Turf Wars

July 6, 2012

The practice of medicine has changed enormously in just the last few years.  While the upcoming implementation of the Affordable Care Act promises even further—and more dramatic—change, one topic which has received little popular attention is the question of exactly who provides medical services.  Throughout medicine, physicians (i.e., those with MD or DO degrees) are being replaced by others, whenever possible, in an attempt to cut costs and improve access to care.

In psychiatry, non-physicians have long been a part of the treatment landscape.  Most commonly today, psychiatrists focus on “medication management” while psychologists, psychotherapists, and others perform “talk therapy.” But even the med management jobs—the traditional domain of psychiatrists, with their extensive medical training—are gradually being transferred to other so-called “midlevel” providers.

The term “midlevel” (not always a popular term, by the way) refers to someone whose training lies “mid-way” between that of a physician and another provider (like a nurse, psychologist, social worker, etc) but who is still licensed to diagnose and treat patients.  Midlevel providers usually work under the supervision (although often not direct) of a physician.  In psychiatry, there are a number of such midlevel professionals, with designations like PMHNP, PMHCNS, RNP, and APRN, who have become increasingly involved in “med management” roles.  This is partly because they tend to demand lower salaries and are reimbursed at a lower rate than medical professionals.  However, many physicians—and not just in psychiatry, by the way—have grown increasingly defensive (and, at times, downright angry, if some physician-only online communities are any indication) about this encroachment of “lesser-trained” practitioners onto their turf.

In my own experience, I’ve worked side-by-side with a few RNPs.  They performed their jobs quite competently.  However, their competence speaks less to the depth of their knowledge (which was impressive, incidentally) and more to the changing nature of psychiatry.  Indeed, psychiatry seems to have evolved to such a degree that the typical psychiatrist’s job—or “turf,” if you will—can be readily handled by someone with less (in some cases far less) training.  When you consider that most psychiatric visits comprise a quick interview and the prescription of a drug, it’s no surprise that someone with even just a rudimentary understanding of psychopharmacology and a friendly demeanor can do well 99% of the time.

This trend could spell (or hasten) the death of psychiatry.  More importantly, however, it could present an opportunity for psychiatry’s leaders to redefine and reinvigorate our field.

It’s easy to see how this trend could bring psychiatry to its knees.  Third-party payers obviously want to keep costs low, and with the passage of the ACA the role of the third-party payer—and “treatment guidelines” that can be followed more or less blindly—will be even stronger.  Patients, moreover, increasingly see psychiatry as a medication-oriented specialty, thanks to direct-to-consumer advertising and our medication-obsessed culture.  Taken together, this means that psychiatrists might be passed over in favor of cheaper workers whose main task will be to follow guidelines or protocols.  If so, most patients (unfortunately) wouldn’t even know the difference.

On the other hand, this trend could also present an opportunity for a revolution in psychiatry.  The predictions in the previous paragraph are based on two assumptions:  first, that psychiatric care requires medication, and second, that patients see the prescription of a drug as equivalent to a cure.  Psychiatry’s current leadership and the pharmaceutical industry have successfully convinced us that these statements are true.  But they need not be.  Instead, they merely represent one treatment paradigm—a paradigm that, for ever-increasing numbers of people, leaves much to be desired.

Preservation of psychiatry requires that psychiatrists find ways to differentiate themselves from midlevel providers in a meaningful fashion.  Psychiatrists frequently claim that they are already different from other mental health practitioners, because they have gone to medical school and, therefore, are “real doctors.”  But this is a specious (and arrogant) argument.  It doesn’t take a “real doctor” to do a psychiatric interview, to compare a patient’s complaints to what’s written in the DSM (or what’s in one’s own memory banks) and to prescribe medication according to a guideline or flowchart. Yet that’s what most psychiatric care is.  Sure, there are those cases in which successful treatment requires tapping the physician’s knowledge of pathophysiology, internal medicine, or even infectious disease, but these are rare—not to mention the fact that most treatment settings don’t even allow the psychiatrist to investigate these dimensions.

Thus, the sad reality is that today’s psychiatrists practice a type of medical “science” that others can grasp without four years of medical school and four years of psychiatric residency training.  So how, then, can psychiatrists provide something different—particularly when appointment lengths continue to dwindle and costs continue to rise?  To me, one answer is to revamp specialty training.  I received my training in two institutions with very different cultures and patient populations.  But both shared a common emphasis on teaching medication management.  Did I need four years to learn how to prescribe drugs?  No.  In reality, practical psychopharmacology can be learned in a one-year (maybe even six-month) course—not to mention the fact that the most valuable knowledge comes from years of experience, something that only real life (and not a training program) can provide.

Beyond psychopharmacology, psychiatry training programs need to beef up psychotherapy training, something that experts have encouraged for years.  But it goes further than that: psychiatry trainees need hands-on experience in the recovery model, community resources and their delivery, addictive illness and recovery concepts, behavioral therapies, case management, and, yes, how to truly integrate medical care into psychiatry.  Furthermore, it wouldn’t hurt to give psychiatrists lessons in communication and critical thinking skills, cognitive psychology principles, cultural sensitivity, economics, business management, alternative medicine (much of which is “alternative” only because the mainstream says so), and, my own pet peeve, greater exposure to the wide, natural variability among human beings in their intellectual, emotional, behavioral, perceptual, and physical characteristics and aptitudes—so we stop labeling everyone who walks in the door as “abnormal.”

One might argue, that sounds great but psychiatrists don’t get paid for those things.  True, we don’t.  At least not yet.  Nevertheless, a comprehensive approach to human wellness, taken by someone who has invested many years learning how to integrate these perspectives, is, in the long run, far more efficient than the current paradigm of discontinuous care, in which one person manages meds, another person provides therapy, another person serves as a case manager—roles which can change abruptly due to systemic constraints and turnover.

If we psychiatrists want to defend our “turf,” we can start by reclaiming some of the turf we’ve given away to others.  But more importantly, we must also identify new turf and make it our own—not to provide duplicate, wasteful care, but instead to create a new treatment paradigm in which the focus is on the patient and the context in which he or she presents, and treatment involves only what is necessary (and which is likely to work for that particular individual).  Only a professional with a well-rounded background can bring this paradigm to light, and psychiatrists—those who have invested the time, effort, expense, and hard work to devote their lives to the understanding and treatment of mental illness—are uniquely positioned to bring this perspective to the table and make it happen.

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Big Brother Is Watching You (Sort Of)

February 17, 2012

I practice in California, which, like most (but not all) states has a service by which I can review my patients’ controlled-substance prescriptions.  “Controlled” substances are those drugs with a high potential for abuse, such as narcotic pain meds (e.g., Vicodin, Norco, OxyContin) or benzodiazepines (e.g., Xanax, Valium, Klonopin).  The thinking is that if we can follow patients who use high amounts of these drugs, we can prevent substance abuse or the illicit sale of these medications on the street or black market.

Unfortunately, California’s program may be on the chopping block.  Due to budget constraints, Governor Jerry Brown is threatening to close the Bureau of Narcotic Enforcement (BNE), the agency which tracks pharmacy data.  At present, the program is being supported by grant money—which could run out at any time—and there’s only one full-time staff member managing it.  Thus, while other states (even Florida, despite the opposition of Governor Rick Scott) are scrambling to implement programs like this one, it’s a travesty that we in California might lose ours.

Physicians (and the DEA) argue that these programs are valuable for detecting “doctor shoppers”—i.e., those who go from office to office trying to obtain Rx’es for powerful opioids with street value or addictive potential.  Some have even argued that there should be a nationwide database, which could help us identify people involved in interstate drug-smuggling rings like the famous “OxyContin Express” between rural Appalachia and Florida.

But I would say that the drug-monitoring programs should be preserved for an entirely different reason: namely, that they help to improve patient care.  I frequently check the prescription histories of my patients.  I’m not “playing detective,” seeking to bust a patient who might be abusing or selling their pills.  Rather, I do it to get a more accurate picture of a patient’s recent history.  Patients may come to me, for example, with complaints of anxiety while the database shows they’re already taking large amounts of Xanax or Ativan, occasionally from multiple providers.  Similarly, I might see high doses of pain medications, which (if prescribed & taken legitimately) cues me in to the possibility that pain management may be an important aspect of treating their psychiatric concerns, or vice versa.

