Community Psychiatry And Its Unintended Consequences

May 10, 2011

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

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

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

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

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

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

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

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

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

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

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

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

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


Psychopharmacology And The Educated Guess

May 6, 2011

Sometimes I feel like a hypocrite.

As a practicing psychiatrist, I have an obligation to understand the data supporting my use of prescription medication.  In my attempts to do so, I’ve found some examples of clinical research that, unfortunately, are possibly irrelevant or misleading.  Many other writers and bloggers have taken this field to task (far more aggressively than I have) for clinical data that, in their eyes, are incomplete, inconclusive, or downright fraudulent.

In fact, we all like to hold our clinical researchers to an exceedingly high standard, and we complain indignantly when they don’t achieve it.

At the same time, I’ll admit I don’t always do the same in my own day-to-day practice.  In other words, I demand precision in clinical trials, but several times a day I’ll use anecdotal evidence (or even a “gut feeling”) in my prescribing practices, completely violating the rigor that I expect from the companies that market their drugs to me.

Of all fields in medicine, psychopharmacology the one where this is not only common, but it’s the status quo.

“Evidence-based” practice is about making a sound diagnosis and using published clinical data to make a rational treatment decision.  Unfortunately, subjects in clinical trials of psychotropic drugs rarely—if ever—resemble “real” patients, and the real world often throws us curve balls that force us to improvise.  If an antipsychotic is only partially effective, what do we do?  If a patient doesn’t tolerate his antidepressant, then what?  What if a drug interferes with my patient’s sleep?  Or causes a nasty tremor?  There are no hard-and-fast rules for dealing with these types of situations, and the field of psychopharmacology offers wide latitude in how to handle them.

But then it gets really interesting.  Nearly all psychiatrists have encountered the occasional bizarre symptom, the unexpected physical finding, or the unexplained lab value (if labs are being checked, that is).  Psychopharmacologists like to look at these phenomena and try to concoct an explanation based on what might be happening based on their knowledge of the drugs they prescribe.  In fact, I’ve always thought that the definition of an “expert psychopharmacologist” is someone who understands the properties of drugs well enough to make a plausible (albeit potentially wrong) molecular or neurochemical explanation of a complex human phenotype, and then prescribe a drug to fix it.

The psychiatric literature is filled with case studies of interesting encounters or “clinical pearls” that illustrate this principle at work.

For example, consider this case report in the Journal of Neuropsychiatry and Clinical Neurosciences, in which the authors describe a case of worsening mania during slow upward titration of a Seroquel dose and hypothesize that an intermediate metabolite of quetiapine might be responsible for the patient’s mania.  Here’s another one, in which Remeron is suggested as an aid to benzodiazepine withdrawal, partially due to its 5-HT3 antagonist properties.  And another small study purports to explain how nizatadine (Axid), an H2 blocker, might prevent Zyprexa-induced weight gain.  And, predictably, such “hints” have even made their way into drug marketing, as in the ads for the new antipsychotic Latuda which suggest that its 5-HT7 binding properties might be associated with improved cognition.

Of course, for “clinical pearls” par excellence, one need look no further than Stephen Stahl, particularly in his book Essential Psychopharmacology: The Prescriber’s Guide.  Nearly every page is filled with tips (and cute icons!) such as these:  “Lamictal may be useful as an adjunct to atypical antipsychotics for rapid onset of action in schizophrenia,” or “amoxapine may be the preferred tricyclic/tetracyclic antidepressant to combine with an MAOI in heroic cases due to its theoretically protective 5HT2A antagonist properties.”

These “pearls” or hypotheses are interesting suggestions, and might work, but have never been proven to be true.  At best, they are educated guesses.  In all honesty, no self-respecting psychopharmacologist would say that any of these “pearls” represents the absolute truth until we’ve replicated the findings (ideally in a proper controlled clinical trial).  But that has never stopped a psychopharmacologist from “trying it anyway.”

It has been said that, “every time we prescribe a drug to a patient, we’re conducting an experiment, with n=1.”  It’s amazing how often we throw caution to the wind and, just because we think we know how a drug might work, and can visualize in our minds all the pathways and receptors that we think our drugs are affecting, we add a drug or change a dose and profess to know what it’s doing.  Unfortunately, when we enter the realm of polypharmacy (not to mention the enormous complexity of human physiology), all bets are usually off.

What’s most disturbing is how often our assumptions are wrong—and how little we admit it.  For every published case study like the ones mentioned above, there are dozens—if not hundreds—of failed “experiments.”  (Heck, the same could be said even when we’re using something appropriately “evidence-based,” like using a second-generation antipsychotic for schizophrenia.)  In psychopharmacology, we like to take pride in our successes (“I added a touch of cyproterone, and his compulsive masturbation ceased entirely!”)  but conveniently excuse our failures (“She didn’t respond to my addition of low-dose N-acetylcysteine because of flashbacks from her childhood trauma”).  In that way, we can always be right.

