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.

About these ads

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.


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.


Stress, Illness, and Biological Determinism

March 27, 2011

Two interesting articles caught my attention this week, on the important subject of “stress” and its relationship to human disease—both psychological and physical.  Each offers some promising ways to prevent stress-related disease, but they also point out some potential biases in precisely how we might go about doing so.

A piece by Paul Tough in the New Yorker profiled Nadine Burke, a San Francisco pediatrician (the article is here, but it’s subscription-only; another link might be here).  Burke works in SF’s poverty-stricken Bayview-Hunters Point neighborhood, where health problems are rampant.  She recognized that in this population, the precursors of disease are not just the usual suspects like poor access to health care, diet/lifestyle, education, and high rates of substance use, but also the impact of “adverse childhood experiences” or ACEs.

Drawing upon research by Vincent Felitti and Robert Anda, Burke found that patients who were subjected to more ACEs (such as parental divorce, physical abuse, emotional neglect, being raised by a family member with a drug problem, etc.) had worse outcomes as adults.  These early traumatic experiences had an effect on the development of illnesses such as cancer, heart disease, respiratory illness, and addiction.

The implication for public health, obviously, is that we must either limit exposure to stressful events in childhood, or decrease their propensity to cause long-term adverse outcomes.  The New Yorker article briefly covers some biological research in the latter area, such as how early stress affects DNA methylation in rats, and how inflammatory markers like C-reactive protein are elevated in people who were mistreated as children.  Burke is quoted as saying, “In many cases, what looks like a social situation is actually a neurochemical situation.”  And a Harvard professor claims, “this is a very exciting opportunity to bring biology into early-childhood policy.”

With words like “neurochemical” and “biology” (not to mention “exciting”) being used this way, it doesn’t take much reading-between-the-lines to assume that the stage is being set for a neurochemical intervention, possibly even a “revolution.”  One can almost hear the wheels turning in the minds of academics and pharmaceutical execs, who are undoubtedly anticipating an enormous market for endocrine modulators, demethylating agents, and good old-fashioned antidepressants as ways to prevent physical disease in the children of Hunters Point.

To its credit, the article stops short of proposing that all kids be put on drugs to eliminate the effects of stress.  The author emphasizes that Burke’s clinic engages in biofeedback, child-parent therapy, and other non-pharmacological interventions to promote secure attachment between child and caregiver.  But in a society that tends to favor the “promises” of neuropharmacology—not to mention patients who might prefer the magic elixir of a pill—is this simply window-dressing?  A way to appease patients and give the impression of doing good, until the “real” therapies, medications, become available?

More importantly, are we expecting drugs to reverse the effects of social inequities, cultural disenfranchisement, and personal irresponsibility?

***

The other paper is a study published this month in the Journal of Epidemiology and Community Health.  In this paper, researchers from Sweden measured “psychological distress” and its effects on long-term disability in more than 17,000 “average” Swedish adults.  The subjects were given a baseline questionnaire in 2002, and researchers followed them over a five-year period to see how many received new disability benefits for medical or psychiatric illness.

Not surprisingly, there was a direct correlation between high “psychological distress” and high rates of disability.  It is, of course, quite possible that people who had high baseline distress were distressed about a chronic and disabling health condition, which worsened over the next five years.  But the study also found that even low levels of psychological stress at baseline were significantly correlated with the likelihood of receiving a long-term disability benefit, for both medical and psychiatric illness.

The questionnaire used by the researchers was the General Health Questionnaire, a deceptively simple, 12-question survey of psychological distress (a typical question is “Have you recently felt like you were under constant strain?” with four possible answers, “not at all” up to “much more than usual”)  and scored on a 12-point scale.  Interestingly, people who scored only 1 point out of 12 were twice as likely to receive a disability reward than those who scored zero, and the rates only went up from there.

I won’t delve into other details of the results here, but as Sweden resembles the US in its high rates of psychiatric “disability” (between 1990 and 2007, the percentage of disability rewards due to psychiatric illness rose from ~15% to over 40%), the implication is clear: even mild psychological “distress” is a risk factor for future illness—both physical and mental—and to reverse this trend, the effects of this distress must be treated or prevented in some way.

***

Both of these articles—from different parts of the world, using different measurement instruments, and looking at somewhat different outcomes—nevertheless reach the same conclusion:  early life stress is a risk factor for future disease.  This is a long-recognized phenomenon (for an easily accessible exploration of the topic, read Why Zebras Don’t Get Ulcers, by Stanford’s Robert Sapolsky, a former mentor of mine).

But what do we do with this knowledge?  My fear is that, rather than looking at ways to minimize “stress” in the first place (through social programs, education, and other efforts to raise awareness of the detrimental effects of stress), we as a society are instead conditioned to think about how we can intervene with a drug or some other way to modulate the “neurochemical situation,” as Nadine Burke put it.  In other words, we’re less inclined to act than to react, and our reactions are essentially chemical in nature.

As a psychiatrist who has worked with an inner-city population for many years, I’m already called upon to make diagnoses and prescribe medications not for what are obviously (to me) clear-cut cases of significant and disabling mental illness, but, rather, the accumulated effects of stress and trauma.  (I’ll write more about this fascinating interface of society and biology in the future.)   True, sometimes the diagnoses do “fit,” and indeed sometimes the medications work.  But I am doing nothing to prevent the initial trauma, nor do I feel that I am helping people cope with their stress by telling them to take a pill once or twice a day.

We as a society need to make sure we don’t perpetuate the false promises of biological determinism.  I applaud Nadine Burke and I’m glad epidemiologists (and the New Yorker) are asking serious questions about precursors of disease.  But let’s think about what really helps, rather than looking solely to biology as our savior.

(Thanks to Michael at The Trusting Heart for leading me to the New Yorker article.)


Follow

Get every new post delivered to your Inbox.

Join 1,381 other followers

%d bloggers like this: