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.

Antidepressants: The New Candy?

August 9, 2011

It should come as no surprise to anyone paying attention to health care (not to mention modern American society) that antidepressants are very heavily prescribed.  They are, in fact, the second most widely prescribed class of medicine in America, with 253 million prescriptions written in 2010 alone.  Whether this means we are suffering from an epidemic of depression is another thing.  In fact, a recent article questions whether we’re suffering from much of anything at all.

In the August issue of Health Affairs, Ramin Mojtabai and Mark Olfson present evidence that doctors are prescribing antidepressants at ever-higher rates.  Over a ten-year period (1996-2007), the percentage of all office visits to non-psychiatrists that included an antidepressant prescription rose from 4.1% to 8.8%.  The rates were even higher for primary care providers: from 6.2% to 11.5%.

But there’s more.  The investigators also found that in the majority of cases, antidepressants were given even in the absence of a psychiatric diagnosis.  In 1996, 59.5% of the antidepressant recipients lacked a psychiatric diagnosis.  In 2007, this number had increased to 72.7%.

In other words, nearly 3 out of 4 patients who visited a nonpsychiatrist and received a prescription for an antidepressant were not given a psychiatric diagnosis by that doctor.  Why might this be the case?  Well, as the authors point out, antidepressants are used off-label for a variety of conditions—fatigue, pain, headaches, PMS, irritability.  None of which have any good data supporting their use, mind you.

It’s possible that nonpsychiatrists might add an antidepressant to someone’s medication regimen because they “seem” depressed or anxious.  It is also true that primary care providers do manage mental illness sometimes, particularly in areas where psychiatrists are in short supply.  But remember, in the majority of cases the doctors did not even give a psychiatric diagnosis, which suggests that even if they did a “psychiatric evaluation,” the evaluation was likely quick and haphazard.

And then, of course, there were probably some cases in which the primary care docs just continued medications that were originally prescribed by a psychiatrist—in which case perhaps they simply didn’t report a diagnosis.

But is any of this okay?  Some, like a psychiatrist quoted in a Wall Street Journal article on this report, argue that antidepressants are safe.  They’re unlikely to be abused, often effective (if only as a placebo), and dirt cheap (well, at least the generic SSRIs and TCAs are).  But others have had very real problems discontinuing them, or have suffered particularly troublesome side effects.

The increasingly indiscriminate use of antidepressants might also open the door to the (ab)use of other, more costly drugs with potentially more devastating side effects.  I continue to be amazed, for example, by the number of primary care docs who prescribe Seroquel (an antipsychotic) for insomnia, when multiple other pharmacologic and nonpharmacologic options are ignored.  In my experience, in the vast majority of these cases, the (well-known) risks of increased appetite and blood sugar were never discussed with the patient.  And then there are other antipsychotics like Abilify and Seroquel XR, which are increasingly being used in primary care as drugs to “augment” antidepressants and will probably be prescribed as freely as the antidepressants themselves.  (Case in point: a senior medical student was shocked when I told her a few days ago that Abilify is an antipsychotic.  “I always thought it was an antidepressant,” she remarked, “after seeing all those TV commercials.”)

For better or for worse, the increased use of antidepressants in primary care may prove to be yet another blow to the foundation of biological psychiatry.  Doctors prescribe—and continue to prescribe—these drugs because they “work.”  It’s probably more accurate, however, to say that doctors and patients think they work.  And this may have nothing to do with biology.  As the saying goes, it’s the thought that counts.

Anyway, if this is true—and you consider the fact that these drugs are prescribed on the basis of a rudimentary workup (remember, no diagnosis was given 72.7% of the time)—then the use of an antidepressant probably has no more justification than the addition of a multivitamin, the admonition to eat less red meat, or the suggestion to “get more fresh air.”

The bottom line: If we’re going to give out antidepressants like candy, then let’s treat them as such.  Too much candy can be a bad thing—something that primary care doctors can certainly understand.  So if our patients ask for candy, then we need to find a substitute—something equally soothing and comforting—or provide them instead with a healthy diet of interventions to address the real issues, rather than masking those problems with a treat to satisfy their sweet tooth and bring them back for more.

Mental Illness IS Real After All… So What Was I Treating Before?

July 26, 2011

I recently started working part-time on an inpatient psychiatric unit at a large county medical center.  The last time I worked in inpatient psychiatry was six years ago, and in the meantime I’ve worked in various office settings—community mental health, private practice, residential drug/alcohol treatment, and research.  I’m glad I’m back, but it’s really making me rethink my ideas about mental illness.