I see no reason whatsoever that this system couldn’t be extended to non-controlled medications.  In fact, it’s just a logical extension of what’s already possible.  Most of my patients don’t recognize that I can call every single pharmacy in town and ask for a list of all their medications.  All I need is the patient’s name and birthdate.  Of course, there’s no way in the world I would do this, because I don’t have enough time to call every pharmacy in town.  So instead, I rely largely on what the patient tells me.  But sometimes there’s a huge discrepancy between what patients say they’re taking and what the pharmacy actually dispenses, owing to confusion, forgetfulness, language barriers, or deliberate obfuscation.

So why don’t we have a centralized, comprehensive database of patient med lists?

Some would argue it’s a matter of privacy.  Patients might not want to disclose that they’re taking Viagra or Propecia or an STD treatment (or methadone—for some reasons patients frequently omit that opioid).  But that argument doesn’t hold much water, because in practice, as I wrote above, I could, in theory, call every pharmacy in one’s town (or state) and find that out.

Another argument is that it would be too complicated to gather data from multiple pharmacies and correlate medication lists with patient names.  I don’t buy this argument either.  Consider “data mining.”  This widespread practice allows pharmaceutical companies to get incredibly detailed descriptions of all medications prescribed by each licensed doctor.  The key difference here, of course, is that the data are linked to doctors, not to patients, so patient privacy is not a concern.  (The privacy of patients is sacred, that of doctors, not so much; the Supreme Court even said so.)  Nevertheless, when my Latuda representative knows exactly how much Abilify, Seroquel, and Zyprexa I’ve prescribed in the last 6 months, and knows more about my practice than I do (unless I’ve decided to opt out of this system), then a comprehensive database is clearly feasible.

Finally, some would argue that a database would be far too expensive, given the costs of collecting data, hiring people to manage it, etc.  Maybe if it’s run by government bureaucrats, yes, but I believe this argument is out of touch with the times.  Why can’t we find some out-of-work Silicon Valley engineers, give them a small grant, and ask them to build a database that would collect info from pharmacy chains across the state, along with patient names & birthdates, which could be searched through an online portal by any verified physician?  And set it up so that it’s updated in real time.  Maintenance would probably require just a few people, tops.

Not only does such a proposal sound eminently doable, it actually sounds like it might be easy (and maybe even fun) to create.  If a group of code warriors & college dropouts can set up microblogging platforms, social networking sites, and online payment sites, fueled by nothing more than enthusiasm and Mountain Dew, then a statewide prescription database could be a piece of cake.

Alas, there are just too many hurdles to overcome.  Although it may seem easy to an IT professional, and may seem like just plain good medicine to a doc like me, history has a way of showing that what makes the best sense just doesn’t happen (especially when government agencies are involved).  Until this changes, I’ll keep bothering my local pharmacists by phone to get the information that would be nice to have at my fingertips already.


Big Brother in Your Medicine Cabinet

June 29, 2011

If there’s one thing I’ve learned from working as a doctor, it is that “what the doctor ordered” is not always what the patient gets.  Sure, I’ve encountered the usual obstacles—like pharmacy “benefit” (ha!) managers whose restrictive formularies don’t cover the medications ordered by their physicians—but I’ve also been amazed by the number of patients who don’t take medications as prescribed.  In psychiatry, the reasons are numerous:  patients may take their SSRI “only when I feel depressed,” they double their dose of a benzodiazepine “because I like the way it makes me feel,” they stop taking two or three of their six medications out of sheer confusion, or they take a medication for entirely different purposes than those for which it was originally prescribed.  (If I had a nickel for every patient who takes Seroquel “to help me sleep,” I’d be a very rich man.)

In the interest of full disclosure, this is not limited to my patients.  Even in my own life, I found it hard to take my antidepressant daily (it really wasn’t doing anything for me, and I was involved in other forms of treatment and lifestyle change that made a much bigger difference).  And after a tooth infection last summer, it was a real challenge to take my penicillin three times a day.  I should know better.  Didn’t I learn about this in med school??

This phenomenon used to be called “noncompliance,” a term which has been replaced by the more agreeable term, “nonadherence.”  It’s rampant.  It is estimated to cost the US health care system hundreds of billions of dollars annually.  But how serious is it to human health?  The medical community—with the full support of Big Pharma, mind you—wants you to believe that it is very serious indeed.  In fact, as the New York Times reported last week, we now have a way to calculate a “risk score” for patients who are likely to skip their medications.  Developed by the FICO company, the “Medication Adherence Score” can predict “which patients are at highest risk for skipping or incorrectly using” their medications.

