If Medications Don’t Work, Why Do I Prescribe Them Anyway?

January 4, 2013

I have a confession to make.  I don’t think what I do each day makes any sense.

sense1-docPerhaps I should explain myself.  Six months ago, I started my own private psychiatry practice (one of the reasons why I haven’t posted much to this blog, but I hope to pick up the pace again!).  I made this decision after working for several years in various community clinics, county mental health systems, and three academic institutions.  I figured that an independent practice would permit me to be a more effective psychiatrist, as I wouldn’t be encumbered by the restrictions and regulations of most of today’s practice settings.

My experience has strengthened my long-held belief that people are far more complicated than diagnoses or “chemical imbalances”—something I’ve written about on this blog and with which most psychiatrists would agree.  But I’ve also made an observation that seems incompatible with one of the central dogmas of psychiatry.  To put it bluntly, I’m not sure that psychiatric medications work.

Before you jump to the conclusion that I’m just another disgruntled, anti-medication psychiatrist who thinks we’ve all been bought and misled by the pharmaceutical industry, please wait.  The issue here is, to me, a deeper one than saying that we drug people who request a pill for every ill.  In fact, it might even be a stretch to say that medications never work.  I’ve seen antidepressants, antipsychotics, mood stabilizers, and even interventions like ECT give results that are actually quite miraculous.

sense2-dahlBut here’s my concern: For the vast majority of my patients, when a medication “works,” there are numerous other potential explanations, and a simple discussion may reveal multiple other hypotheses for the clinical response.  And when you consider the fact that no two people “benefit” in quite the same way from the same drug, it becomes even harder to say what’s really going on. There’s nothing scientific about this process whatsoever.

And then, of course, there are the patients who just don’t respond at all.  This happens so frequently I sometimes wonder whether I’m practicing psychiatry wrong, or whether my patients are playing a joke on me.  But no, as far as I can tell, I’m doing things right: I prescribe appropriately, I use proper doses, and I wait long enough to see a response.  My training is up-to-date; I’ve even been invited to lecture at national conferences about psychiatric meds.  I can’t be that bad at psychiatry, can I?

Probably not.  So if I assume that I’m not a complete nitwit, and that I’m using my tools correctly, I’m left to ask a question I never thought I’d ask:  is psychopharmacology just one big charade?  **

Maybe I feel this way because I’m not necessarily looking for medications to have an effect in the first place.  I want my patients to get better, no matter what that entails.  I believe that treatment is a process, one in which the patient (not just his or her chemistry) is central.  When drugs “work,” several factors might explain why, and by the same token, when drugs don’t work, it might mean that something else needs to be treated instead—rather than simply switching to a different drug or changing the dose.  Indeed, over the course of several sessions with a patient, many details inevitably emerge:  persistent anxiety, secretive substance abuse, a history of trauma, an ongoing conflict with a spouse, or a medical illness.  These often deserve just as much attention as the initial concern, if not more.

sense3-pathophysiologyAlthough our understanding of the pathophysiology of mental illness is pure conjecture, prescribing a medication (at least at present) is an acceptable intervention.  What happens next is much more important.  I believe that prescribers should continue to collect evidence and adjust their hypotheses accordingly.  Unfortunately, most psychopharmacologists rarely take the time to discuss issues that can’t be explained by neurochemistry (even worse, they often try to explain all issues in terms of unproven neurochemistry), and dwindling appointment times mean that those who actually want to explore other causes don’t have the chance to do so.

So what’s a solution?  This may sound extreme, but maybe psychiatry should reject the “biochemical model” until it’s truly “biochemical”—i.e., until we have ways of diagnosing, treating, and following illnesses as we do in most of the rest of medicine.  In psychiatry, the use of medications and other “somatic” treatments is based on interview, gut feeling, and guesswork—not biology.  That doesn’t mean we can’t treat people, but we shouldn’t profess to offer a biological solution when we don’t know the nature of the problem.  We should admit our ignorance.

It would also help to allow (if not require) more time with psychiatric patients.  This is important.  If I only have 15-20 minutes with a patient, I don’t have time to ask about her persistent back pain, her intrusive brother-in-law, or her cocaine habit.  Instead, I must restrict my questions to those that pertain to the drug(s) I prescribed at the last visit.  This, of course, creates the perfect opportunity for confirmation bias—where I see what I expect to see.

sense4-mentalWe should also make an effort to educate doctors and patients alike about how little we actually know.  The subjects in trials to obtain FDA approval do NOT resemble real-world patients and are not evaluated or treated like real-world patients (and this is unlikely to change anytime soon because it works so well for the drug companies).  Patients should know this.  They should also know that the reliability of psychiatric diagnosis is poor in the first place, and that psychiatric illnesses have no established biochemical basis with which to guide treatment.