An inpatient psychiatry unit is not just a locked version of an outpatient clinic.  The key difference—which would be apparent to any observer—is the intensity of patients’ suffering.  Of course, this should have been obvious to me, having treated patients like these before.  But I’ll admit, I wasn’t prepared for the abrupt transition.  Indeed, the experience has reminded me how severe mental illness can be, and has proven to be a “wake-up” call at this point in my career, before I get the conceited (yet naïve) belief that “I’ve seen it all.”

Patients are hospitalized when they simply cannot take care of themselves—or may be a danger to themselves or others—as a result of their psychiatric symptoms.  These individuals are in severe emotional or psychological distress, have immense difficulty grasping reality, or are at imminent risk of self-harm, or worse.  In contrast to the clinic, the illnesses I see on the inpatient unit are more incapacitating, more palpable, and—for lack of a better word—more “medical.”

Perhaps this is because they also seem to respond better to our interventions.  Medications are never 100% effective, but they can have a profound impact on quelling the most distressing and debilitating symptoms of the psychiatric inpatient.  In the outpatient setting, medications—and even psychotherapy—are confounded by so many other factors in the typical patient’s life.  When I’m seeing a patient every month, for instance—or even every week—I often wonder whether my effort is doing any good.  When a patient assures me it is, I think it’s because I try to be a nice, friendly guy.  Not because I feel like I’m practicing any medicine.  (By the way, that’s not humility, I see it as healthy skepticism.)

Does this mean that the patient who sees her psychiatrist every four weeks and who has never been hospitalized is not suffering?  Or that we should just do away with psychiatric outpatient care because these patients don’t have “diseases”?  Of course not.  Discharged patients need outpatient follow-up, and sometimes outpatient care is vital to prevent hospitalization in the first place.  Moreover, people do suffer and do benefit from coming to see doctors like me in the outpatient setting.

But I think it’s important to look at the differences between who gets hospitalized and who does not, as this may inform our thinking about the nature of mental illness and help us to deliver treatment accordingly.  At the risk of oversimplifying things (and of offending many in my profession—and maybe even some patients), perhaps the more severe cases are the true psychiatric “diseases” with clear neurochemical or anatomic foundations, and which will respond robustly to the right pharmacological or neurosurgical cure (once we find it), while the outpatient cases are not “diseases” at all, but simply maladaptive strategies to cope with what is (unfortunately) a chaotic, unfair, and challenging world.

Some will argue that these two things are one and the same.  Some will argue that one may lead to the other.  In part, the distinction hinges upon what we call a “disease.”  At any rate, it’s an interesting nosological dilemma.  But in the meantime, we should be careful not to rush to the conclusion that the conditions we see in acutely incapacitated and severely disturbed hospital patients are the same as those we see in our office practices, just “more extreme versions.”  In fact, they may be entirely different entities altogether, and may respond to entirely different interventions (i.e., not just higher doses of the same drug).

The trick is where to draw the distinction between the “true” disease and its “outpatient-only” counterpart.  Perhaps this is where biomarkers like genotypes or blood tests might prove useful.  In my opinion, this would be a fruitful area of research, as it would help us better understand the biology of disease, design more suitable treatments (pharmacological or otherwise), and dedicate treatment resources more fairly.  It would also lead us to provide more humane and thoughtful care to people on both sides of the double-locked doors—something we seem to do less and less of these days.

Psychiatry, Homeostasis, and Regression to the Mean

July 20, 2011

Are atypical antipsychotics overprescibed?  This question was raised in a recent article on the Al Jazeera English website, and has been debated back and forth for quite some time on various blogs, including this one.  Not surprisingly, their conclusion was that, yes, these medications are indeed overused—and, moreover, that the pharmaceutical industry is responsible for getting patients “hooked” on these drugs via inappropriate advertising and off-label promotion of these agents.

However, I don’t know if this is an entirely fair characterization.

First of all, let’s just be up front with what should be obvious.  Pharmaceutical companies are businesses.  They’re not interested in human health or disease, except insofar as they can exploit people’s fears of disease (sometimes legitimately, sometimes not) to make money.  Anyone who believes that a publicly traded drugmaker might forego their bottom line to treat malaria in Africa “because it’s the right thing to do” is sorely mistaken.  The mission of companies like AstraZeneca, Pfizer, and BMS is to get doctors to prescribe as much Seroquel, Geodon, and Abilify (respectively) as possible.  Period.

