able to live productive, satisfying lives.

I would bet that most doctors and most patients agree with me.  With the proper supports and interventions, all patients (or “users” or “consumers,” if you prefer those terms) can have the opportunity to succeed, and potentially extricate themselves from invisible chains of mental illness.  In Frank’s case, he is was almost there.

But the fact that we as a society provide an institution called “disability,” which provides benefits to people with a psychiatric diagnosis, requiring that they see a psychiatrist, and often requiring that they take medication, sends a very powerful—and potentially unhealthy—psychological message to those who can overcome their disability.  To Frank, it directly contradicts the messages of hope and encouragement I try to offer at each visit.  It makes him dependent upon me, rather than upon himself and his own resources and abilities.  In other words, to a man like Frank, disability is anti-recovery.

I don’t have an easy answer to this problem.  For starters, changing the name of “disability” to something like “temporary psychological material support”—a substitute label, nothing more—might be helpful.  Also, rewarding recipients (e.g., not repealing their benefits) for meeting predetermined milestones of recovery (part-time work, independent housing, etc) may also help.  But the more I think about the life-affirming and empowering potential of recovery, and about how we allocate our scarce resources, the more I believe that the recovery-based—as opposed to disability-based—practice of psychiatry has much more to offer the future of our patients, our profession, and our nation, than the current status quo.  For the sake of Frank’s recovery, and the recovery of countless other men and women like him, maybe it’s time to make that happen.


“Dollars For Docs” – What It Really Means

September 25, 2011

A few weeks ago I received an invitation to an October 1 symposium on Latuda, a new antipsychotic from Sunovion (formerly known as Sepracor).  Latuda (lurasidone) was released about six months ago amidst much fanfare—and very aggressive marketing—as a new atypical antipsychotic with, among other advantages, pro-cognitive properties.

I have only prescribed Latuda to three patients, so I have only limited experience with it.  (In case you’re wondering:  one success, one failure, one equivocal.)  However, I have read several papers about Latuda, and I am interested in learning more about it.  The symposium’s plenary speaker is Stephen Stahl from the Neuroscience Education Institute.  Dr Stahl has received money from Sunovion (which is obvious from his publications and disclosures) but he is also a very knowledgeable neuroscientist.  I figured he would be able to describe the differences between Latuda and the other atypical antipsychotics currently on the market.  So I accepted the invitation.

However, upon further thought, I wondered whether my attendance might represent a “payment” from the Sunovion Corporation.  I was not offered any money from Sunovion to attend this event (in fact, you can see my invitation here: page1, page2).  Nevertheless, according to the Physician Payment Sunshine Act, which was passed as part of PPACA (i.e., “Obamacare”), all pharmaceutical companies and medical device manufacturers, as of 2013, are required to report payments to physicians, including direct compensation as well as “food, entertainment, research funding, education or conference funding,” and so forth.

Despite the mandatory 2013 reporting date, several companies have already started reporting.  Other major drug firms to self-report thus far include AstraZeneca, Eli Lilly, Merck, and Pfizer.  Their reports have been widely publicized at sites such as “Dollars For Docs,” which “allows the public to search for individual physicians to see whether they’ve been on pharma’s payroll.”  Several other sites encourage patients to use this site to ask “Does your doc get money from drug companies?”

A quick search of my own name reveals that I received $306 from Pfizer in the year 2010.  Wow!  I had no idea!  What exactly does this mean?  Am I a Pfizer slave?  Did my Pfizer rep walk up to me on 12/31/10, hand me a personal check for $306 and say, “Thank you, Dr. Balt, for prescribing Geodon and Pristiq this year—here’s $306 for your work, and we look forward to more in 2011″?

The answer is no.  I received no money from Pfizer (and, to be frank, I didn’t prescribe any Pristiq last year, because it’s essentially Effexor).  As it happens, during 2010 I worked part-time at a community mental health clinic.  The clinic permitted drug reps to come to the office, bring lunch, and distribute information about their products.  We had lunches 1-2 days out of the week, consisting of modest fare:  Panera sandwiches, trays of Chinese food, or barbecued ribs.  Most of the doctors didn’t have time to eat—or if we did, we scarfed it down in between patients—but we would often talk to the reps, ask questions about their drugs, and accept product literature (which virtually always went straight into the trash), reprints, and educational materials from them.