Finally, I should say that even though I call myself a psychiatrist and I prescribe drugs, I do not believe I’m taking advantage of my patients by doing so.  All of my patients are suffering, and they deserve treatment.  For some, drugs may play a key role in their care.  But when I see my entire profession move towards a biochemical approach—without any good evidence for such a strategy, and without a fair assessment of alternative explanations for behavior—and see, in my own practice, how medications provide no real benefit (or, frequently, harm) compared with other treatments, I have to wonder whether we’ve gone WAY beyond what psychopharmacology can truly offer, and whether there’s any way to put some logic back into what we call psychiatric treatment.

** There are areas in which psychopharmacology is most definitely not a “charade.”  These would include the uses of benzodiazepines, psychostimulants, and opioids like methadone and Suboxone.  With each of these agents, the expected effect is quite predictable, and they can be very effective drugs for many people.  Unfortunately, each of these can have an effect even in the absence of a diagnosis, and—probably not coincidentally—each has a potential for abuse.

Explain To Me Again Why Psychologists Can’t Prescribe Meds?

November 25, 2012

Consider the following two clinical scenarios:

A.  William, a 62 year-old accountant, has been feeling “depressed” since his divorce 5 years ago.  His practice, he says, is “falling apart,” as he has lost several high-profile clients and he believes it’s “too late” for his business to recover.  His adult son and daughter admire him greatly, but his ex-wife denigrates him and does everything she can to keep their children from seeing him.  William spends most of his days at his elderly parents’ house, a two-hour drive away, where he sleeps in the room (and bed) he occupied in his childhood.

William has been seeing Dr Moore every 1-2 weeks for the last 2 years.  Dr Moore has tried to support William’s ill-fated attempts to build up his practice, spend more time with his children, and engage in more productive activities, including dating and other social endeavors.  But William persistently complains that it’s “of no use,” he’ll “never meet anyone,” and his practice is “doomed to fail.”  At times, Dr Moore has feared that William may in fact attempt suicide, although to this point no attempt has been made.

B.  Claudia is a 68 year-old Medicare recipient with a history of major depression, asthma, diabetes, peripheral neuropathy, chronic renal failure, low back pain, and—for the last year—unexplained urinary incontinence.  She sees Dr Smith approximately every four weeks.  In each visit (which typically lasts about 20 minutes), Dr Smith must manage all of Claudia’s complaints and concerns, and while Dr Smith has made referrals to the appropriate medical specialists, Claudia’s condition has not improved.  In fact, Claudia now worries that she’s a “burden” on everyone else, especially her family, and “just wants to die.”  She and her daughter ask Dr Smith to “do something” to help.

Each of these scenarios is an actual case from my practice (with details changed to maintain anonymity).  Both William and Claudia are in emotional distress, and a case could be made for a trial of a psychiatric medication in each of them.

The problem, however, lies in the fact that only one of these “doctors” is a medical doctor: in this case, Dr Smith.  As a result, despite whatever experience or insight Dr Moore may have in the diagnosis of mental illness, he’s forbidden from prescribing a drug to treat it.

I recently gave a presentation to a Continuing Education program sponsored by the California School of Professional Psychology.  My audience was a group of “prescribing psychologists”—licensed psychologists who have taken over 500 hours of psychopharmacology course work in addition to the years to obtain their psychology PhDs.  By virtue of their core training, these psychologists do not see patients as “diseases” or as targets for drugs.  Although they do receive training in psychiatric diagnosis (and use the same DSM as psychiatrists), neuroanatomy, and testing/assessment, their interventions are decidedly not biological.  Most of them see psychotherapy as a primary intervention, and, more importantly, they are well versed in determining when and how medications can be introduced as a complement to the work done in therapy.  Most states, however (including my own, California) do not permit psychologists to obtain prescribing privileges, resulting in a division of labor that ultimately affects patient care.

Let’s return to the scenarios: in scenario “A,” Dr Moore could not prescribe William any medication, although he followed William through two brief antidepressant trials prescribed by William’s primary care physician (with whom, incidentally, Dr Moore never spoke).  When Dr Moore referred William to me, I was happy to see him but didn’t want to see myself as just a “prescriber.”  Thus, I had two long phone conversations with Dr Moore to hear his assessment, and decided to prescribe one of the drugs that he recommended.  William still sees both Dr Moore and me.  It’s arguably a waste of time (and money), since each visit is followed by a telephone call to Dr Moore to make sure I’m on the right track.