FICO?  Where have you heard of them before?  Yes, that’s right, they’re the company who developed the credit score:  that three-digit number which determines whether you’re worthy of getting a credit card, a car loan, or a home mortgage.  And now they’re using their clout and influence actuarial skills to tell whether you’re likely to take your meds correctly.

To be sure, some medications are important to take regularly, such as antiretrovirals for HIV, anticoagulants, antiarrhythmics, etc, because of the risk of severe consequences after missed doses.  As a doctor, I entered this profession to improve lives—and oftentimes medications are the best way for my patients to thrive.  [Ugh, I just can't use that word anymore… Kaiser Permanente has ruined it for me.]

But let’s consider psychiatry, shall we?  Is a patient going to suffer by skipping Prozac or Neurontin for a few days?  Or giving them up altogether to see an acupuncturist instead?  That’s debatable.

Anyway, FICO describes their score as a way to identify patients who would “benefit from follow-up phone calls, letters, and emails to encourage proper use of medication.”  But you can see where this is going, can’t you?  It’s not too much of a stretch to see the score being used to set insurance premiums and access (or lack thereof) to name-brand medications.  Hospitals and clinics might also use it to determine which patients to accept and which to avoid.

Independently (and coincidentally?), the National Consumers League inaugurated a program last month called “Script Your Future,” which asks patients to make “pledges” to do things in the future (like “walk my daughter down the aisle” or “always be there for my best friend”) that require—or so it is implied—adherence to their life-saving medications.  Not surprisingly, funds for the campaign come from a coalition including “health professional groups, chronic disease groups, health insurance plans, pharmaceutical companies, [and] business organizations.”  In other words: people who want you to take drugs.

The take-home message to consumers patients, of course, is that your doctors, drug companies, and insurers care deeply about you and truly believe that adherence to your medication regimen is the key to experiencing the joy of seeing your children graduate from college or retiring to that villa in the Bahamas.  Smile, take our drugs, and be happy.  (And don’t ask questions!)

If a patient doesn’t want to take a drug, that’s the patient’s choice—which, ultimately, must always be respected (even if ends up shortening that patient’s life).  At the same time, it’s the doctor’s responsibility to educate the patient, figure out the reasons for this “nonadherence,” identify the potential dangers, and help the patient find suitable alternatives.  Perhaps there’s a language barrier, a philosophical opposition to drugs, a lack of understanding of the risks and benefits, or an unspoken cultural resistance to Western allopathic medicine.  Each of these has its merits, and needs to be discussed with the patient.

Certainly, if there are no alternatives available, and a patient still insists on ignoring an appropriate and justifiable medical recommendation, we as a society have to address how to hold patients accountable, so as not to incur greater costs to society down the road (I’m reminded here of Anne Fadiman’s excellent book The Spirit Catches You And You Fall Down).  At the same time, though, we might compensate for those increased costs by not overprescribing, overtreating, overpathologizing, and then launching campaigns to make patients complicit in (and responsible for!) these decisions.

Giving patients a “score” to determine whether they’re going to take their meds is the antithesis of good medicine.  Good medicine requires discussion, interaction, understanding, and respect.  Penalizing patients for not following doctors’ orders creates an adversarial relationship that we can do without.


Dr. Quickfix, Redux

March 7, 2011

Last weekend’s NY Times article, which I wrote about in my last post, has, predictably, resulted in a deluge of responses from many observers.  The comments posted to the NYT “Well” blog (over 160 as of this writing) seem to be equally critical of Dr Levin and of our health care reimbursement system, which, according to the article, forced him to make the Faustian bargain to sacrifice good patient care in favor of a comfortable retirement.  Other bloggers and critics have used this as an opportunity to champion the talents and skills of psychologists, psychotherapists, and nurse practitioners, none of whom, according to the article, face the same financial pressures—or selfishness—of psychiatrists like Dr Levin.

