Measuring The Immeasurable

February 9, 2012

Is psychiatry a quantitative science?  Should it be?

Some readers might say that this is a ridiculous question.  Of course it should be quantitative; that’s what medicine is all about.  Psychiatry’s problem, they argue, is that it’s not quantitative enough.  Psychoanalysis—that most qualitative of “sciences”—never did anyone any good, and most psychotherapy is, likewise, just a bunch of hocus pocus.  A patient saying he feels “depressed” means nothing unless we can measure how depressed he is.  What really counts is a number—a score on a screening tool or checklist, frequency of a given symptom, or the blood level of some biomarker—not some silly theory about motives, drives, or subconscious conflicts.

But sometimes measurement can mislead us.  If we’re going to measure anything, we need to make sure it’s something worth measuring.

By virtue of our training, physicians are fond of measuring things.  What we don’t realize is that the act of measurement itself leads to an almost immediate bias.  As we assign numerical values to our observations, we start to define values as “normal” or “abnormal.”  And medical science dictates that we should make things “normal.”  When I oversee junior psychiatry residents or medical students, their patient presentations are often filled with such statements as “Mr. A slept for 5 hours last night” or “Ms. B ate 80% of her meals,” or “Mrs. C has gone two days without endorsing suicidal ideation,” as if these are data points to be normalized, just as potassium levels and BUN/Cr ratios need to be normalized in internal medicine.

The problem is, they’re not potassium levels or BUN/Cr ratios.  When those numbers are “abnormal,” there’s usually some underlying pathology which we can discover and correct.  In psychiatry, what’s the pathology?  For a woman who attempted suicide two days ago, does it really matter how much she’s eating today?  Does it really matter whether an acutely psychotic patient (on a new medication, in a chaotic inpatient psych unit with nurses checking on him every hour) sleeps 4 hours or 8 hours each night?  Even the questions that we ask patients—“are you still hearing voices?”, “how many panic attacks do you have each week?” and the overly simplistic “can you rate your mood on a scale of 1 to 10, where 1 is sad and 10 is happy?”— attempt to distill a patient’s overall subjective experience into an elementary quantitative measurement or, even worse, into a binary “yes/no” response.

Clinical trials take measurement to an entirely new level.  In a clinical trial, often what matters is not a patient’s overall well-being or quality of life (although, to be fair, there are ways of measuring this, too, and investigators are starting to look at this outcome measure more closely), but rather a HAM-D score, a MADRS score, a PANSS score, a Y-BOCS score, a YMRS score, or any one of an enormous number of other assessment instruments.  Granted, if I had to choose, I’d take a HAM-D score of 4 over a score of 24 any day, but does a 10- or 15-point decline (typical in some “successful” antidepressant trials) really tell you anything about an individual’s overall state of mental health?  It’s hard to say.

One widely used instrument, the Clinical Global Impression scale, endeavors to measure the seemingly immeasurable.  Developed in 1976 and still in widespread use, the CGI scale has three parts:  the clinician evaluates (1) the severity of the patient’s illness relative to other patients with the same diagnosis (CGI-S); (2) how much the patient’s illness has improved relative to baseline (CGI-I); and (3) the efficacy of treatment.  (See here for a more detailed description.)  It is incredibly simple.  Basically, it’s just a way of asking, “So, doc, how do you think this patient is doing?” and assigning a number to it.  In other words, subjective assessment made objective.

The problem is, the CGI has been criticized precisely for that reason—it’s too subjective.  As such, it is almost never used as a primary outcome measure in clinical trials.  Any pharmaceutical company that tries to get a drug approved on the basis of CGI improvement alone would probably be laughed out of the halls of the FDA.  But what’s wrong with subjectivity?  Isn’t everything that counts subjective, when it really comes down to it?  Especially in psychiatry?  The depressed patient who emerges from a mood episode doesn’t describe himself as “80% improved,” he just feels “a lot better—thanks, doc!”  The psychotic patient doesn’t necessarily need the voices to disappear, she just needs a way to accept them and live with them, if at all possible.  The recovering addict doesn’t think in terms of “drinking days per month,” he talks instead of “enjoying a new life.”

Nevertheless, measurement is not a fad, it’s here to stay.  And as the old saying goes, resistance is futile.  Electronic medical records, smartphone apps to measure symptoms, online checklists—they all capitalize on the fact that numbers are easy to record and store, easy to communicate to others, and satisfy the bean counters.  They enable pharmacy benefit managers to approve drugs (or not), they enable insurers to reimburse for services (or not), and they allow pharmaceutical companies to identify and exploit new markets.  And, best of all, they turn psychiatry into a quantitative, valid science, just like every other branch of medicine.