Psychopharmacology is a potentially dangerous playground.  It’s important that we follow some well-established rules—like demanding rigorous clinical trials—and if we’re going to veer from this path, it’s important that we exercise the right safeguards in doing so.  At the same time, we should exercise some humility, because sometimes we have to admit we just don’t know what we’re doing.


Mental Illness and Social Realities

May 2, 2011

Does the definition of “mental illness” differ from place to place?  Is there a difference between “depression” in a poor individual and in one of means?  Are the symptoms identical?  What about the neurobiology?  The very concept of a psychiatric “disease” implies that certain core features of one’s illness transcend the specifics of a person’s social or cultural background.  Nevertheless, we know that disorders look quite different, depending on the setting in which they arise.  This is why people practice psychiatry, not computers or checklists.  (Not yet, at least.)

However, sometimes a person’s environment can elicit reactions and behaviors that might appear—even to a trained observer—as mental illness.  If unchecked, this may create an epidemic of “disease” where true disease does not exist.  And the consequences could be serious.

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For the last three years, I have had the pleasure of working part-time in a community mental health setting.  Our clinic primarily serves patients on Medicaid and Medicare, in a gritty, crime-ridden expanse of a major city.  Our patients are, for the most part, impoverished, poorly educated, have little or no access to primary care services, and live in communities ravaged by substance abuse, crime, unemployment, familial strife, and a deep, pervasive sense of hopelessness.

Even though our resources are extremely limited, I can honestly say that I have made a difference in the lives of hundreds, if not thousands, of individuals.  But the experience has led me to question whether we are too quick to make psychiatric diagnoses for the sake of convenience and expediency, rather than on the basis of a fair, objective, and thorough evaluation.

Almost predictably, patients routinely present with certain common complaints:  anxiety, “stress,” insomnia, hopelessness, fear, worry, poor concentration, cognitive deficits, etc.  Each of these could be considered a feature of a deeper underlying disorder, such as an anxiety disorder, major depression, psychosis, thought disorder, or ADHD.  Alternatively, they might also simply reflect the nature of the environment in which the patients live, or the direct effects of other stressors that are unfortunately too familiar in this population.

Given the limitations of time, personnel, and money, we don’t usually have the opportunity for a thorough evaluation, collaborative care with other professionals, and frequent follow-up.  But psychiatric diagnostic criteria are vague, and virtually everyone who walks into my office endorses symptoms for which it would be easy to justify a diagnosis.  The “path of least” resistance” is often to do precisely that, and move to the next person in the long waiting-room queue.

This tendency to “knee-jerk” diagnosis is even greater when patients have already had some interaction—however brief—with the mental health system:  for example, a patient who visited a local crisis clinic and was given a diagnosis of “bipolar disorder” (on the basis of a 5-minute evaluation) and a 14-day supply of Zyprexa, and told to “go see a psychiatrist”; or the patient who mentioned “anxiety” to the ER doc in our county hospital (note: he has no primary care MD), was diagnosed with panic disorder, and prescribed PRN Ativan.

We all learned in our training (if not from a careful reading of the DSM-IV) that a psychiatric diagnosis should be made only when other explanations for symptoms can be ruled out.  Psychiatric treatment, moreover, should be implemented in the safest possible manner, and include close follow-up to monitor patients’ response to these interventions.

But in my experience, once a patient has received a diagnosis, it tends to stick.  I frequently feel an urge to un-diagnose patients, or, at the very least, to have a discussion with them about their complaints and develop a course of treatment—which might involve withholding medications and implementing lifestyle changes or other measures.  Alas, this takes time (and money—at least in the short run).  Furthermore, if a person already believes she has a disorder (even if it’s just “my mother says I must be bipolar because I have mood swings all the time!!!”), or has experienced the sedative, “calming,” “relaxing” effect of Seroquel or Klonopin, it’s difficult to say “no.”

There are consequences of a psychiatric diagnosis.  It can send a powerful message.  It might absolve a person of his responsibility to make changes in his life—changes which he might indeed have the power to make.  Moreover, while some see a diagnosis as stigmatizing, others may see it as a free ticket to powerful (and potentially addictive) medications, as well as a variety of social services, from a discounted annual bus pass, to in-home support services, to a lifetime of Social Security disability benefits.  Very few people consciously abuse the system for their own personal gain, but the system is set up to keep this cycle going.  For many, “successful” treatment means staying in that cycle for the rest of their lives.

—–

The patients who seek help in a community mental health setting are, almost without exception, suffering in many ways.  That’s why they come to see us.  Some clinics do provide a wide assortment of services, including psychotherapy, case management, day programs, and the like.  For the truly mentally ill, these can be a godsend.

For many who seek our services, however, the solutions that would more directly address their suffering—like safer streets, better schools, affordable housing, stable families, less access to illicit drugs, etc.—are difficult or costly to implement, and entirely out of our hands.  In cases such as these, it’s unfortunately easier to diagnose a disease, prescribe a drug which (in the words of one of my colleagues) “allows them to get through just one more night,” and make poor, unfortunate souls even more dependent on a system which sees them as hopeless and unable to emerge from the chaos of their environment.

In my opinion, that’s not psychiatry.  But it’s being practiced every day.


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