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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.

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Maybe Stuart Smalley Was Right All Along

July 31, 2011

To many people, the self-help movement—with its positive self-talk, daily feel-good affirmations, and emphasis on vague concepts like “gratitude” and “acceptance”—seems like cheesy psychobabble.  Take, for instance, Al Franken’s fictional early-1990s SNL character Stuart Smalley: a perennially cheerful, cardigan-clad “member of several 12-step groups but not a licensed therapist,” whose annoyingly positive attitude mocked the idea that personal suffering could be overcome with absurdly simple affirmative self-talk.

Stuart Smalley was clearly a caricature of the 12-step movement (in fact, many of his “catchphrases” came directly from 12-step principles), but there’s little doubt that the strategies he espoused have worked for many patients in their efforts to overcome alcoholism, drug addiction, and other types of mental illness.

Twenty years later, we now realize Stuart may have been onto something.

A review by Kristin Layous and her colleagues, published in this month’s Journal of Alternative and Complementary Medicine, shows evidence that daily affirmations and other “positive activity interventions” (PAIs) may have a place in the treatment of depression.  They summarize recent studies examining such interventions, including two randomized controlled studies in patients with mild clinical depression, which show that PAIs do, in fact, have a significant (and rapid) effect on reducing depressive symptoms.

What exactly is a PAI?  The authors offer some examples:  “writing letters of gratitude, counting one’s blessings, practicing optimism, performing acts of kindness, meditation on positive feelings toward others, and using one’s signature strengths.”  They argue that when a depressed person engages in any of these activities, he or she not only overcomes depressed feelings (if only transiently) but can also can use this to “move past the point of simply ‘not feeling depressed’ to the point of flourishing.”

Layous and her colleagues even summarize results of clinical trials of self-administered PAIs.  They report that PAIs had effect sizes of 0.31 for depressive symptoms in a community sample, and 0.24 and 0.23 in two studies specifically with depressed patients.  By comparison, psychotherapy has an average effect size of approximately 0.32, and psychotropic medications (although there is some controversy) have roughly the same effect.

[BTW, an “effect size” is a standardized measure of the magnitude of an observed effect.  An effect size of 0.00 means the intervention has no impact at all; an effect size of 1.00 means the intervention causes an average change (measured across the whole group) equivalent to one standard deviation of the baseline measurement in that group.  An effect size of 0.5 means the average change is half the standard deviation, and so forth.  In general, an effect size of 0.10 is considered to be “small,” 0.30 is “medium,” and 0.50 is a “large” effect.  For more information, see this excellent summary.]

So if PAIs work about as well as medications or psychotherapy, then why don’t we use them more often in our depressed patients?   Well, there are a number of reasons.  First of all, until recently, no one has taken such an approach very seriously.  Despite its enormous common-sense appeal, “positive psychology” has only been a field of legitimate scientific study for the last ten years or so (one of its major proponents, Sonja Lyubomirsky, is a co-author on this review) and therefore has not received the sort of scientific scrutiny demanded by “evidence-based” medicine.

A related explanation may be that people just don’t think that “positive thinking” can cure what they feel must be a disease.  As Albert Einstein once said, “You cannot solve a problem from the same consciousness that created it.”  The implication is that one must seek outside help—a drug, a therapist, some expert—to treat one’s illness.  But the reality is that for most cases of depression, “positive thinking” is outside help.  It’s something that—almost by definition—depressed people don’t do.  If they were to try it, they may reap great benefits, while simultaneously changing neural pathways responsible for the depression in the first place.

Which brings me to the final two reasons why “positive thinking” isn’t part of our treatment repertoire.  For one thing, there’s little financial incentive (to people like me) to do it.  If my patients can overcome their depression by “counting their blessings” for 30 minutes each day, or acting kindly towards strangers ten times a week, then they’ll be less likely to pay me for psychotherapy or for a refill of their antidepressant prescription.  Thus, psychiatrists and psychologists have a vested interest in patients believing that their expert skills and knowledge (of esoteric neural pathways) are vital for a full recovery, when, in fact, they may not be.

Finally, the “positive thinking” concept may itself become too “medicalized,” which may ruin an otherwise very good idea.  The Layous article, for example, tries to give a neuroanatomical explanation for why PAIs are effective.  They write that PAIs “might be linked to downregulation of the hyperactivated amygdala response” or might cause “activation in the left frontal region” and lower activity in the right frontal region.  Okay, these explanations might be true, but the real question is: does it matter?  Is it necessary to identify a mechanism for everything, even interventions that are (a) non-invasive, (b) cheap, (c) easy, (d) safe, and (e) effective?   In our great desire to identify neural mechanisms or “pathways” of PAIs, we might end up finding nothing;  it would be a shame if this result (or, more accurately, the lack thereof) leads us to the conclusion that it’s all “pseudoscience,” hocus-pocus, psychobabble stuff, and not worthy of our time or resources.

At any rate, it’s great to see that alternative methods of treating depression are receiving some attention.  I just hope that their “alternative-ness” doesn’t earn immediate rejection by the medical community.  On the contrary, we need to identify those for whom such approaches are beneficial; engaging in “positive activities” to treat depression is an obvious idea whose time has come.