If this grand march towards increased quantification persists, the human science of psychiatry may cease to exist.  Unless we can replace these instruments with outcome measures that truly reflect patients’ abilities and strengths, rather than pathological symptoms, psychiatry may be replaced by an impersonal world of questionnaires, checklists, and knee-jerk treatments.  In some settings, that that’s what we have now.  I don’t think it’s too late to salvage the human element of what we do.  A first step might be simply to use great caution when we’re asked to give a number, measure a symptom, or perform a calculation, on something that is intrinsically a subjective phenomenon.  And to remind ourselves that numbers don’t capture everything.

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Where Doctors Get Their Information

January 24, 2012

Doctors spend four years in medical school, still more years in residency, and some devote even more years to fellowship training.   All of this work is done under direct supervision, and throughout the process, trainees learn from their teachers, mentors, and supervisors.  But medicine changes very rapidly.  After all of this training—i.e., once the doctor is “out in the real world”—how does he or she keep up with the latest developments?

Medical journals are the most obvious place to start.  Many doctors subscribe to popular journals like the New England Journal of Medicine or JAMA, or they get journals as a perk of membership in their professional society (for example, the American Journal of Psychiatry for members of the APA).  But the price of journals—and professional society memberships—can accumulate quickly, as can the stacks of unread issues on doctors’ desks.

A second source is continuing medical education credit.  “CMEs” are educational units that doctors are required to obtain in order to keep their medical license.  Some CME sources are excellent, although most CMEs are absurdly easy to obtain (e.g., you watch an online video; answer a few multiple-choice questions about a brief article; or show up for the morning session of a day-long conference, sign your name, then head out the door for a round of golf), making their educational value questionable.  Also, lots of CMEs are funded by pharmaceutical or medical device manufacturers (see here), where bias can creep in.

Direct communication with drug companies—e.g., drug sales reps—can also be a source of information.  Some universities and health-care organizations have “cracked down” on this interaction, citing inappropriate sales techniques and undue influence on doctors.  While docs can still contact the medical departments (or “medical science liaisons”) of big drug companies, this source of info appears to be running dry.

So what’s left?  Medical textbooks?  They’re usually several years out of date, even at the time of publication.  Medical libraries?  Unless you’re affiliated with a teaching hospital, those libraries are off-limits.  “Throwaway” journals?  Every specialty has them—they arrive in the mail, usually unrequested, and contain several topical articles and lots of advertising; but these articles generally aren’t peer-reviewed, and the heavy advertising tends to bias their content.  Medical websites?  Same thing.  (WebMD, for instance, is heavily funded by industry—a point that has not escaped the attention of watchdog senator Charles Grassley.)

Thus, the doctor in the community (think of the psychiatrist in a small group practice in your hometown) is essentially left alone, in the cold, without any unbiased access to the latest research.  This dilemma has become starkly apparent to me in the last several months.  Since last summer, I have worked primarily in a community hospital.  Because it is not an academic institution, it does not provide its employees or trainees access to the primary literature (and yes, that includes psychiatry residents).  I, on the other hand, have been fortunate enough to have had a university affiliation for most of my years of practice, so I can access the literature.  If I need to look up the details of a recent study, or learn about new diagnostic procedures for a given disorder, or prepare for an upcoming talk, I can find just about anything I need.  But this is not the case for my colleagues.  Instead, they rely on textbooks, throwaway journals, or even Wikipedia.  (BTW, Wikipedia isn’t so bad, according to a recent study out of Australia.  But I digress…)

Obviously, if one uses “free” resources to obtain medical information, that info is likely to be as unbiased as the last “free” Cymbalta dinner he or she attended.  Many doctors don’t recognize this.

When it comes to journals, it gets potentially more interesting.  All of the top medical journals are available online.  And, like many online newspapers and magazines, articles are available for a fee.  But the fees are astronomical—typically $30 or $35 per article—which essentially prohibits any doc from buying more than one or two, let alone doing exhaustive research on a given subject.

Interestingly, some articles are freely available (“open access” is the industry term).  You can try this yourself:  go to pubmed.gov and search for a topic like “bipolar disorder” or “schizophrenia.”  You’ll get thousands of results.  Some results are accompanied by the “Free Article” tag.  You can guess which articles most docs will choose to read.