While the above observations are largely valid (although one colleague pointed out that psychologists and NPs can have financial pressures too!), I chose to consider the patients’ point of view.  In my post, I pointed out that many patients seem to be satisfied with the rapid, seemingly slapdash approach of modern psychopharmacology.  I wrote how, in one of my clinic settings, a community mental health center, I see upwards of 20-30 patients a day, often for no more than 10-15 minutes every few months.  Although there are clear exceptions, many patients appreciate the attention I give them, and say they like me.  The same is also true for patients with “good insurance” or for those who pay out-of-pocket:  a 15-minute visit seems to work just fine for a surprising number of folks.

I remarked to a friend yesterday that maybe there are two types of patients:  those who want hour-long, intense therapy sessions on an ongoing basis (with or without medications), and those who are satisfied with quick, in-and-out visits and medication management alone.  My argument was that our culture has encouraged this latter approach in an unfortunate self-propagating feedback cycle:  Not only does our reimbursement process force doctors (and patients) to accept shorter sessions just to stay afloat, but our hyperactive, “manic” culture favors the quick visits, too; indeed, some patients just can’t keep seated in the therapist’s chair for more than ten minutes!

She responded, correctly, that I was being too simplistic.  And she’s right.  While there are certainly examples of the two populations I describe above, the vast majority of patients accept it because the only other option is no care at all.  (It’s like the 95% of people with health insurance who said during the health care reform debate that they were “satisfied” with their coverage; they said so because they feared the alternative.)  She pointed out that the majority of patients don’t know what good care looks like.  They don’t know what special skills a psychiatrist can bring to the table that a psychologist or other counselor cannot (and vice versa, for that matter).  They don’t know that 15 minutes is barely enough time to discuss the weather, much less reach a confident psychiatric diagnosis.  They don’t know that spending a little more money out of pocket for specialized therapy, coaching, acupuncture, Eastern meditation practice, a gym membership, or simply more face-time with a good doc, could result in treatment that is more inspiring and life-affirming than any antidepressant will ever be.

So while my colleagues all over the blogosphere whine about the loss of income wrought by the nasty HMOs and for-profit insurance companies (editorial comment: they are nasty) and the devolution of our once-noble profession into an army of pill pushers, I see this as a challenge to psychiatry.  We must make ourselves more relevant, and to do so we have to let patients know that what we can offer is much more than what they’re getting.  Patients should not settle for 10 minutes with a psychiatrist and a hastily written script. But they’ll only believe this if we can convince them otherwise.

It’s time for psychiatrists to think beyond medications, beyond the DSM, and beyond the office visit.  Psychiatrists need to make patients active participants in their care, and challenge them to become better people, not just receptacles for pills.  Psychiatrists also need to be doctors, and help patients to understand the physical basis of mental symptoms, how mental illness can disrupt physical homeostasis, and what our drugs do to our bodies.

Patients need to look at psychiatrists as true shepherds of the mind, soul, and body, and, in turn, the psychiatrist’s responsibility is to give them reason to do so.  It may cost a little more in terms of money and time, but in the long run it could be money well spent, for patients and for society.

Psychiatrists are highly educated professionals who entered this field not primarily to make money, but to help others.  If we can do this more effectively than we do now, the money will surely follow, and all will be better served.


Dr. Quickfix Will See You Now

March 5, 2011

A cover story by Gardiner Harris in Sunday’s New York Times spotlights the changes in modern psychiatry, from extensive, psychotherapy-based interaction to brief, medication-oriented “psychopharm” practice.  The shift has transpired over the last decade or longer; it was brilliantly described in T.R. Luhrmann’s 2000 book Of Two Minds, and has been explored ad nauseum in the psychiatric literature, countless blogs (including this one), and previously in the New York Times itself.

The article shares nothing new, particularly to anyone who has paid any attention to the rapid evolution of the psychiatric profession over the last ten years (or who has been a patient over the same period).  While the article does a nice job of detailing the effect this shift has had on Donald Levin, the psychiatrist profiled in the article, I believe it’s equally important to consider the effect it has had on patients, which, in my opinion, is significant.

First, I should point out that I have been fortunate to work in a variety of psychiatric settings.  I worked for years in a long-term residential setting, which afforded me the opportunity to engage with patients about much more than just transient symptoms culminating in a quick med adjustment.  I have also chosen to combine psychotherapy with medication management in my current practice (which is financially feasible—at least for now).

However, I have also worked in a psychiatric hospital setting, as well as a busy community mental health center.  Both have responded to the rapid changes in the health care reimbursement system by requiring shorter visits, more rushed appointments, and an emphasis on medications—because that’s what the system will pay for.  This is clearly the direction of modern psychiatry, as demonstrated in the Times article.