Claudia’s case was a very different story.  Because Claudia complained of being a “burden” and “wanting to die”—complaints also found in major depression—Dr Smith, her primary care physician, decided to prescribe an antidepressant.  He prescribed Celexa, and about one month later, when it had had no obvious effect, he gave Claudia some samples of Abilify, an antipsychotic sometimes used for augmentation of antidepressants.  (In fact, Dr Smith told Claudia to take Abilify three times daily, with the admonishment “if you want to stop crying, you need to take this Abilify three times a day, but if you stop taking it, you’ll start crying again.”)  Like it or not, this counts as “mental health care” for lots of patients.

Some would argue that the only ones qualified to prescribe medications are medical doctors.  They would claim that Dr Moore, a psychologist, might have crossed a professional boundary by “suggesting” an antidepressant for William, while Dr Smith, a physician, has the full ability to assess interactions among medications and to manage complex polypharmacy, even without consulting a psychiatrist.  In reality, however, Dr Smith’s “training” in psychotropic drugs most likely came from a drug rep (and his use of samples was a telltale sign), not from advanced training in psychopharmacology.  When one considers that the majority of psychotropic medication is prescribed by non-psychiatrists like Dr Smith, it’s fairly safe to say that much use of psychiatric drugs is motivated by drug ads, free samples, and “educational dinners” by “key opinion leaders,” and provided without much follow-up.

Furthermore, Dr Smith’s training in mental health most likely pales in comparison to that of Dr Moore.  Psychologists like Dr Moore have five or more years of postgraduate training, 3000 or more hours of clinical supervision, research experience, and have passed a national licensing exam.  But they’re forbidden from using medications that have been FDA-approved for precisely the conditions that they are extraordinarily well-equipped to evaluate, diagnose, and treat.

A satisfactory alternative would be an integrated behavioral health/primary care clinic in which professionals like Dr Moore can consult with a psychiatrist (or another “psychiatric prescriber”) to prescribe.  This arrangement has been shown to work in many settings.  It also allows for proper follow-up and limits the number of prescribers.  Indeed, pharmaceutical companies salivate at the prospect of more people with prescribing authority—it directly expands the market for their drugs—but the fact is that most of them simply don’t work as well as advertised and cause unwanted side effects.  (More about that in a future post.)

The bottom line is that there are ways of delivering mental health care in a more rational fashion, by people who know what they’re doing. As it currently stands, however, anyone with an MD (or DO, or NP) can prescribe a drug, even if others may possess greater experience or knowledge, or provide higher-quality care.  As an MD, I’m technically licensed to perform surgery, but trust me, you don’t want me to remove your appendix.  By the same token, overworked primary care docs whose idea of treating depression is handing out Pristiq samples every few months are probably not the best ones to treat depression in the medically ill.  But they do, and maybe it’s time for that to change.

Is James Holmes Mentally Ill? Does It Matter?

July 25, 2012

Last Saturday’s early-morning massacre at a crowded movie theater in Aurora, Colorado, stands as one of the most horrific rampages in American history.  But before anyone had any clue as to James Holmes’ motive for such a heinous act—even before the bodies had been removed from the site of the carnage—websites and social media were abuzz with suspicions that the gunman was either mentally ill, or was under the effect of psychotropic medications—one (or both) of which may have contributed to his crime.

As of this writing, any statement about Holmes’ psychiatric history is pure conjecture (although as I post this, I see a Fox News report claiming that Holmes mailed a notebook to “a psychiatrist” detailing his plan—more will surely be revealed).  Acquaintances quoted in the media have described him as a shy person, but have reported no erratic or unusual behaviors to arouse suspicion of an underlying mental illness.  Until recently, he was even enrolled in a graduate neuroscience program.  Some reports suggest that Holmes had spent weeks engineering an elaborate and complex scheme, hinting at some highly organized—albeit deadly—motive.  Nevertheless, the fact remains that we simply don’t know about any diagnosis, medication, or other psychiatric condition or treatment, which might shed light on Holmes’ frame of mind.

Those who focus on Holmes’ mental state at the time of the murders seem to fall in one of two camps.  Some argue that medications (if he were under the influence of any) may have enabled or facilitated this horrific act.  Others say that if Holmes had been diagnosed with a psychiatric illness, then this catastrophe serves as proof that we need more aggressive treatment—including medications—and services for the mentally ill.