Why are some articles free while others aren’t?  What’s the catch?  Well, sometimes there is no catch.  For one, the National Institutes of Health (NIH) requires any research done with its funding to be freely available within six months of a paper’s publication.  This makes sense: NIH funds are our tax dollars, so it’s only fair that we get to see the data.  (But even this is coming under attack, since the publishers want to protect their content—and revenue stream.)

Interestingly, though, some journals also have a “pay-for-open-access” policy, in which an author can pay a higher publication fee to make his/her article freely available.  In other words, if I publish a (non-NIH-funded) study but want it to reach a wider audience than simply those ivory-tower types with access to fully-stocked libraries, I can just pay extra.  That’s right, some publishers give me the option to pay to attract readers like community docs, the lay public, journalists, and others (not to mention potential investors in a company with which I’m affiliated).  The policy for Elsevier, one of the world’s largest academic publishers, on such “sponsored articles” can be found here.

You can see where this might lead.  Call me cynical, but paying for more eyeballs sounds a lot like advertising.  Of course, these are peer-reviewed articles, so they do meet some standards of scientific integrity.  (Or do they?  A recent article suggests that “narrative reviews” often misrepresent or overstate claims of medication efficacy.  See also this summary of the article by Neuroskeptic.)

Anyway, the take-home message is, unfortunately, one that we’ve heard all too often.  Science is supposed to be pristine, objective, and unbiased, but it’s clearly not.  Even when you take out the obvious advertising, the drug-rep showmanship, and the pharma-funded CME, there are still ways for a product-specific message to make its way to a doctor’s eyes and ears.  And if our medical journals supposedly represent the last bastion of scientific integrity—the sacred repository of truth in a world of direct-to-consumer advertising, biased KOLs, and Big Pharma largesse—we should be particularly cautious when they fail to serve that purpose.


Talk Is Cheap

October 9, 2011

I work part-time in a hospital psychiatry unit, overseeing residents and medical students on their inpatient psychiatry rotations.  They are responsible for three to six patients at any given time, directing and coordinating the patients’ care while they are admitted to our hospital.

To an outsider, this may seem like a generous ratio: one resident taking care of only 3-6 patients.  One would think that this should allow for over an hour of direct patient contact per day, resulting in truly “personalized” medicine.  But instead, the absolute opposite is true: sometimes doctors only see patients for minutes at a time, and develop only a limited understanding of patients for whom they are responsible.  I noticed this in my own residency training, when halfway through my first year I realized the unfortunate fact that even though I was “taking care” of patients and getting my work done satisfactorily, I couldn’t tell you whether my patients felt they were getting better, whether they appreciated my efforts, or whether they had entirely different needs that I had been ignoring.

In truth, much of the workload in a residency program (in any medical specialty) is related to non-patient-care concerns:  lectures, reading, research projects, faculty supervision, etc.  But even outside of the training environment, doctors spend less and less time with patients, creating a disturbing precedent for the future of medicine.  In psychiatry in particular, the shrinking “therapy hour” has received much attention, most recently in a New York Times front-page article (which I blogged about it here and here).  The responses to the article echoed a common (and growing) lament among most psychiatrists:  therapy has been replaced with symptom checklists, rapid-fire questioning, and knee-jerk prescribing.

In my case, I don’t mean be simply one more voice among the chorus of psychiatrists yearning for the “glory days” of psychiatry, where prolonged psychotherapy and hour-long visits were the norm.  I didn’t practice in those days, anyway.  Nevertheless, I do believe that we lose something important by distancing ourselves from our patients.

Consider the inpatient unit again.  My students and residents sometimes spend hours looking up background information, old charts, and lab results, calling family members and other providers, and discussing differential diagnosis and possible treatment plans, before ever seeing their patient.  While their efforts are laudable, the fact remains that a face-to-face interaction with a patient can be remarkably informative, sometimes even immediately diagnostic to the skilled eye.  In an era where we’re trying to reduce our reliance on expensive technology and wasteful tests, patient contact should be prioritized over the hours upon hours that trainees spend hunched over computer workstations.

In the outpatient setting, direct patient-care time has been largely replaced by “busy work” (writing notes; debugging EMRs; calling pharmacies to inquire about prescriptions; completing prior-authorization forms; and performing any number of “quality-control,” credentialing, or other mandatory “compliance” exercises required by our institutions).  Some of this is important, but at the same time, an extra ten or fifteen minutes with a patient may go a long way to determining that patient’s treatment goals (which may disagree with the doctor’s), improving their motivation for change, or addressing unresolved underlying issues– matters that may truly make a difference and cut long-term costs.