My concern is that when a patient comes to a clinic knowing that he’ll only have 10 or 15 minutes with a doctor, the significance of his complaints gets minimized.  He is led to believe that his personal struggles—which may in reality be substantial—only deserve a few minutes of the doctor’s time, or can be cured with a pill.  To be sure, it is common practice to refer patients to therapists when significant lifestyle or psychosocial issues may underlie their suffering (and if they’re lucky, insurance might pay for it), but when this happens, the visit with the doctor is even more rushed.

I could make an argument here for greater reimbursement for psychiatrists doing therapy, or even for prescribing privileges for psychologists (who provide the more comprehensive psychotherapy).  But what’s shocking to me is that patients often seem to be okay with this hurried, fragmented, disconnected care.

Quoting from the article (emphasis mine):

[The patient] said she likes Dr. Levin and feels that he listens to her.

Dr. Levin expressed some astonishment that his patients admire him as much as they do.

“The sad thing is that I’m very important to them, but I barely know them,” he said. “I feel shame about that, but that’s probably because I was trained in a different era.”

It is sad.  I’ve received the same sort of praise and positive feedback from a surprising number of patients, even when I feel that I’ve just barely scratched the surface of their distress (and might have even forgotten their names since their last visit!), and believe that I’m simply pacifying them with a prescription.  At times, calling myself a “psychiatrist” seems unfair, because I feel instead like a prescription dispenser with a medical school diploma on the wall.

And yet people tell me that they like me, just as they like Dr. Levin.  They believe I’m really helping them by listening to them for a few minutes, nodding my head, and giving a pill.  Are the pills really that effective?  (Here I think the answer is clearly no, because treatment failures are widespread in psychiatry, and many are even starting to question the studies that got these drugs approved in the first place.)  Or do my words—as brief as they may be—really have such healing power?

I’ve written about the placebo effect, which can be defined as either the ability of a substance to exert a much more potent effect than what would be anticipated, or as a person’s innate ability to heal oneself.  Perhaps what we’re seeing at work here is a different type of placebo effect—namely, the patient’s unconscious acceptance of this new way of doing things (i.e., spending less time trying to understand the origins of one’s suffering, and the belief that a pill will suffice) and, consequently, the efficacy of this type of ultra-rapid intervention, which goes against everything we were trained to do as psychiatrists and therapists.

In an era where a person’s deepest thoughts can be shared in a 140-character “tweet” or in a few lines on Facebook (and Charlie Sheen can be diagnosed in a five-minute Good Morning America interview), perhaps it’s not surprising that many Americans believe that depression, anxiety, mood swings, impulsivity, compulsions, addictions, eating disorders, personality disorders, and the rest of the gamut of human suffering can be treated in 12-minute office visits four months apart.

Either that, or health insurance and pharmaceutical companies have done a damn good job in training us that we’re much less complicated than we thought we were.


What Psychiatrists Treat and Why

February 20, 2011

Do we treat diseases or symptoms in psychiatry?  While this question might sound philosophical in nature, it’s actually a very practical one in terms of treatment strategies we espouse, medications and other interventions we employ, and, of course, how we pay for mental health care.  It’s also a question that lies at the heart of what psychiatry is all about.

Anyone who has been to medical school or who has watched an episode of House knows that a disease has (a) an underlying pathology, often hidden to the naked eye but which is shared by all patients with that diagnosis, and (b) signs and symptoms, which are readily apparent upon exam but which may differ in subtle ways from patient to patient.  An expert physician performing a comprehensive examination can often make a diagnosis simply on the basis of signs and symptoms.  In some cases, more sophisticated tools (lab tests, scans, etc) are required to confirm the diagnosis.  In the end, once a diagnosis is obtained, treatment can commence.

(To be sure, sometimes a diagnosis is not apparent, and a provisional or “rule-out” diagnosis is given.  The doctor may initiate treatment on an empiric basis but will refine the diagnosis on the basis of future observations, responses to treatment, and/or disease course.)