It will be some time before we get answers in Holmes’ case.  And to me, that’s just as well.  Determining whether he has a mental illness, or was under the influence of psychotropic drugs last weekend, unfortunately reframes the question in such a way that further propagates the rift between these two factions, and fails to address how we should handle future cases like Holmes’ more humanely.  If, for example, Holmes is found to suffer from untreated schizophrenia, our society’s (and profession’s) reaction will be to lobby for more aggressive treatment, greater access to medication, more widespread screening programs, and, perhaps, a lower threshold by which to hospitalize psychotic individuals we deem as potentially “dangerous to others.”  If, on the other hand, a toxicology report reveals that Holmes had an antidepressant or antipsychotic in his bloodstream at the time of the murders, our inclination will be to restrict our use of these drugs, remove them from our formularies, and the outcries against psychopharmacology will grow ever louder.

Whether Holmes has a mental illness or not is irrelevant.  He was in crisis—probably for quite some time before last weekend—and that‘s what matters.  There was no one—and no way—to reach out to him and meet his needs in such a way to prevent this tragedy, and that, in my opinion, transcends whether he is “mentally ill” or not.

How can we fix this?  In his column in Monday’s New York Times, David Brooks almost provides a solution.  He writes, correctly, that prevention of such catastrophic events occurs through “relationships”—relatives or neighbors, for instance, who might recognize a change in someone’s behavior and encourage him to get help.  Admittedly, establishing a caring relationship with someone who suffers a history of trauma, grief over a recent loss, poor self-esteem, pathological narcissism, or acute psychosis may be difficult.  But relatives and neighbors are indeed often the first to notice questionable behavior and are well positioned to help those in need.  Perhaps in Holmes’ case, too, we’ll soon learn of some classmates or coworkers who felt something was amiss.

Brooks goes on to argue that it’s the responsibility of that neighbor or relative to “[get] that person treatment before the barbarism takes control.”  He doesn’t define what sort of “treatment” he has in mind.  But he does say that killers are “the product of psychological derangements, not sociological ones,” so the aggressive treatment options he endorses presumably include more aggressive psychological (or psychiatric) treatment.  But to expect a neighbor or relative to help an individual access treatment is precisely a sociological phenomenon.  It puts the onus on our culture at large to pay attention to how our neighbors think and act, and to offer a helping hand or a safe environment (or a locked psychiatric unit, if it has progressed that far) to those of us who think and behave differently or who are suffering a crisis.

That, unfortunately, is not what Brooks is arguing for.  (After all, the title of his essay is “More Treatment Programs.”)  If mass murderers suffer from psychological problems, which is what Brooks seems to believe, the solution “has to start with psychiatry.”  But this introduces the longstanding problem of defining that arbitrary border between “normal” and “abnormal”—a virtually impossible task.  And, of course, once we pathologize the “abnormal,” we’re then obligated to provide treatments (antipsychotic medication, involuntary hospitalization, assisted outpatient treatment, forced drugging) which, yes, might decrease the likelihood of further dangerousness, but which also compromise patients’ civil rights and do not always enable them to recover.

Brooks is right on one point.  Relationships are part of the answer.  Relationships can provide compassion and support in one’s most difficult times.  One take-home message from the Aurora tragedy should be that people like Holmes—regardless of whatever he is even “mentally ill” at all—need the security and comfort of safe, trustworthy individuals who are looking out for his (and society’s) best interests and who can intervene at a much earlier stage and in a much less aggressive way, perhaps even avoiding conventional psychiatric treatment altogether.

Getting to that point, unfortunately, requires a sea change in how we deal more compassionately with those in our society who are different from the rest of us—a change that our nation may be unwilling, or unable, to make.  If we fail to make it, we’ll be stuck with the never-ending debate over the validity of psychiatric diagnoses, the effectiveness of psychiatric drugs, the ethics of forced treatment, and the dilemma of defining when antisocial behavior becomes a “disease.”  In the meantime, troubled souls like James Holmes will continue to haunt us, left to their own devious plans until psychiatric treatment—or worse—is the only available option.

Yes, We Still Need Psychiatrists, But For What?

April 15, 2012

If anyone’s looking for a brief primer on the popular perception of psychiatry and the animosity felt by those who feel hurt or scarred by this (my) profession, a good place to start would be a recent post by Steven Moffic entitled “Why We Still Need Psychiatrists!” on Robert Whitaker’s site, Mad In America.