In reality, pharmaceutical company revenues would be zero if doctors (OK, and nurse practitioners and—at least in some states—psychologists) didn’t prescribe their drugs.  So it’s doctors who have made antipsychotics one of the most prescribed classes of drugs in America, not the drug companies.  Why is this?  Has there been an epidemic of schizophrenia?  (NB:  most cases of schizophrenia do not fully respond to these drugs.)  Are we particularly susceptible to drug marketing?  Do we believe in the clear and indisputable efficacy of these drugs in the many psychiatric conditions for which they’ve been approved (and those for which they haven’t)?

No, I like to think of it instead as our collective failure to appreciate that patients are more resilient and adaptive than we give them credit for, not to mention our infatuation with the concept of biological psychiatry.  In fact, much of what we attribute to our drugs may in fact be the result of something else entirely.

For an example of what I mean, take a look at the following figure:

This figure has nothing to do with psychiatry.  It shows the average body temperature of two groups of patients with fever—one who received intravenous Tylenol, and the other who received an intravenous placebo.  As you can easily see, Tylenol cut the fever short by a good 30-60 minutes.  But both groups of patients eventually reestablished a normal body temperature.

This is a concept called homeostasis.  It’s the innate ability of a living creature to keep things constant.  When you have a fever, you naturally perspire to give off heat.  When you have an infection, you naturally mobilize your immune system to fight it.  (BTW, prescribing antibiotics for viral respiratory infections is wasteful:  the illness resolves itself “naturally” but the use of a drug leads us to believe that the drug is responsible.)  When you’re sad and hopeless, lethargic and fatigued, you naturally engage in activities to pull yourself out of this “rut.”  All too often, when we doctors see these symptoms, we jump at a diagnosis and a treatment, neglecting the very real human capacity—evolutionarily programmed!!—to naturally overcome these transient blows to our psychological stability and well-being.

There’s another concept—this one from statistics—that we often fail to recognize.  It’s called “regression to the mean.”  If I survey a large number of people on some state of their psychological function (such as mood, or irritability, or distractibility, or anxiety, etc), those with an extreme score on their first evaluation will most likely have a more “normal” score on their next evaluation, and vice versa, even in the absence of any intervention.  In other words, if you’re having a particularly bad day today, you’re more likely to be having a better day the next time I see you.

This is perhaps the best argument for why it takes multiple sessions with a patient—or, at the very least, a very thorough psychiatric history—to make a confident psychiatric diagnosis and to follow response to treatment.  Symptoms—especially mild ones—come and go.  But in our rush to judgment (not to mention the pressures of modern medicine to determine a diagnosis ASAP for billing purposes), endorsement of a few symptoms is often sufficient to justify the prescription of a drug.

Homeostasis and regression to the mean are not the same.  One is a biological process, one is due to natural, semi-random variation.  But both of these concepts should be considered as explanations for our patients “getting better.”  When these changes occur in the context of taking a medication (particularly one like an atypical antipsychotic, with so many uses for multiple nonspecific diagnoses), we like to think the medication is doing the trick, when the clinical response may be due to something else altogether.

Al Jazeera was right: the pharmaceutical companies have done a fantastic job in placing atypical antipsychotics into every psychiatrist’s armamentarium.  And yes, we use them, and people improve.  The point, though, is that the two are sometimes not connected.  Until and unless we find some way to recognize this—and figure out what really works—Big Pharma will continue smiling all the way to the bank.

The Virtual Clinic Is Open And Ready For Business

July 9, 2011

Being an expert clinician requires mastery of an immense body of knowledge, aptitude in physical examination and differential diagnosis, and an ability to assimilate all information about a patient in order to institute the most appropriate and effective treatment.

Unfortunately, in many practice settings these days, such expertise is not highly valued.  In fact, these age-old skills are being shoved to the side in favor of more expedient, “checklist”-type medicine, often done by non-skilled providers or in a hurried fashion.  If the “ideal” doctor’s visit is a four-course meal at a highly rated restaurant, today’s medical appointments are more like dining at the Olive Garden, if not McDonald’s or Burger King.

At the rate we’re going, it’s only a matter of time before medical care becomes available for take-out or delivery.  Instead of a comprehensive evaluation, your visit may be an online questionnaire followed by the shipment of your medications directly to your door.

Well, that time is now.  Enter “Virtuwell.”

The Virtuwell web site describes itself as “the simplest and most convenient way to solve the most common medical conditions that can get in the way of your busy life.”  It is, quite simply, an online site where (for the low cost of $40) you can answer a few questions about your symptoms and get a “customized Treatment Plan” reviewed and written by a nurse practitioner.  If necessary, you’ll also get a prescription written to your pharmacy.  No appointments, no waiting, no insurance hassles.  And no embarrassing hospital gowns.