We were visited by most of the major drug companies in 2010.  (BTW, this continued into 2011, but we are no longer allowed—under our contract with the County mental health department—to accept free samples, and we no longer accept lunches.  Interestingly, my Pfizer rep told us that payments would be reported only as of 1/1/11 and NOT earlier; obviously that was untrue.)  All of the lunches were generally the same, and consisted of inexpensive, modest food, mainly consumed by the clinic staff—secretaries, administrators, assistants—since the doctors were actually working through the lunch hour.  I have since learned that the formula for calculating doctors’ payouts was to take the full cost of the lunch (including all staff members, remember), divide it by the number of doctors in the office, and report that sum.   That’s where you get my $306.00.

[In the interest of full disclosure, in my four years of practice post-residency, I have only been offered one “material” non-food gift: about three years ago, Janssen gave me a $100 voucher for a textbook; I used it to purchase Glen Gabbard’s psychodynamic psychotherapy text.]

Anyway, back to the Latuda symposium.  Knowing what I now know about drug companies, I wouldn’t be surprised if Sunovion reports a $1000+ payout to me if I attend this half-day symposium.  (Facility rental + A/V costs + Xeroxing/handouts + coffee service + refreshments, all divided by the # of docs in attendance.)  I frankly don’t want my future patients searching my name on Dollars For Docs and finding I received a huge “payment” from Sunovion in Q3 2011.  On the other hand, I would like to learn more about Latuda and whether/how it differs from other antipsychotics on the market (including generic first-generation agents).  If possible, I would also like to question Steve Stahl directly about some of what he’s written about this drug (including his Sunovion-funded articles).  What better forum to do this than in a public symposium??

[Note: please see ADDENDUM below.]  I have contacted two different Sunovion sales reps to ask whether my attendance will be “reported” as a payment, and if so, how much.  I have not received a response.  I also called the RSVP number for the symposium.  The registration is being managed by Arbor Scientia, a medical communications company contracted by Sunovion to manage these events.  I was directed to Heather of Arbor Scientia; I left her a message but have not yet received a return call.

So at this point, I am looking forward to attending an event to learn more about a new drug—and the opportunity to challenge the experts on the advantages (if any) of this drug over others—but in doing so, I might also be reported as having “received” a large payment from Sunovion, perhaps even larger than what Pfizer reported they paid me in 2010.

Patients should recognize that sometimes the only way for their doctors to learn about new drugs is to attend such events (assuming they can remain objective, which can be hard when the wine is freely flowing!).  Admittedly, there are doctors who accept much larger sums as speakers or “key opinion leaders,” but organizations like ProPublica should differentiate those doctors (with whom I, personally, have an ethical gripe) from those who are simply workaday folks like me who want to get as much information as they can, provide effective and cost-efficient care—and maybe inhale a free sandwich every once in a while.

ADDENDUM Sept. 26:  Today I received a phone call from Arbor Scientia (from a number that is actually registered as NEI’s main number—as it turns out, they are located in the same building) to assure me that Sunovion adheres to the Physician’s Sunshine Act provision: namely, that they’ll report “payments” to doctors only after January 1, 2012.  (See also here.)  Interestingly, my local Sunovion rep had told me 1/1/11.  (This is only somewhat reassuring: my Pfizer rep had told me they would start reporting as of 1/1/11, but clearly my “payments” from 2010 were reported.)


How To Retire At Age 27

September 4, 2011

A doctor’s primary responsibility is to heal, and all of our efforts and resources should be devoted to that goal.  At times, it is impossible to restore a patient to perfect health and he or she must unfortunately deal with some degree of chronic disability.  Still other times, though, the line between “perfect health” and “disability” is blurred, and nowhere (in my opinion) is this more problematic than in psychiatry.