Moffic, a psychiatrist at the Medical College of Wisconsin, is a published author, a regular contributor to Psychiatric Times, and a member of the Group for the Advancement of Psychiatry.  Whitaker is a journalist best known for his books Mad in America and Anatomy of an Epidemic, both of which have challenged modern psychiatric practice.

Moffic’s thesis is that we still “need” psychiatrists, particularly to help engineer necessary changes in the delivery of psychiatric care (for example, integration of psychiatry into primary care, incorporating therapeutic communities and other psychosocial treatments into the psychiatric mainstream, etc).  He argues that we are the best to do so by virtue of our extensive training, our knowledge of the brain, and our “dedication to the patient.”

The reaction by readers was, predictably, swift and furious.  While Whitaker’s readers are not exactly a representative sample (one reader, for example, commented that “the search for a good psychiatrist can begin in the obituary column” – a comment which was later deleted by Mr Whitaker), their comments—and Moffic’s responses—reinforce the idea that, despite our best intentions, psychiatrists are still not on the same page as many of the people we intend to serve.

As I read the comments, I find myself sympathetic to many of Moffic’s critics.  There’s still a lot we don’t know about mental illness, and much of what we do might legitimately be called “pseudoscience.”  However, I am also keenly aware of one uncomfortable fact:  For every patient who argues that psychiatric diagnoses are fallacies and that medications “harm” or “kill” people, there are dozens—if not hundreds—of others who not only disagree, but who INSIST that they DO have these disorders and who don’t just accept but REQUEST drug treatment.

For instance, consider this response to Moffic’s post:

Stop chemically lobotomizing adults, teens, children, and infants for your imaginary psychiatric ‘brain diseases.’  Stop spreading lies to the world about these ‘chronic’ (fake) brain illnesses, telling people they can only hope to manage them with ‘appropriate’ (as defined by you and yours) ‘treatments,’ so that they are made to falsely believe in non-existent illnesses and deficiencies that would have them ‘disabled’ for a lifetime and too demoralized about it to give a damn.

I don’t know how Moffic would respond to such criticism.  If he’s like most psychiatrists I know, he may just shrug it off as a “fringe” argument.  But that’s a dangerous move, because despite the commenter’s tone, his/her arguments are worthy of scientific investigation.

Let’s assume this commenter’s points are entirely correct.  That still doesn’t change the fact that lots of people have already “bought in” to the psychiatric model.  In my practice, I routinely see patients who want to believe that they have a “brain disease.”  They ask me for the “appropriate treatment”—often a specific medication they’ve seen on TV, or have taken from a friend, and don’t want to hear about the side effects or how it’s not indicated for their condition.  (It takes more energy to say “no” than to say “yes.”)  They often appreciate the fact that there’s a “chemical deficiency” or “imbalance” to explain their behavior or their moods.  (Incidentally, family members, the criminal justice system, and countless social service agencies also appreciate this “explanation.”)  Finally, as I’ve written about before, many patients don’t see “disability” as such a bad thing; in fact, they actively pursue itsometimes even demanding this label—despite my attempts to convince them otherwise.

In short, I agree with many of the critics on Whitaker’s site—and Whitaker himself—that psychiatry has far overstepped its bounds and has mislabeled and mistreated countless people.  (I can’t tell you how many times I’ve been asked to prescribe a drug for which I think to myself “what in the world is this going to do????”)  But the critics fail to realize is that this “delusion” of psychiatry is not just in psychiatrists’ minds.  It’s part of society.  Families, the legal system, Social Security, Medicaid/Medicare, Big Pharma, Madison Avenue, insurance companies, and employers of psychiatrists (and, increasingly, non-psychiatrists) like me—all of them see psychiatry the same way:  as a way to label and “pathologize” behaviors that are, oftentimes, only slight variants of “normal” (whatever that is) and seek to “treat” them, usually with chemicals.

Any attempt to challenge this status quo (this “shared delusion,” as I wrote in my response to Moffic’s post) is met with resistance, as illustrated by the case of Loren Mosher, whom Moffic discusses briefly.  The influence of the APA and drug companies on popular thought—not to mention legislation and allocation of health-care resources—is far more deeply entrenched than most people realize.