As you might expect, some doctors are upset at what they perceive as a travesty of our profession.  (For example, some comments posted on an online discussion group for MDs: “the public will have to learn the hard way that you get what you pay for”; “they have no idea what they don’t know—order a bunch of tests and antibiotics and call it ‘treated'”; and “I think this is horrible and totally undermines our profession.”)  But then again, isn’t this what we have been doing for quite a while already?  Isn’t this what a lot of medicine has become, with retail clinics, “doc-in-a-box” offices in major shopping centers, urgent-care walk-in sites, 15-minute office visits, and managed care?

When I worked in community mental health, I know that some of my fellow MDs saw 30-40 patients per day, and their interviews may just as well have been done over the telephone or online.  It wasn’t ideal, but most patients did just fine, and few complained about it.  (Well, if they did, their complaints carried very little weight, sadly.)  Maybe it’s true that much of what we do does not require 8+ years of specialty education and the immense knowledge that most physicians possess, and many conditions are fairly easy to treat.  Virtuwell is simply capitalizing on that reality.

With the advent of social media, the internet, and services like Virtuwell, the role of the doctor will further be called into question, and new ways of delivering medical care will develop.  For example, this week also saw the introduction of the “Skin Scan,” an iPhone app which allows you to follow the growth of your moles and uses a “proprietary algorithm” to determine whether they’re malignant.  Good idea?  If it saves you from a diagnosis of melanoma, I think the answer is yes.

In psychiatry—a specialty in which treatment decisions are largely based on what the patient says, rather than a physical exam finding—the implications of web-based “office visits” are particularly significant.  It’s not too much of a stretch to envision an HMO providing online evaluations for patients with straightforward complaints of depression or anxiety or ADHD-like symptoms, or even a pharmaceutical company selling its drugs directly to patients based on an online “mood questionnaire.”  Sure, there might be some issues with state Medical Boards or the DEA, but nothing that a little political pressure couldn’t fix.  Would this represent a decline in patient care, or would it simply be business as usual?  Perhaps it would backfire, and prove that a face-to-face visit with a psychiatrist is a vital ingredient in the mental well-being of our patients.  Or it might demonstrate that we simply get in the way.

These are questions we must consider for the future of this field, as in all of medicine.  One might argue that psychiatry is particularly well positioned to adapt to these changes in health care delivery systems, since so many of the conditions we treat are influenced and defined (for better or for worse) by the very cultural and societal trends that lead our patients to seek help in these new ways.

The bottom line is, we can’t just stubbornly stand by outdated notions of psychiatric care (or, for that matter, by our notions of “disease” and “treatment”), because cultural influences are already changing what it means to be healthy or sick, and the ways in which our patients get better.  To stay relevant, we need to embrace sites like Virtuwell, and use these new technologies when we can.  When we cannot, we must demonstrate why, and prove how we can do better.

[Credit goes to Neuroskeptic for the computer-screen psychiatrist.  Classic!]

Is Weiner Really Such A Bad Guy?

June 25, 2011

I don’t use this blog as a platform for political opinions or broad social commentary, but the Anthony Weiner “sexting” fiasco has raised some issues in my mind.  And I guess, in a roundabout way, it actually does pertain to psychiatry and medicine, so I figured I’d share these thoughts.

Unless you’ve been exiled to the Gulag for the last month, you probably know that Weiner, a Democratic New York congressman, was forced to resign from his post after the outcry over lewd photographs he sent to women from his Twitter account.  He left his office in disgrace and is apparently entering rehab.  (Maybe I’ll write about the wisdom of that move in a different post.)

The thing is, Weiner was a generally well-liked Congressman and was reportedly a leading candidate to run for mayor of New York in 2013.    He had many supporters and, until the “Weinergate” scandal broke, was seen as a very capable politican.  One might argue, in fact, that his sexual exploits had no effect on his ability to legislate, despite the vociferous (and at times rabid) barbs levied upon him by pundits and critics after the scandal became public.

Now, don’t get me wrong.  I am not condoning his behavior.  I am not saying that we should ignore it because “he’s otherwise a good guy.”  In no way should we turn a blind eye to something that shows such poor taste, a profound lack of judgment, and a disregard for his relationship with his wife.

But does it require the sudden unraveling of an entire political career?  Weiner has done some bad things.  But do they make him a bad congressman?

Some of the same questions arose during the recent flurry of stories about doctors who speak for drug companies.  As ProPublica has written in its “Dollars for Docs” series, some doctors have earned tens of thousands of dollars speaking on behalf of companies when they are also expected to be fair and unbiased in their assessment of patients, or in their analysis and presentation of data from clinical trials.