In psychiatry, which is recognized as a branch of medicine and (should) subscribe to the same principles of diagnosis and treatment, the expectations are the same.  There are a number of diseases (or disorders) listed in the DSM-IV, each theoretically with its own underlying pathology and natural history, and each recognizable by a set of signs and symptoms.  A careful psychiatric evaluation and mental status exam will reveal the true diagnosis and suggest a treatment plan to the clinician.

It sounds simple, but it doesn’t always work out this way.  Psychiatrists may disagree about a given diagnosis, or make diagnoses based on “soft” signs.  Moreover, there are very few biological or biochemical tests to “rule in” a psychiatric diagnosis.  As a result, treatment plans for psychiatric patients often include multiple approaches that don’t make sense;  for example, using an antidepressant to treat bipolar disorder, or using antipsychotics to treat anxiety or insomnia symptoms in major depression.

The psychiatrist Nassir Ghaemi at Tufts has written about this before (click here for a very accessible version of his argument and here [registration required] for a more recent dialogue in which he argues his point further).  Ghaemi argues in favor of what he calls “Hippocratic psychopharmacology.” Specifically, we should understand and respect the normal course of a disease before initiating treatment.  He also emphasizes that we not treat symptoms, but rather the disease (this is also known as Osler’s Rule, in honor of Sir William Osler, the “founder of modern medicine”).  For example, Ghaemi makes a fairly compelling argument that bipolar disorder should be treated with a mood stabilizer alone, and not with an antidepressant, or an antipsychotic, or a sedative, because those drugs treat symptoms which should resolve as a person goes through the natural course of the disease.  In other words, we miss the diagnostic forest by focusing on the symptomatic trees.

The problem is, this is a compelling argument only if there is such a diagnosis as “bipolar disorder.”  Or, to be more specific, a clear, unitary entity with a distinct pathophysiological basis that gives rise to the symptoms that we see as mania and depression, and which all “bipolar” patients share.  And I don’t believe this assumption has been borne out.

My personal bias is that bipolar disorder does exist.  So do major depression, schizophrenia, panic disorder, anorexia nervosa, ADHD, and (almost) all the other diagnoses listed in the DSM-IV.  And a deeper understanding of the pathophysiology of each might help us to develop targeted treatments that will be far more effective than what have now.  But we’re not there yet.  In the case of bipolar disorder, lithium is a very effective drug, but it doesn’t work in everyone with “bipolar.”  Why not?  Perhaps “bipolar disorder” is actually several different disorders.  Not just formes frustes of the same condition but separate entities altogether, with entirely different pathophysiologies which might appear roughly the same on the outside (sort of like obesity or alcoholism).  Of course, there are also many diagnosed with “bipolar” who might really have no pathology at all– so it is no surprise that they don’t respond to a mood stabilizer (I won’t elaborate on this possibility here, maybe some other time).

The committee in charge of writing the DSM-5 is almost certainly facing this conundrum.  One of the “holy grails” of 21st century psychiatry (which I wrote about here) is to identify biochemical or genetic markers that predict or diagnose psychiatric disease, and it was hoped that the next version of the DSM would include these markers amongst its diagnostic criteria.   Unfortunately, this isn’t happening, at least not with DSM-5.  In fact, what we’re likely to get is a reshuffling and expansion of diagnostic criteria.  Which just makes matters worse:  how can we follow Osler’s advice to treat the disease and not the symptom when the definition of disease will change with the publication of a new handbook?

As a practicing psychiatrist, I’d love to be able to make a sound and accurate diagnosis and to use this diagnosis to inform my treatment, practicing in the true Hippocratic tradition and following Osler’s Rule, which has benefited my colleagues in other fields of medicine.  I also recognize that this approach would respect Dr Ghaemi’s attempt at bringing some order and sensibility to psychiatric practice.  Unfortunately, this is hard to do because (a) we still don’t know the underlying cause(s) of psychiatric disorders, and (b) restricting myself to pathophysiology and diagnosis means ignoring the psychosocial and environmental factors that are (in many ways) even more important to patients than what “disease” they have.

It has frequently been said that medicine is an art, not a science, and psychiatry is probably the best example of this truism.  Let’s not stop searching for the biological basis of mental illness, but also be aware that it may not be easy to find.  Until then, whether we treat “diagnoses” or “symptoms” is a matter of style.  Yes, the insurance company wants a diagnosis in order to provide reimbursement, but the patient wants management of his or her symptoms in order to live a more satisfying life.


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