But the good thing is that Moffic’s arguments for why we need psychiatrists can just as easily be used as arguments for why psychiatrists are uniquely positioned to change this state of affairs.  Only psychiatrists—with their years of scientific education—can dig through the muck (as one commenter wrote, “to find nuggets in the sewage”) and appropriately evaluate the medical literature.  Psychiatrists should have a commanding knowledge of the evidence for all sorts of treatments (not just “biological” ones, even though one commenter lamented that she knew more about meds than her psychiatrist!) and argue for their inclusion and reimbursement in the services we provide.

Psychiatrists can (or should) also have the communication skills to explain to patients how they can overcome “illnesses” or, indeed, to educate them that their complaints are not even “illnesses” in the first place.  Finally, psychiatrists should command the requisite authority and respect amongst policymakers to challenge the broken “disability” system, a system which, I agree, does make people “too demoralized to give a damn.”

This is an uphill battle.  It’s particularly difficult when psychiatrists tenaciously hold on to a status quo which, unfortunately, is also foisted upon them by their employers.  (And I fear that Obamacare, should it come to pass, is only going to intensify the overdiagnosis and ultrarapid biological management of patients—more likely by providers with even less education than the psychiatrist).  But it’s a battle we must fight, not just for the sake of our jobs, but—as Whitaker’s readers emphasize—for the long-term well-being of millions of patients, and, quite possibly, for the well-being of our society as a whole.

The Second Law of Thermodynamics and The “Med Check”

February 12, 2012

On one of my recent posts, a psychiatrist made a very thought-provoking comment.  He/she wrote that they interviewed at a clinic where the psychiatrist saw 20 patients per day and made well over $300,000 per year.  At a different clinic the psychiatrists saw many fewer patients (and, of course, made less money) but, the commenter opined, the patients probably received much better care.

This problem of “med checks” serving as the psychiatrist’s bread-and-butter has been discussed ad nauseum, particularly since the infamous New York Times “Talk Doesn’t Pay” article (see my comments here and here).  It’s almost universally accepted that this style of practice is cold, impersonal, sometimes reckless, and often focuses on symptoms and medications rather than people.  I would add that this approach also makes patient care more disorderly and confusing.  Moreover, minimizing this confusion would require more time and energy than most psychiatric practices currently allow.

I work part-time in one setting where the 15-20 minute “med check” is the standard of care.  Because my own personal strategy is to minimize medication usage in general, I’ve been able to use this time, with most patients, to discuss lifestyle changes or offer brief supportive therapy, keeping the lid (hopefully) on irresponsible prescribing.  However, I frequently get patients who have been seen by other docs, or from other clinics, who come to me with complicated medication regimens or questionable diagnoses, and who almost universally complain that “my last doctor never talked to me, he just pushed drugs,” or “he just kept prescribing medication but never told me what they were for,” or “I had a side effect from one drug so he just added another one to take care of it,” or some combination of the above.

These patients present an interesting dilemma.  On the one hand, they are usually extraordinarily fascinating, often presenting tough diagnostic challenges or complicated biological conundrums that test my knowledge of psychopharmacology.  On the other hand, a 15- or 20-minute “med check” appointment offers me little time or flexibility to do the work necessary to improve their care.

Consider one patient I saw recently.  She’s in her mid-20s and carries diagnoses of “bipolar II” (more about that diagnosis in a future post, if I have the guts to write it) and Asperger syndrome.  She is intelligent, creative, and has a part-time job in an art studio.  She has a boyfriend and a (very) involved mother, but few other social contacts.  She was hospitalized once in her teens for suicidal ideation.  Her major struggles revolve around her limited social life and the associated anxiety.  She’s also on six psychiatric medications: two antipsychotics, two mood stabilizers, a benzodiazepine, and a PRN sleep agent (and an oral contraceptive, whose efficacy is probably inhibited by one of her mood stabilizers—something that she says she was never warned about), and complains of a handful of mild physical symptoms that are most likely medication side effects.  She (and her mother) told me that her last two doctors “never took the time” to answer their questions or engage in discussion, instead “they just gave me drugs and kept asking me to come back in three months.”

What to do with such an individual?  My first wish would be to discontinue all medications, assess her baseline, help to redefine her treatment goals, and identify tools to achieve them.  But remember, I only have 20 minutes.  Even the simplest of maneuvers—e.g., start a gradual taper of one of her medications—would require a detailed explanation of what to expect and how to deal with any difficulties that might arise.  And if I can’t see her for another 2-3 months—or if I have only 13 annual visits with her, as is the case in my Medicaid practice—then this option becomes far more difficult.