To illustrate, consider the following example from my practice:

Keisha (not her real name), a 27 year-old resident of a particularly impoverished and crime-ridden section of a large city, came to my office for a psychiatric intake appointment.  I reviewed her intake questionnaire; under the question “Why are you seeking help at this time?” she wrote: “bipolar schizophrenia depression mood swings bad anxiety ADHD panic attacks.”  Under “past medications,” she listed six different psychiatric drugs (from several different categories).  She had never been hospitalized.

When I first saw her, she appeared overweight but otherwise in no distress.  An interview revealed no obvious thought disorder, no evidence of hallucinations or delusions, nor did she complain of significant mood symptoms.  During the interview, she told me, “I just got my SSDI so I’m retired now.”  I asked her to elaborate.  “I’m retired now,” she said.  “I get my check every month, I just have to keep seeing a doctor.”  When I asked why she’s on disability, she replied, “I don’t know, whatever they wrote, bipolar, mood swings, panic attacks, stuff like that.”  She had been off medications for over two months (with no apparent symptoms); she said she really “didn’t notice” any effect of the drugs, except the Valium 20 mg per day, which “helped me settle down and relax.”

Keisha is a generally healthy 27 year-old.  She graduated high school (something rare in this community, actually) and took some nursing-assistant classes at a local vocational school.  She dropped out, however, because “I got stressed out.”  She tried looking for other work but then found out from a family member that she could “apply for disability.”  She applied and was denied, but then called a lawyer who specialized in disability appeals and, after about a year of resubmissions, received the good news that she can get Social Security Disability, ensuring a monthly check.

How is Keisha “disabled”?  She’s disabled because she went to see a doctor and, presumably, told that doctor that she can’t work because of “stress.”  That doctor probably asked her a series of questions like “are you unable to work because of your depressed mood?”, “Do you find it hard to deal in social situations because of your mood swings?” etc., and she answered them in the affirmative.  I’ve seen dozens—if not hundreds—of disability questionnaires, which ask the same questions.

I have no doubt that Keisha lives a stressful life.  I’ve driven through her part of town.  I’ve read about the turf wars being waged by the gangs there.  I know that her city has one of the highest murder rates in America, unemployment is high, schools are bad, and drug abuse and criminal activity are widespread.  I would be surprised if anyone from her neighborhood was not anxious, depressed, moody, irritable, or paranoid.

But I am not convinced that Keisha has a mental illness.

Lest you think that I don’t care about Keisha’s plight, I do.  Keisha may very well be struggling, but whether this is “major depression,” a true “anxiety disorder,” or simply a reaction to her stressful situation is unclear.  Unfortunately, psychiatry uses simple questions to arrive at a diagnosis—and there are no objective tests for mental illness—so a careless (or unscrupulous) provider can easily apply a label, designating Keisha’s situation as a legitimate medical problem.  When combined with the law firms eager to help people get “the government money they deserve,” and the very real fact that money and housing actually do help people like Keisha, we’ve created the illusion that mental illness is a direct consequence of poverty, and the way to treat it is to give out monthly checks.

As a physician, I see this as counter-therapeutic for a number of reasons.  With patients like Keisha, I often wonder, what exactly am I “treating”?  What constitutes success?  An improvement in symptoms?  (What symptoms?)  Or successfully getting her on the government dole?  And when a patient comes to me, already on disability after receiving a diagnosis of MDD (296.34) or panic disorder (300.21) from some other doctor or clinic, I can’t just say, “I’m sorry about your situation, but let’s see what we can do to overcome it together,” because there’s no incentive to overcome it.  (This is from someone who dealt with severe 307.51 for sixteen years, but who also had the promise of a bright future to help overcome it.)

Moreover, making diagnoses where there is no true pathology artificially inflates disease prevalence, further enlarging state and county mental health bureaucracies.  It enables massive over-prescription of expensive (e.g., atypical antipsychotics like Seroquel and Zyprexa), addictive (like stimulants and benzodiazepines), or simply ineffective (like SSRIs) medications.  And far from helping the downtrodden who claim to be its “victims,” this situation instead rewards drug companies and doctors, some of whom prefer serving this population because of the assembly-line nature of this sort of practice:  see the patient, make the diagnosis, write the script, and see them again in 3-6 months.