This is, in my opinion, a clear conflict of interest.  However, some of the articles went one step further and pointed out that many of those doctors have been disciplined by their respective Medical Boards, or have had other blemishes on their record.  Are these conflicts of interest?  No.  To me, it seems more like muckraking.  It’s further ammunition with which critics can attack Big Pharma and the “bad” doctors who carry out its dirty work.

Now I don’t mean to say that every sin or transgression should be ignored.  If one of those doctors had been disciplined for excessive or inappropriate prescribing, or for prescription fraud, or for questionable business practices, then I can see why it might be an issue worthy of concern.  But to paint all these doctors with a broad stroke and malign them even further because of past disciplinary action (and not simply on the basis of the rather obvious financial conflicts of interest), seems unfair.

The bottom line is, sometimes good people do bad things.  And unfortunately, even when those “bad things” are unrelated to the business at hand, we sometimes ruin lives and careers in our attempts to exact justice.  Whatever happened to rehabilitation and recovery?  A second chance?  Can we evaluate doctors (and politicians) by the quality of their work and their potential current conflicts, rather than something they did ten or twenty years ago?

(By the way, there are some bad—i.e., uninformed, irresponsible—doctors out there who have no disciplinary actions and no relationships with pharmaceutical companies.  Where are the journalists and patient-advocacy groups looking into their malfeasance?)

In our society, we are quick to judge—particularly those in positions of great power and responsibility.  And those judgments stick.  They become a lens through which we see a person, and those lenses rarely come off, regardless of how hard that person has worked to overcome those characterizations.  Ask any recovered alcoholic or drug addict.  Ask any ex-felon who has cleaned up his act.  Ask any “impaired professional.”  (In the interest of full disclosure, I am one of those professionals, whose “impairments” stemmed from a longstanding mental illness [now in remission] and affected none of my patients or colleagues, but which have introduced significant obstacles to my employability for the last five years.)  And ask any politician who has had to surrender an office due to a personal failing like Weiner’s.

Come to think of it, ask any patient who has been given a psychiatric diagnosis and whose words and actions will be interpreted by her friends, family,  doctors, or boss as part of her “borderline personality” or “bipolar” or “psychosis.”  It’s hard to live that down.

When evaluations matter, we should strive to judge people by the criteria that count, instead of the criteria that strengthen our biases, confirm our misconceptions, and polarize us further.  If we are able to do so, we may make it easier for people to recover and emerge even stronger after making mistakes or missteps in their lives.  We also might get along with each other just a little better.

Biomarker Envy IV: The Exmobaby

June 12, 2011

To what lengths would you go to keep your child healthy?  Organic, non-GMO baby food?  Hypoallergenic baby lotions and shampoos?  Bisphenol-free baby bottles?  How about a battery-powered biosensor garment that transmits ECG, skin temperature, and other biometric data about your baby wirelessly to your computer or via SMS message to your smartphone in real time?

Never fear, the Exmobaby is here.  Introduced late last year (and shown in the picture above—by the way, I don’t think that’s Jeff Daniels as a paid spokesman), the Exmobaby is a sleep garment designed for babies aged 0-12 months, which contains “embedded, non-contact sensors, a battery-powered Zigbee transmitter pod, a USB Zigbee receiver dongle that plugs into a Windows PC,” and all the necessary software.  Their slogan is “We Know How Your Baby Feels.”

It sounds like science fiction, but in reality it’s just a souped-up, high-tech version of a baby monitor.  But is it an improvement upon the audio- or video baby monitors currently available?  Exmovere certainly thinks so.  And, luckily for them, there’s no shortage of worried parents who are willing to pay for peace of mind (the device starts at $1000 and goes up to $2500, plus monthly data charges). [Note: please see addendum below.]

But while this might be an example of “a fool and his money being soon parted,” Exmovere makes some claims about the product that are highly questionable.  I first learned about the Exmobaby in a post on the KevinMD website, in which Exmovere’s CEO, David Bychkov, commented that “using Exmobaby to observe and record physiological data symptomatic of emotional changes can be useful… if you are a parent of a child with autism.”

In other words, this isn’t just a fancy monitoring device, this is a high-tech way of understanding your child’s thoughts and emotions—an “emotional umbilical cord between mother and child”—and, quite possibly, a way to diagnose a psychiatric, neurodevelopmental disorder in your newborn, all in the comfort of your own home.