As a result, it’s easier to add stuff than to take it away.  It brings to mind the second law of thermodynamics in physics, which (very loosely) says that a system will always develop greater disorder (or randomness, or “entropy”) unless work is done on that system.  Stated from a clinical point of view:  unless we invest more time and energy in our patients, their care will become more scattered, disorganized, and chaotic.

Some of that time and energy can come from a dedicated physician (which will, of course, require the additional investment of money in the form of greater out-of-pocket cost).  Other times, it can come from the patient him- or herself; there are an impressive—and growing—number of websites and books dedicated to helping patients understand their mental illness and what to expect from specific medications or from their discontinuation (for instance, here’s one to which I’ve referred several patients), often written by patients or ex-patients themselves.  But without some external input, I’m afraid the current status quo sets many patients adrift with little or no guidance, direction, or hope.

It’s disheartening to think that psychiatric care has a tendency to make patients’ lives more disorganized and unstable, particularly when most of us entered this field to do the exact opposite.  It’s also discouraging to know that for those patients who do benefit from mental health care, it’s often in spite of, not because of, the psychiatrist’s involvement (something I’ve written about here).  But if our training programs, health care system, and large financial interests like the pharmaceutical companies—not to mention the increasingly narrow expertise of today’s psychiatrists—continue to drive psychiatric care into brief med-management appointments (which, BTW, I find insulting to call “psychiatry,” but that’s an argument for another time), then we must also prepare for the explosion in diagnoses, the overprescription of largely useless (and often damaging) drugs, skyrocketing rates of psychiatric “disability,” and the bastardization that currently passes as psychiatric care.

When “Adherence” Is A Dirty Word

January 16, 2012

Recently, I’ve been spending a lot of time reading the literature on “recovery” from mental illness.  Along the way, I’ve been introduced to the writings of Richard Warner and William Anthony, and peer-leaders in the field like Daniel Fisher and Pat Deegan.  Coincidentally, I also learned recently that my local county mental health system will start training patients and providers in Wellness Recovery Action Planning (“WRAP”), a peer-led illness self-management program which promotes autonomy and recovery.

In the interest of “evidence-based medicine,” the developers of WRAP have performed actual controlled trials of this intervention, comparing it to conventional mental health treatment.  In several studies, they have found that patients engaged in a WRAP program are typically more hopeful, more engaged in their recovery, and—quite surprisingly—have fewer psychiatric symptoms than those who are not.

One such paper was published just last month (pdf here).  The investigators showed that WRAP participants in public clinics throughout Ohio were more engaged in “self-advocacy” than patients who were not involved in WRAP, and that this led to improvements in quality of life and—consistent with their earlier studies—a reduction in psychiatric symptoms.  Their measure of “self-advocacy” was the Patient Self-Advocacy Scale (PSAS), “an instrument designed to measure a person’s propensity to engage in self-activism during health care encounters.”

Throughout the intervention, WRAP patients had a consistently higher PSAS score than others.  But their scores were particularly elevated in one subscale: “Mindful Non-Adherence.”

Non-adherence?  I must confess, I did a double-take.  If my years of training in modern psychiatry have taught me one thing, it is that adherence is a primary (yet elusive) goal in patients with serious mental illness.  In fact, the high rate of non-adherence has become the biggest sales pitch for new long-acting injectable antipsychotics like Invega Sustenna.

And now a paper is showing that non-adherence—i.e., the active refusal of medications or other suggestions from one’s doctor—is a good thing.  Really?

Intrigued, I looked more closely at the PSAS scale.  It was developed in 1999 by Dale Brashers of the communications department at the University of Illinois.  The scale was designed not to be a clinical tool, but rather a measure of how people manage interactions with their health care providers.  Their initial studies focused on patients in the HIV-AIDS community (e.g., in organizations like ACT UP) and health care communication patterns among patients who describe themselves as “activists.”

The PSAS scale includes three dimensions:  illness education, assertiveness, and “potential for mindful non-adherence.”  The first two are fairly self-explanatory.  But the third one is defined as “a tendency to reject treatments” or “a willingness to be nonadherent when treatments fail to meet the patient’s expectations.”  Four questions on the PSAS survey assess this potential, including #10: “Sometimes I think I have a better grasp of what I need than my doctor does” and #12: “I don’t always do what my physician or health care worker has asked me to do.”

In the WRAP study published last month, greater agreement with these questions—i.e., greater willingness to be nonadherent—resulted in a greater PSAS score.  I should point out that in a separate analysis, high non-adherence scores were not associated with better clinical outcomes, but education and assertiveness (and overall PSAS scores) were.  Nevertheless, when data suggest that patients might benefit from the active “defiance” of doctors’ orders, we physicians should take this seriously.