The bottom line is, here in America we’ve got thousands (perhaps millions?) of able-bodied people who, for one socioeconomic (i.e., not psychiatric) reason or another, can’t find work and have fallen upon psychiatric “disability” as their savior.  I’d love to help them, but, almost by definition, I cannot.  And neither can any other doctor.  Sure, they struggle and suffer, but their suffering is relieved by a steady job, financial support, and yes, direct government assistance.  These are not part of the psychiatric armamentarium.  It’s not medicine.

Psychiatry should not be a tool for social justice.  (We’ve tried that before.  It failed.)  Using psychiatric labels to help patients obtain taxpayers’ money, unless absolutely necessary and legitimate, is wasteful and dishonest.  More importantly, it harms the very souls we have pledged an oath to protect.


How To Get Rich In Psychiatry

August 17, 2011

Doctors choose to be doctors for many reasons.  Sure, they “want to help people,” they “enjoy the science of medicine,” and they give several other predictable (and sometimes honest) explanations in their med school interviews.  But let’s be honest.  Historically, becoming a doctor has been a surefire way to ensure prestige, respect, and a very comfortable income.

Nowadays, in the era of shrinking insurance reimbursements and increasing overhead costs, this is no longer the case.  If personal riches are the goal, doctors must graze other pastures.  Fortunately, in psychiatry, several such options exist.  Let’s consider a few.

One way to make a lot of money is simply by seeing more patients.  If you earn a set amount per patient—and you’re not interested in the quality of your work—this might be for you.  Consider the following, recently posted by a community psychiatrist to an online mental health discussion group:

Our county mental health department pays my clinic $170 for an initial evaluation and $80 for a follow-up.  Of that, the doctor is paid $70 or $35, respectively, for each visit.  There is a wide range of patients/hour since different doctors have different financial requirements and philosophies of care.  The range is 3 patients/hour to 6 patients/hour.

This payment schedule incentivizes output.  A doctor who sees three patients an hour makes $105/hr and spends 20 minutes with each patient.  A doctor who sees 6 patients an hour spends 10 minutes with each patient and makes $210.  One “outlier” doctor in our clinic saw, on average, 7 patients an hour, spending roughly 8 minutes with each patient and earning $270/hr.  His clinical notes reflected his rapid pace…. [but] Despite his shoddy care of patients, he was tolerated at the clinic because he earned a lot of money for the organization.

If this isn’t quite your cup of tea, you can always consider working in a more “legit” capacity, like the Department of Corrections.  You may recall the Bloomberg report last month about the prison psychiatrist who raked in over $800,000 in one year—making him the highest-paid state employee in California.  As it turns out, that was a “data entry error.”  (Bloomberg issued a correction.)  Nevertheless, the cat was out of the bag: prison psychiatrists make big bucks (largely for prescribing Seroquel and benzos).  With seniority and “merit-based increases,” one prison shrink in California was able to earn over $600,000—and that’s for a shrink who was found to be “incompetent.”  Maybe they pay the competent ones even more?

Another option is to be a paid drug speaker.  I’m not referring to the small-time local doc who gives bland PowerPoint lectures to his colleagues over a catered lunch of even blander ham-and-cheese sandwiches.  No sir.  I’m talking about the psychiatrists hired to fly all around the country to give talks at the nicest five-star restaurants in the nation’s biggest drug markets cities.  The advantage here is that you don’t even have to be a great doc.  You just have to own a suit, follow a script, speak well, and enjoy good food and wine.

As most readers of this blog know, ProPublica recently published a list of the sums paid by pharmaceutical companies to doctors for these “educational programs.”  Some docs walked away with checks worth tens—or hundreds—of thousands of dollars.  And, not surprisingly, psychiatrists were the biggest offenders earners.  I guess there is gold in explaining the dopamine hypothesis or the mechanism of neurotransmitter reuptake inhibition to yet another doctor.