The future direction of psychiatry doesn’t look promising, as this vanishing emphasis on the patient’s words and deeds is likely to make treatment even less cost-effective.  For example, there is a growing effort to develop biomarkers for diagnosis of mental illness and to predict medication response.  In my opinion, the science is just not there yet (partly because the DSM is still a poor guide by which to make valid diagnoses… what are depression and schizophrenia anyway?).  And even if the biomarker strategy were a reliable one, there’s still nothing that could be learned in a $745+ blood test that couldn’t be uncovered in a good, thorough clinical examination by a talented diagnostician, not to mention the fact that the examination would also uncover a large amount of other information– and establish valuable rapport– which would likely improve the quality of care.

The blog “1boringoldman” recently featured a post called “Ask them about their lives…” in which a particularly illustrative case was discussed.  I’ll refer you there for the details, but I’ll repost the author’s summary comments here:

I fantasize an article in the American Journal of Psychiatry entitled “Ask them about their lives!” Psychiatrists give drugs. Therapists apply therapies. Who the hell interviews patients beyond logging in a symptom list? I’m being dead serious about that…

I share Mickey’s concern, as this is a vital question for the future of psychiatry.  Personally, I chose psychiatry over other branches of medicine because I enjoy talking to people, asking about their lives, and helping them develop goals and achieve their dreams.  I want to help them overcome the obstacles put in their way by catastrophic relationships, behavioral missteps, poor insight, harmful impulsivity, addiction, emotional dysregulation, and– yes– mental illness.

However, if I don’t have the opportunity to talk to my patients (still my most useful diagnostic and therapeutic tool), I must instead rely on other ways to explain their suffering:  a score on a symptom list, a lab value, or a diagnosis that’s been stuck on the patient’s chart over several years without anyone taking the time to ask whether it’s relevant.  Not only do our patients deserve more than that, they usually want more than that, too; the most common complaint I hear from a patient is that “Dr So-And-So didn’t listen to me, he just prescribed drugs.”

This is not the psychiatry of my forefathers.  This is neither Philippe Pinel’s “moral treatment,” Emil Kraepelin’s meticulous attention to symptoms and patterns thereof, nor Aaron Beck’s cognitive re-strategizing.  No, it’s the psychiatry of HMOs, Wall Street, and an over-medicalized society, and in this brave new world, the patient is nowhere to be found.


How Abilify Works, And Why It Matters

September 13, 2011

One lament of many in the mental health profession (psychiatrists and pharmascolds alike) is that we really don’t know enough about how our drugs work.  Sure, we have hypothetical mechanisms, like serotonin reuptake inhibition or NMDA receptor antagonism, which we can observe in a cell culture dish or (sometimes) in a PET study, but how these mechanisms translate into therapeutic effect remains essentially unknown.

As a clinician, I have noticed certain medications being used more frequently over the past few years.  One of these is Abilify (aripiprazole).  I’ve used Abilify for its approved indications—psychosis, acute mania, maintenance treatment of bipolar disorder, and adjunctive treatment of depression.  It frequently (but not always) works.  But I’ve also seen Abilify prescribed for a panoply of off-label indications: “anxiety,” “obsessive-compulsive behavior,” “anger,” “irritability,” and so forth.  Can one medication really do so much?  And if so, what does this say about psychiatry?

From a patient’s perspective, the Abilify phenomenon might best be explained by what it does not do.  If you ask patients, they’ll say that—in general—they tolerate Abilify better than other atypical antipsychotics.  It’s not as sedating as Seroquel, it doesn’t cause the same degree of weight gain as Zyprexa, and the risk of contracting uncomfortable movement disorders or elevated prolactin is lower than that of Risperdal.  To be sure, many people do experience side effects of Abilify, but as far as I can tell, it’s an acceptable drug to most people who take it.

Abilify is a unique pharmacological animal.  Like other atypical antipsychotics, it binds to several different neurotransmitter receptors; this “signature” theoretically accounts for its therapeutic efficacy and side effect profile.  But unlike others in its class, it doesn’t block dopamine (specifically, dopamine D2) or serotonin (specifically, 5-HT1A) receptors.  Rather, it’s a partial agonist at those receptors.  It can activate those receptors, but not to the full biological effect.  In lay terms, then, it can both enhance dopamine and serotonin signaling where those transmitters are deficient, and inhibit signaling where they’re in excess.