I surfed over to the Exmobaby web site, whose home page shows a smiling, happy infant wearing these newfangled jammies.  Cute!  And the device (?) looks harmless enough.  But the FAQ page is where it gets interesting (or scary, depending on your position).  One question asks, “how is it possible to detect emotional states using Exmobaby?”  The response sounds like pure 21st century biobehavioral mumbo jumbo:

Detection of emotion involves software that compares heart rate, delta temperature and movement data (arousal) to heart rate variability and skin temperature (valence). These data, if tracked over time, enable a system to “guess” from a series of words that could be used to describe an emotional state: anger, fatigue, depression, joy, etc….In the case of babies, Exmovere is asking its users to try something new: name states. Exmobaby software will monitor trends in vital states. Parents will be asked to name states, such as “giggly” or “grumpy,” and the system can and will alert them when the underlying readings that match those states are detected. The idea is … to create a deeper level of communication between babies and their parents at the beginning of such a critical relationship.

In plain English: they’re asking parents to correlate data from the Exmobaby software (rather than their direct observations of the baby, which is how parents used to interact with their kids) with what they consider to be the baby’s emotional state.  Thus:  “My baby’s happy because the software says he is” rather than using old-fashioned signs—you know, like smiles and giggles.

The Exmovere website also includes an article, clearly written for parents, on “Exmobaby and Autism.”  Now, autism and “autism-spectrum disorders” (ASDs) are hot topics receiving a great deal of attention these days.  ASDs currently have an estimated prevalence of 1 in 110 (and rising rapidly), with an average age of diagnosis of approximately 4 years.  Nonetheless, parents of children with ASDs begin to identify concerns by the age of 12 to 18 months, and finding a “biomarker” to enable earlier diagnosis would allay the fears and insecurities of new parents.

But is Exmovere preying on precisely these fears and insecurities?  Well, let’s first ask: is it even reasonable to think about diagnosing ASDs before the age of 12 months (when the Exmobaby garment would be worn?).  A recent study showed that ASDs could be diagnosed as early as 14 months of age, based on social and communication development (but no biometric measures).  The American Association of Pediatrics recommends ASD screening (an interview with the parents and structured observation of the child) at ages 18 and 24 months, no earlier.  And a recent article in Pediatrics remarked that there are few measures sensitive and specific enough to detect ASD before 2 years of age (and, again, no “biological” measures to speak of).

The Exmobaby handout (which I’ve uploaded here), on the other hand, is a perfect example of a drug/device manufacturer capitalizing on the fears of parents by conflating statistics, commentary, and recommendations in a way that makes their device sound like a vital necessity for healthy infant development.  It’s deceptive marketing, pure and simple.

For example, it states “One of the ‘red flags’ in early diagnosis of ASDs is a lack of response from baby to the use of their name. Parents can potentially use Exmobaby to record times when baby’s name was said so that the reports will correlate any movement or vital sign response.”  Also, “specific tests can be designed in consultation with pediatricians to use Exmobaby to assist with diagnoses of ASDs and related developmental disorders.”  Never mind that there’s nothing in the literature correlating movement or vital-sign responses with diagnosing ASDs in this age group.

Conveniently, Exmovere also included its marketing strategy on its website (available here). It’s clear they’re planning to market Exmobaby as a garment (“a $5 billion per year worldwide market”) and not as a medical device.  That’s probably a good idea.  Or is it?  Bypassing medical professionals and tapping into a wide market of “worried well” might be good for business, but what about the “downstream” impact on our health care system?

So many questions.  But I’ll have to address them some other time, because I need to go make a sandwich.  I just got a text message telling me I’m hungry.

Addendum:  After posting this article, I received an email from Exmovere’s Investor Relations Advisor who pointed out that the $1000-$2500 prices I quoted above are for Evaluation Kits, specifically for distributors, researchers, and hospitals.  Exmobaby is not available for retail purchase at this time.  They anticipate a lower cost when the device/garment is sold directly to end users.

How Not To Be A Difficult Patient

June 5, 2011

One of the more interesting posters at last month’s American Psychiatric Association Annual Meeting was presented by Ricardo Salazar of UT San Antonio and the South Texas Psychiatric Practice-Based Research Network (PBRN).  The topic was “the Difficult Patient in Psychiatric Practice” and it surveyed psychiatrists about which patients they considered “difficult” and why.

It might sound somewhat disrespectful (and maybe a little naïve) to label a patient as “difficult.”  However, doctors are people too, and it would be even more naïve to think that doctors don’t have their own reactions to (and opinions of) the patients they treat—something referred to in psychoanalytic theory as “countertransference.”  Let’s face it:  doctors simply don’t like dealing with some patients.  (That’s why some choose private practice, to cherry-pick those whom they do like.)