How Much Should Addiction Treatment Cost?

May 22, 2011

Drug and alcohol abuse are widespread social, behavioral, and—if we are to believe the National Institutes of Health and most addiction professionals—medical problems.  In fact, addiction medicine has evolved into its own specialty, and a large number of other allied health professionals have become engaged in the treatment of substance abuse and dependence.

If addiction is a disease, then we should be able to develop ways to treat addictions effectively, and the costs of accepted treatments can be used to determine how we provide (and reimburse for) these services.  Unfortunately, unlike virtually every other (non-psychiatric) disease process—and despite tremendous efforts to develop ways to treat addictions effectively—there are still no universally accepted approaches for management of addictive disorders.  And the costs of treating an addict can range from zero to tens (or hundreds) of thousands of dollars.

I started thinking of this issue after reading a recent article on abcnews.com, in which addiction psychiatrist Stefan Kruszewski, MD, criticized addiction treatment programs for their tendency to take people off one addictive substance and replace it with another one (e.g., from heroin to Suboxone; or from alcohol to a combination of a benzodiazepine, an antidepressant, and an antipsychotic), often at a very high cost.  When seen through the eyes of a utilization reviewer, this seems unwise, expensive, and wasteful.

I agree with Dr Kruszewski, but for a slightly different reason.  To me, current treatment approaches falsely “medicalize” addiction and avoid the more significant psychological (or even spiritual) meaning of our patients’ addictive behaviors.  [See my posts “Misplaced Priorities in Addiction Treatment” and “When Does Treatment End.”]  They also cost a lot of money:  Suboxone induction, for instance, can cost hundreds of dollars, and the medication itself can cost several hundred more per month.  Likewise, the amounts being spent to develop new pharmacotherapies for cocaine and stimulant addiction are very high indeed.

Residential treatment programs—particularly the famous ones like Cirque Lodge, Sierra Tucson, and The Meadows—are also extremely expensive.  I, myself, worked for a time as a psychiatrist for a long-term residential drug and alcohol treatment program.  Even though we tried to err on the side of avoiding medications unless absolutely necessary (and virtually never discharged patients on long-term treatments like Suboxone or methadone), our services were quite costly:  upwards of $30,000 for a four-month stay, plus $5000/month for “aftercare” services.  (NB:  Since my departure, the center has closed, due in part to financial concerns.)

There are cheaper programs, like state- and county-sponsored detox centers for those with no ability to pay, as well as free or low-cost longer-term programs like the Salvation Army.  There are also programs like Phoenix House, a nonprofit network of addiction treatment programs with a variety of services—most of which are based on the “therapeutic community” approach—which are free to participants, paid for by public and private funding.

And then, of course, are the addicts who quit “cold turkey”—sometimes with little or no support at all—and those who immerse themselves in a mutual support program like Alcoholics Anonymous (AA).  AA meetings can be found almost everywhere, and they’re free.  Even though the success rate of AA is probably quite low (probably less than 10%, although official numbers don’t exist), the fact of the matter is that some people do recover completely without paying a dime.

How to explain this discrepancy?  The treatment “industry,” when challenged on this point, will argue that the success rate of AA alone is abysmal, and without adequate long-term care (usually in a group setting), relapse is likely, if not guaranteed.  This may in fact be partially true; it has been shown, for instance, that the likelihood of long-term sobriety does correlate with duration of treatment.

But at what cost?  Why should anyone pay $20,000 to $50,000 for a month at a premiere treatment center like Cirque Lodge or Promises Malibu?  Lindsay Lohan and Britney Spears can afford it, but few else—and virtually no insurance plans—can.

And the services offered by these “premiere” treatment programs sound like a spa menu, rather than a treatment protocol:  acupuncture, biofeedback, equine therapy, massage, chiropractic, art therapy, nature hikes, helicopter rides, gourmet meals or private chef services, “light and sound neurotherapy,” EMDR, craniosacral therapy, reiki training, tai chi, and many others.

Unfortunately, the evidence that any one of these services improves a patient’s chance of long-term sobriety is essentially nil.  Moreover, if addiction is purely a medical illness, then learning how to ride a horse should do absolutely nothing to help someone kick a cocaine habit.  Furthermore, medical insurance should not pay for those services (or, for that matter, for group therapy or a therapeutic-community approach).

Nevertheless, some recovering addicts may genuinely claim that they owe their sobriety to some of these experiences:  trauma recovery treatment, experiential therapy, “male bonding” activities (hat tip to the Prescott House), and yes, even the helicopter rides.

The bottom line is, we still don’t know how to treat addiction, or even what it really is in the first place.  Experts have their own ideas, and those in recovery have their own explanations.  My opinion is that, in the end, treatment must be individualized.  For every alcoholic who gets sober by attending daily AA meetings, or through religious conversion, there’s another addict who has tried and failed AA numerous times, and who must enroll in multiple programs (costing tens of thousands of dollars) to achieve remission.