Admittedly, that’s a crude oversimplification of Abilify’s effects, and an inadequate description of how a “partial agonist” works.  Nevertheless, it’s the convenient shorthand that most psychiatrists carry around in their heads:  with respect to dopamine and serotonin (the two neurotransmitters which, at least in the current vernacular, are responsible for a significant proportion of pathological behavior and psychiatric symptomatology), Abilify is not an all-or-none drug.  It’s not an on-off switch. It’s more of a “stabilizer,” or, in the words of Stephen Stahl, a “Goldilocks drug.”

Thus, Abilify can be seen, at the same time, as both an antipsychotic, and not an antipsychotic.  It’s both an antidepressant, and not an antidepressant.  And when you have a drug that is (a) generally well tolerated, (b) seems to work by “stabilizing” two neurotransmitter systems, and (c) resists conventional classification in this way, it opens the floodgates for all sorts of potential uses in psychiatry.

Consider the following conditions, all of which are subjects of Abilify clinical trials currently in progress (thanks to clinicaltrials.gov):  psychotic depression; alcohol dependence; “aggression”; improvement of insulin sensitivity; antipsychotic-induced hyperprolactinemia; cocaine dependence; Tourette’s disorder; postpartum depression; methamphetamine dependence; obsessive-compulsive disorder (OCD); late-life bipolar disorder; post-traumatic stress disorder (PTSD); cognitive deficits in schizophrenia; alcohol dependence; autism spectrum disorders; fragile X syndrome; tardive dyskinesia; “subsyndromal bipolar disorder” (whatever that is) in children; conduct disorder; ADHD; prodromal schizophrenia; “refractory anxiety”; psychosis in Parkinson’s disease; anorexia nervosa; substance-induced psychosis; prodromal schizophrenia; trichotillomania; and Alzheimers-related psychosis.

Remember, these are the existing clinical trials of Abilify.  Each one has earned IRB approval and funding support.  In other words, they’re not simply the fantasies of a few rogue psychiatrists; they’re supported by at least some preliminary evidence, or at least a very plausible hypothesis.  The conclusion one might draw from this is that Abilify is truly a wonder drug, showing promise in nearly all of the conditions we treat as psychiatrists.  We’ll have to wait for the clinical trial results, but what we can say at this point is that a drug which works as a “stabilizer” of two very important neurotransmitter systems can be postulated to work in virtually any way a psychopharmalogist might want.

But even if these trials are negative, my prediction is that this won’t stop doctors from prescribing Abilify for each of the above conditions.  Why?  Because the mechanism of Abilify allows for such elegant explanations of pathology (“we need to tune down the dopamine signal to get rid of those flashbacks” or “the serotonin 1A effect might help with your anxiety” – yes, I’ve heard both of these in the last week), that it would be anathema, at least to current psychiatric practice, not to use it in this regard.

This fact alone should lead us to ask what this says about psychiatry as a whole.  The fact that one drug is prescribed so widely—owing to its relatively nonspecific effects and a good deal of creative psychopharmacology on the part of doctors like me—and is so broadly accepted by patients, should call into question our hypotheses about the pathophysiology of mental illness, and how psychiatric disorders are distinguished from one another.  It should challenge our theories of neurotransmitters and receptors and how their interactions underlie specific symptoms.  And it should give us reason to question whether the “stories” we tell ourselves and our patients carry more weight than the medications we prescribe.


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.


CME, CE, and What Makes A Psychiatrist

May 25, 2011

Why do psychiatrists do what they do?  How— and why— is a psychiatrist different from a psychotherapist?  I believe that most psychiatrists entered this field wanting to understand the many ways to understand and to treat what’s “abnormal,” but have instead become caught up in (or brainwashed by?) the promises of modern-day psychopharmacology.  By doing so, we’ve found ourselves pigeonholed into a role in which we prescribe drugs while others provide the more interesting (and more rewarding) psychosocial interventions.

Exceptions certainly do exist.  But psychiatrists are rapidly narrowing their focus to medication management alone.  If we continue to do so, we’d better be darn sure that what we’re doing actually works.  If it doesn’t, we may be digging ourselves a hole from which it will be difficult—if not impossible—to emerge.