Nevertheless, I think this topic needs more attention, particularly in today’s environment.  Much of what we do in mental health (both psychopharmacologically and in therapy) has a questionable evidence base, and yet the experience of clinicians and of patients is that our interventions frequently work.  I maintain that clinical benefit often results more from the interpersonal relationship between a patient and a doctor who listens and seems to understand, than from the pill that a doctor prescribes or the specific protocol that a therapist follows.  (This is yet another reason why quick-throughput psychiatry, dictated by brain scans, blood tests, and checklists, is bound to fail for most patients.)

Anyway, Dr Salazar’s study used a scale called the “Difficult Doctor-Patient Relationship Questionnaire (DDPRQ-10),” developed by Steven Hahn and colleagues in 1994.  I had not heard of this scale before.  Here are some sample questions:

1.  How much are you looking forward to this patient’s next visit after today?
3.  How manipulative is this patient?
4.  To what extent are you frustrated by this patient’s vague complaints?
6.  Do you find yourself secretly hoping this patient will not return?
8.  How time-consuming is caring for this patient?

As a patient, I might find some of these questions mildly offensive (“does my doctor secretly hope I won’t return??”), but as a doctor I must admit that some days I look at my schedule and see a name that makes me dread that hour.  (If you’re a doctor and you’re reading this and you do not agree, you’re either fooling yourself, you’re perfect, or you’re IBM’s Watson.)  Recognizing those feelings, however, often helps me to prepare for the session—and examine my own biases and faults—and such appointments often turn out to be the most satisfying (at least for the patient).

Salazar’s study showed that, on average, psychiatrists considered approximately 15% of their patients to be “difficult.”  The most common diagnoses among the “difficult” patients were schizophrenia (32%), bipolar disorder (19%), cognitive disorder (24%), and personality disorder (32%).  Patients with depression (11%) or anxiety (9%)—and, interestingly, patients who were in psychotherapy (11%)—were considered less difficult.  Not surprisingly, patients with alcohol and substance use disorders were also labeled difficult (23%), but patients with somatization (defined in this study as “unexplained physical complaints”) were less so (10%).

A fascinating review of 94 studies published between 1979 and 2004 described four reasons why patients may be considered “difficult”:  (1) chronicity– i.e., patients fail to improve over time; (2) severe, unmet dependency needs which patients then project onto the caregiver; (3) severe character pathology (especially borderline, narcissistic, and paranoid types); and (4) an inability to “reflect” (which the authors attribute to a history of insecure attachment early in life).  The authors also described three types of difficult patients:  the “unwilling care avoider” who doesn’t see himself as sick; the “ambivalent care seeker” who is often demanding and dependent, but is frequently self-destructive and self-sabotaging; and the “demanding care claimer” who is aggressive, attention-seeking and manipulative, but who sees himself as a patient only when necessary to achieve his own goals (legal, financial, or otherwise).

Of course, every patient interaction is a two-way street.  Regarding psychiatrists, the Salazar study found that young (<40 yrs old) psychiatrists, and those working in a group practice, claimed to have more difficult patients.  Another large study published in 2006 examined 1391 physicians to identify which features of doctors underlie their perceptions of patients as “frustrating.”  They found that high frustration was associated with doctors who were younger (<40 yrs old), worked >55 hrs/week, had symptoms of depression, stress, or anxiety (yes, that’s in the doctor, not the patient), and had “a greater number of patients with psychosocial problems or substance abuse.”  Two-way street, indeed.

It’s commonly said that “there’s no such thing as a stupid question.”  By the same token, I would posit that there’s no such thing as a difficult patient.  To be sure, some patients present with difficult problems, challenging histories, poor interpersonal skills, and needs that simply can’t be met with the interventions available to the physician.  But every patient suffers in his or her own way.  Doctors bring their own baggage to the interaction, too, in the form of strong opinions, personal biases, lack of knowledge, or—conversely—the perception that we know what’s going on, when in reality we do not.

When you add in the extrinsic factors that make the interaction even more strained—shorter appointments, care that is dictated by some third party rather than the doctor or the patient, poorly designed electronic medical record systems, or financial conflicts of interest that violate the doctor-patient trust—the “difficulties” just keep piling up.

It’s important that we look at every aspect of the doctor-patient interaction in order to improve the quality and efficacy of the care we provide.  Patients should not need to worry about whether they’re perceived as “difficult” or “frustrating.”  And when these perceptions do exist, we must critically examine the impact it has on their care, and what it says about the professionals we call upon to treat them.

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.