What are we as a society willing to pay for?  Or should we simply maintain the free-market status quo, in which some can pay big bucks to sober up with celebrities on the beaches of Malibu, while others must detox on the bathroom floor and stagger to the AA meetings down the street?  Until we determine how best to tailor treatment to the individual, there’s no shortage of people who are willing to try just about anything to get help—and a lot of money to be made (and spent) along the way.


Cognitive Therapy in Schizophrenia: Worth Another Look

February 15, 2011

While writing my recent post on the placebo effect in schizophrenia (and while reviewing some of the comments I received on this post), I started to think about what aspects of the patients’ experience are most susceptible to change, which might account for the “placebo effect” seen in clinical studies of antipsychotics.  As one commenter correctly pointed out, the placebo effect should not be viewed as a mysterious consequence of ingesting some inert drug, but rather a reflection of the patient’s inherent ability to heal.  Unfortunately we know very little about the mechanisms involved, and we are devoting even less effort to understanding how to capitalize (no pun intended) on this process in the long-term management of psychotic disorders.

I realized, however, that I didn’t acknowledge the fact that psychotherapy does have a place in the treatment of schizophrenia.  Psychosocial treatment approaches, for instance, are routinely employed, with varying degrees of success, and some groups have used cognitive behavioral therapy techniques as well.  Cognitive therapy, in a nutshell, is based on the assumption that early experiences and social environment can give rise to “schemas” about the self, other people, and the world.  These beliefs then lead to cognitive distortions, negative styles of thinking, and misinterpretations of events in the world (or in one’s own mind).  Cognitive therapy aims to question or challenge these distortions and misinterpretations to engender a healthier, more functional view of oneself and one’s ability to master his surroundings.

At first glance, cognitive therapy seems like it would be ineffective in a psychotic patient, who may not be able to appreciate the discrepancy between his subjective experiences and objective reality.  Nevertheless, it has shown some promise, and a classic paper in this field is the 1994 article “Cognitive Behaviour Therapy of Schizophrenia” by Kingdon, Turkington, and John, in the British Journal of Psychiatry.  It is a fascinating, and eye-opening, read.

A particularly striking aspect of the paper (and keep in mind that I received my psychiatric training within the last 10 years, firmly in the atypical antipsychotic era) is that it says nothing about eliminating psychotic symptoms.  The current literature, in contrast, starts with the assumption that hallucinations, delusions, and cognitive deficits of schizophrenia are biochemical entities (which they are, of course, like any other mental phenomenon), but they are deviant and/or undesirable, and biological interventions (i.e., drugs) abolish or “correct” them.  The Kingdon article assumes that schizophrenic thought content lies on a continuum with “normal” cognition, and in fact some of the same cognitive processes are employed, albeit improperly or deficiently.  The authors claim that “abnormal beliefs” can be more or less “amenable to reason” (as with any cognitive distortion in CBT) and a key element of therapy is to “identify meaning in delusional material and then assess alternative explanations.”  In other words, it emphasizes the patient’s subjective experience, rather than the symptoms witnessed by the clinician.

Another surprising feature of the Kingdon article is its implicit acknowledgment that certain delusions or hallucinations may be entirely acceptable.  Schizophrenic patients, they claim, often do not have the ability to “meta-think”– i.e., to think about thinking– so they frequently are not aware that their unusual sensory or perceptual experiences differ from normal thought.  As a result, they cannot usually be “argued out of” a belief, even with the most skilled cognitive behavioral approach, and we must accept that they’ll find their own personal meaning for their experience.  “It may be,” the authors write, “that the reassurance of finding a meaningful explanation, however improbable, in a distressing and perplexing situation is sufficient to explain why the delusion is reached for and clung to, so energetically and with such certainty.”

Newer applications of CBT-based techniques, reviewed in an excellent 2009 article by Tai and Turkington in Schizophrenia Bulletin, have taken advantage of this viewpoint and start with the belief that “it is the individual’s personal meaning, understanding, and coping with symptoms that are the focus of treatment” – not the mere presence or absence of hallucinations or delusions.  In particular, mindfulness-based approaches, acceptance and commitment therapy (ACT), and compassionate mind training (CMT), are therapeutic techniques that involve awareness of one’s experience, acceptance of internal events, and minimization of shame and self-criticism that can arise from paranoid or persecutory thoughts, respectively.

Schizophrenia is probably not a single disease; in fact it is likely to comprise many different cognitive, developmental, physiological, and externally mediated disruptions, all of which lie on a spectrum with the “normal” state.  (The Kingdon article, in fact, goes to great lengths to point out how even non-psychotic individuals can experience “psychotic” beliefs in the form of superstitious thought, overvalued ideas, or psychosis induced by sleep deprivation or hallucinogenic drugs.)  To be sure, some psychotic symptoms in some patients will respond best to a dopamine antagonist, but it is imperative that we employ other tools at our disposal to help patients overcome them, amend them, or just accept them.  Unfortunately, too few psychiatrists in my generation have learned those tools—all we have is the antipsychotic hammer, and “schizophrenia” is the proverbial, monolithic nail.


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