Which brings me to perhaps the most tried-and-true way to convert one’s medical education into cash:  become an entrepreneur.  Discovering a new drug or unraveling a new disease process might revolutionize medical care and improve the lives of millions.  And throughout the history of medicine, numerous physician-researchers have converted their groundbreaking discoveries (or luck) into handsome profits.

Unfortunately, in psychiatry, paradigm shifts of the same magnitude have been few and far between.  Instead, the road to riches has been paved by the following formula: (1) “Buy in” to the prevailing disease model (regardless of its biological validity); (2) Develop a drug that “fits” into the model; (3) Find some way to get the FDA to approve it; (4) Promote it ruthlessly; (5) Profit.

In my residency program, for example, several faculty members founded a biotech company whose sole product was a glucocorticoid receptor antagonist which, they believed, might treat psychotic depression (you know, with high stress hormones in depression, etc).  The drug didn’t work (rendering their stock options worth only millions instead of tens of millions).  But that didn’t stop them.  They simply searched for other ways to make their compound relevant.  As I write, they’re looking at it as a treatment for Cushing’s syndrome (a more logical—if far less profitable—indication).

The psychiatry blogger 1boringoldman has written a great deal about the legions of esteemed academic psychiatrists who have gotten caught up in the same sort of rush (no pun intended) to bring new drugs to market.  His posts are definitely worth a read.  Frankly, I see no problem with psychiatrists lending their expertise to a commercial enterprise in the hopes of capturing some of the windfall from a new blockbuster drug.  Everyone else in medicine does it, why not us?

The problem, as mentioned above, is that most of our recent psychiatric meds are not blockbusters.  Or, to be more accurate, they don’t represent major improvements in how we treat (or even understand) mental illness.  They’re largely copycat solutions to puzzles that may have very little to do with the actual pathology—not to mention psychology—of the conditions we treat.

To make matters worse, when huge investments in new drugs don’t pay off, investigators (including the psychiatrists expecting huge dividends) look for back-door ways to capture market share, rather than going back to the drawing board to refine their initial hypotheses.  Take, for instance, RCT Logic, a company whose board includes the ubiquitous Stephen Stahl and Maurizio Fava, two psychiatrists with extensive experience in clinical drug trials.  But the stated purpose of this company is not to develop novel treatments for mental illness; they have no labs, no clinics, no scanners, and no patients.  Instead, their mission is to develop clinical trial designs that “reduce the detrimental impact of the placebo response.”

Yes, that’s right: the new way to make money in psychiatry is not to find better ways to treat people, but to find ways to make relatively useless interventions look good.

It’s almost embarrassing that we’ve come to this point.  Nevertheless, as someone who has decidedly not profited (far from it!) from what I consider to be a dedicated, intelligent, and compassionate approach to my patients, I’m not surprised that docs who are “in it for the money” have exploited these alternate paths.  I just hope that patients and third-party payers wake up to the shenanigans played by my colleagues who are just looking for the easiest payoff.

But I’m not holding my breath.

FootnoteFor even more ways to get rich in psychiatry, see this post by The Last Psychiatrist.


Community Psychiatry And Its Unintended Consequences

May 10, 2011

What impact can psychiatry have on the health of a community?

For three years, I have worked part-time in a non-profit psychopharmacology clinic, treating a wide range of individuals from a poor, underserved urban area.  In a recent post, I wrote that many of the complaints endorsed by patients from this population may be perceived as symptoms of a mental illness.  At one point or another (if not chronically), people complain of “anxiety,” “depression,” “insomnia,” “hopelessness,” etc.—even if these complaints simply reflect their response to environmental stressors, and not an underlying mental illness.

However, because diagnostic criteria are so nonspecific, these complaints can easily lead to a psychiatric diagnosis, especially when the diagnostic evaluation is limited to a self-report questionnaire and a 15- or 20-minute intake appointment.

Personally, I struggle with two opposing biases:  On the one hand, I want to believe that mental illness is a discrete entity, a pathological deviation from “normal,” and presents differently (longer duration, greater intensity, etc) from one’s expected reaction to a situation, however distressing that situation may be.  On the other hand, if I take people’s complaints literally, everyone who walks into my office can be diagnosed as mentally ill.