Biomarker Envy I: Cortical Thickness

May 13, 2011

In the latest attempt to look for biological correlates or predictors of mental illness, a paper in this month’s Archives of General Psychiatry shows that children with major depressive disorder (MDD) have thinner cortical layers than “healthy” children, or children with obsessive-compulsive disorder (OCD).  Specifically, researchers performed brain MRI scans on 78 children with or without a diagnosis, and investigated seven specific areas of the cerebral cortex.  Results showed four areas which were thinner in children with MDD than in healthy children, two which were thicker, and one that did not vary.

These results add another small nugget of data to our (admittedly scant) understanding of mental illness—particularly in children, before the effects of years of continuous medication treatment.  They also represent the bias towards imaging studies in psychiatry, whose findings—even if statistically significant—are not always that reliable or meaningful.  (But I digress…)

An accompanying press release, however, was unrealistically enthusiastic.  It suggested that this study “offers an exciting new way to identify more objective markers of psychiatric illness in children.”  Indeed, the title of the paper itself (“Distinguishing between MDD and OCD in children by measuring regional cortical thickness”) might suggest a way to use this information in clinical practice right away.  But it’s best not to jump to these conclusions just yet.

For one, there was tremendous variability in the data, as shown in the figure at left (click for larger view).  While on average the children with MDD had a thinner right superior parietal gyrus (one of the cortical regions studied) than healthy children or children with OCD, no individual measurement was predictive of anything.

Second, the statement that we can “distinguish between depression and OCD” based on a brain scan reflects precisely the type of biological determinism and certainty (and hype?) that psychiatry has been striving for, but may never achieve (just look at the figure again).  Lay readers—and, unfortunately, many clinicians—might read the headline and believe that “if we just order an MRI for Junior, we’ll be able to get the true diagnosis.”  The positive predictive value of any test must be high enough to warrant its use in a larger population, and so far, the predictive value of most tests in psychiatry is poor.

Third, there is no a priori reason why there should be a difference between the brains (or anything else, for that matter) of patients with depression and patients with OCD, when you consider the overlap between these—and other—psychiatric conditions.  There are many shades of grey between “depression” and “OCD”:  some depressed children will certainly have OCD-like traits, and vice versa.  Treating the individual (and not necessarily the individual’s brain scan) is the best way to care for a person.

To be fair, the authors of the study, Erin Fallucca and David Rosenberg from Wayne State University in Detroit, do not state anywhere in their paper that this approach represents a “novel new diagnostic method” or make any other such sweeping claims about their findings.  In fact, they write that the differences they observed “merit further investigation” and highlight the need to look “beyond the frontal-limbic circuit.”  In other words, our current hypotheses about depression are not entirely supported by their findings (true), so we need to investigate further (also true).  And this, admittedly, is how science should proceed.

However, the history of psychiatry is dotted with tantalizing neurobiological theories or findings which find their way into clinical practice before they’ve been fully proven, or even shown any great clinical relevance.  Pertinent examples are the use of SPECT scans to diagnose ADHD, championed by Daniel Amen; quantitiative EEG to predict response to psychotropics; genotyping for metabolic enzymes; and the use of SSRIs to treat depression.  (Wait, did I say that???)

The quest to identify “biomarkers” of psychiatric illness may similarly lead us to believe we know more about a disease than we do.  A biomarker is a biological feature (an endocrine or inflammatory measure, a genotype, a biochemical response to a particular intervention) that distinguishes a person with a condition from one without.  They’re used throughout medicine for diagnosis, risk stratification and monitoring treatment response.   A true biomarker for mental illness would represent a significant leap ahead in personalized treatment.  Or would it?  What if a person’s clinical presentation differs from what the marker predicts?  “I’m sorry Mrs. Jones, but even though Katie compulsively washes her hands and counts to twelve hundreds of times a day, her right superior parietal gyrus is too thin for a diagnosis of OCD.”

Other fields of medicine don’t experience this dilemma.  If you have an elevated hsCRP and high LDL, even though you “feel fine,” you are still at elevated risk for cardiovascular disease and really ought to take preventive measures (exercise, diet, etc).  (However, see this recent editorial in the BMJ about “who should define disease.”)  But if your brain scan shows cortical thinning and you have no symptoms of depression, do you need to be treated?  Are you even at risk?

Some day (hopefully) these questions will be answered, as we gain a greater understanding of the biology of mental illness.  But until then, let’s keep research and clinical practice separate until we know what we’re doing.  Psychiatry doesn’t have to be like other fields of medicine.  Patients suffer and come to us for help; let’s open our eyes and ears before sending them off to the scanner or the lab.  In doing so, we might learn something important.

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