How did we get to this point?  I’m a (relatively) young psychiatrist, so I’ll admit I don’t have the historical perspective of some of my mentors.  But in my brief career, I’ve seen these influences:  training programs that emphasize psychopharmacology over psychotherapy; insurance companies that reimburse for medication visits but not for therapy; patients who demand medications as a quick fix to their problems (and who either can’t access, or don’t want, other therapeutic options); and treatment settings in which an MD is needed to prescribe drugs while the “real work” is done by others.

But there’s yet another factor underlying psychiatry’s increasing separation from other behavioral health disciplines:  Continuing Medical Education, or CME.

All health care professionals must engage in some sort of professional education or “lifelong learning” to maintain their licenses.  Doctors must complete CME credits.  PAs, nurses, psychologists, social workers, and others must also complete their own Continuing Education (CE) credits, and the topics that qualify for credit differ from one discipline to the next.

The pediatrician and blogger Claudia Gold, MD, recently wrote about a program on “Infant-Parent Mental Health,” a three-day workshop she attended, which explored “how early relationships shape the brain and influence healthy emotional development.”  She wrote that the program “left me well qualified to do the work I do,” but she couldn’t receive CME credits because they only offered credit for psychologists—not for doctors.

I had a similar experience several years ago.  During my psychiatry residency, I was invited to attend a “Summit for Clinical Excellence” in Monterey, sponsored by the Ben Franklin Institute.  The BFI offers these symposia several times a year; they’re 3- or 4-day long programs consisting of lectures, discussions, and workshops on advanced mental health topics such as addictions, eating disorders, relationship issues, personality disorders, trauma, ethics, etc.—in other words, areas which fall squarely under the domain of “mental health,” but which psychiatrists often don’t treat (mainly because there are no simple “medication solutions” for many of these problems).

Even though my residency program did not give me any days off for the event (nor did they provide any financial support), I rearranged my schedule and attended anyway.  It turned out to be one of the most memorable events of my training.  I got to meet (yes, literally meet, not just sit in an audience and listen to) influential figures in mental health like Helen Fisher, Harville Hendrix, Daniel Amen, Peter Whybrow, and Bill O’Hanlon.  And because most of my co-attendees were not physicians, the discussions were not about medications, but rather about how we can best work with our patients on a human and personal level.  Indeed, the lessons I learned there (and the professional connections I made) have turned out to be extraordinarily valuable in my everyday work.  (For a link to their upcoming summits, see this link.  Incidentally, I am not affiliated with the BFI in any way.)

Unfortunately, like Dr Gold, I didn’t receive any CME credits for this event either, even though my colleagues in other fields did get credit.  A few days ago, out of curiosity, I contacted BFI and inquired about their CME policy.  I was told that “the topic [of CME] comes up every few years, and we’ve thought about it,” but they’ve decided against it for two reasons.  First, there’s just not enough interest.  (I guess psychiatrists are too busy learning about drugs to take time to learn about people or ideas.)  Second, they said that the application process for CME accreditation is expensive and time-consuming (the application packet “is three inches thick”), and the content would require “expert review,” meaning that it would probably not meet criteria for “medical” CME because of its de-emphasis of medications.

To be fair, any doctor can attend a BFI Summit, just as anyone could have attended Dr Gold’s “Infant-Parent Mental Health” program.  And even though physicians don’t receive CME credits for these programs, there are many other simple (and free, even though much of it is Pharma-supported) ways to obtain CME.

At any rate, it’s important—and not just symbolically—to look at where doctors get their training.  I want to learn about non-pharmacological, “alternative” ways to treat my patients (and to treat patients who don’t fit into the simple DSM categories—which is, well, pretty much everyone).  But to do so, it would have to be on my own dime, and without CME credit.  On the other hand, those who do receive this training (and the credit) are, in my opinion, prepared to provide much better patient care than those of us who think primarily about drugs.

At the risk of launching a “turf war” with my colleagues in other behavioral health disciplines, I make the following proposal: if psychologists lobby for the privilege to prescribe medications (a position which—for the record—I support), then I also believe that psychiatrists should lobby their own professional bodies (and the Accreditation Council for CME [ACCME]) to broaden the scope of what counts as “psychiatric CME.”  Medications are not always the answer.  Similarly, neurobiology and genetics will not necessarily lead us to better therapeutics.  And even if they do, we still have to deal with patients—i.e., human beings—and that’s a skill we’re neither taught nor encouraged to use.  I think it’s time for that to change.


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.


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