Where do we draw the line?  The question is an important one.  The obvious answer is to use clinical judgment and experience to distinguish “illness” from “health.”  But this boundary is vague, even under ideal circumstances.  It breaks down entirely when patients have complicated, confusing, chaotic histories (or can’t provide one) and our institutions are designed for the rapid diagnosis and treatment of symptoms rather than the whole person.  As a result, patients may be given a diagnosis where a true disorder doesn’t exist.

This isn’t always detrimental.  Sometimes it gives patients access to interventions from which they truly benefit—even if it’s just a visit with a clinician every couple of months and an opportunity to talk.  Often, however, our tendency to diagnose and to pathologize creates new problems, unintended diversions, and potentially dire consequences.

The first consequence is the overuse of powerful (and expensive) medications which, at best, may provide no advantage over a placebo and, at worst, may cause devastating side effects, not to mention extreme costs to our overburdened health care system.  Because Medicaid and Medicare reimbursements are better for medication management than for other non-pharmacological interventions, “treatment” often consists of brief “med check” visits every one to six months, with little time for follow-up or exploring alternative approaches.  I have observed colleagues seeing 30 or 40 patients in a day, sometimes prescribing multiple antipsychotics with little justification, frequently in combination with benzodiazepines or other sedatives, and asking for follow-up appointments at six-month intervals.  How this is supposed to improve one’s health, I cannot fathom.

Second, overdiagnosis and overtreatment diverts resources from where they are truly needed.  For instance, the number of patients who can access a mental health clinic like ours but who do not have a primary care physician is staggering.  Moreover, patients with severe, persistent mental illness (and who might be a danger to themselves or others when not treated) often don’t have access to assertive, multidisciplinary treatment.  Instead, we’re spending money on medications and office visits by large numbers of patients for whom diagnoses are inaccurate, and medications provide dubious benefit.

Third, this overdiagnosis results in a massive population of “disabled,” causing further strain on scarce resources.  The increasing number of patients on disability due to mental illness has long been chronicled.  Some argue that the disability is itself a consequence of medication.  It is also possible that some people may abuse the system to obtain certain resources.  More commonly, however, I believe that the failure of the system (i.e., we clinicians) to perform an adequate evaluation—and our inclination to jump to a diagnosis—has swollen the disability ranks to an unsustainably high level.

Finally—and perhaps most distressingly—is the false hope that a psychiatric diagnosis communicates to a patient.  I believe it can be quite disempowering for a person to hear that his normal response to a situation which is admittedly dire represents a mental illness.  A diagnosis may provide a transient sense of relief (or, at the very least, alleviate one’s guilt), but it also tells a person that he is powerless to change his situation, and that a medication can do it for him.  Worse, it makes him dependent upon a “system” whose underlying motives aren’t necessarily in the interest of empowering the neediest, weakest members of our society.  I agree with a quote in a recent BBC Health story that a lifetime on disability “means that many people lose their sense of self-worth, identity, and esteem.”  Again, not what I set out to do as a psychiatrist.

With these consequences, why does the status quo persist?  For any observer of the American health care system, the answer seems clear:  vested interests, institutional inertia, a clear lack of creative thought.  To make matters worse, none of the examples described above constitute malpractice; they are, rather, the standard of practice.

As a lone clinician, I am powerless to reverse this trend.  That’s not to say I haven’t tried.  Unfortunately, my attempts to change the way we practice have been met with resistance at many levels:  county mental health administrators who have not returned detailed letters and emails asking to discuss more cost-effective strategies for care; fellow clinicians who have looked with suspicion (if not derision) upon my suggestions to rethink our approach; and—most painfully to me—supervisors who have labeled me a bigot for wanting to deprive people of the diagnoses and medications our (largely minority) patients “need.”

The truth is, my goal is not to deprive anyone.  Rather, it is to encourage, to motivate, and to empower.  Diagnosing illness where it doesn’t exist, prescribing medications for convenience and expediency, and believing that we are “helping” simply because we have little else to offer, unfortunately do none of the above.


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