We can start by helping patients make reasoned treatment decisions.  The term “mindful non-adherence” implies that the patient knows something valuable, and that he or she is willing to act on this knowledge, against the wishes of the physician.  Few providers would admit that the patient has greater knowledge than the “expert” clinician.  After all, that’s why most of us engage in psychoeducation: to inform, enable, and empower our patients.

However, maybe the matters on which we “educate” our patients are ultimately irrelevant.  Maybe patients don’t want (or need) to know which parts of their brains are affected in psychosis, ADHD, or OCD, or how dopamine blockade reduces hallucinations; they just want strategies to alleviate their suffering.  The same may hold true for other areas of medicine, too.  As discussed in a recent article in the online Harvard Business Review, serious problems may arise when too much information is unloaded on patients without the guidance of a professional or, better yet, a peer who has “been there.”

Mental health care may provide the perfect arena in which to test the hypothesis that patients, when given enough information, know what’s best for themselves in the long run.  In a field where one’s own experience is really all that matters, maybe a return to patient-centered decision-making—what Pat Deegan calls the “dignity of risk” and the “right to failure”—is necessary.  At the very least, we physicians should get comfortable with the fact that, sometimes, a patient saying “no” may be the best prescription possible.

“Explanation” vs. “Exploration” in Mental Illness

January 11, 2012

A quickie post here today:  I invite you all to go check out my most recent contribution to the “Couch in Crisis” blog at Psychiatric Times online, entitled “Symptoms and What They Mean.”


Free registration at Psychiatric Times is required.  Cheers!

Two New Ways To Get Sued

January 6, 2012

The last week hasn’t been a very uplifting one for psychiatrists who pay attention to the news.  For as much as we complain about shrinking reimbursements, the undue influence of Big Pharma, and government meddling in our therapeutic work, we psychiatrists now have two new reasons to be concerned.

And, maybe, to lawyer up.

I. APA Threatens Blogger

Most readers who follow this blog will certainly have seen this story already, after first being reported in Allen Frances’ Psychology Today blog.  So I know I’m just preaching to the choir here, but frankly, in my opinion, this story cannot receive too much attention.

As you probably know, American Psychiatric Publishing, a branch of the APA, threatened to sue a British blogger, Suzy Chapman, for her blog “dsm5watch.”  They argued that the use of “dsm5” in her blog title constituted trademark infringement.  She has moved her content to “dxrevisionwatch” and describes her reasons for doing so here.

I had been following the “dsm5watch” blog since February 2011 via my RSS feed, and have linked to its content in some of my posts.  It was first launched way back in December 2009.  I thought it was a fair, balanced way for readers to keep abreast of the DSM-5 development process (for a while, I actually thought it was published by the APA!!).  Granted, many of the posts were about CFS/ME (chronic fatigue syndrome/myalgic encephalomyelitis), and the blog often mentioned the DSM-5 controversy, but nothing that hadn’t been published anywhere else.

In my humble opinion, shutting it down was simply a misguided, heavy-handed move by the APA.  Why “misguided”?  As psychotherapist and author Gary Greenberg wrote in his blog Thursday, “the APA is a corporation that, like any other, will do anything to protect itself from harm…. And it spends a lot of time imagining dangers.”

Suzy Chapman, congratulations, you are the “bad object” of the APA’s paranoid projection.

This entire fiasco has the potential to become a huge embarrassment to the field of psychiatry.  I guess I can understand why the APA might wish to protect its intellectual property, but the idea of “picking on the little guy”—especially when the “little guy” is simply keeping readers informed about developments in our field of (supposedly) intellectual, scientific endeavor—makes me ashamed to think that these men and women speak for me.

II. Patients Sue Doctors for Creating “Valium Addicts”

This article, too, has made the rounds on several blogs and news sites, and while it was published in a UK tabloid well-known for several anti-medication stories in the past, I think the message it sends is an important one.

Benzodiazepines, or “benzos” (which include Valium, Xanax, Klonopin, and Ativan), are some of the most widely prescribed drugs in the US and Great Britain, and among the most addictive.  Tolerance to the anxiolytic effects of benzos develops very rapidly, so people often request higher doses; but overdose can be deadly due to respiratory depression, and the withdrawal syndrome—which can include seizures and delirium—can also be life-threatening.

Benzos have been popular since the 1960s.  They replaced the barbiturates, made popular by the Rolling Stones as “Mother’s Little Helpers” back in 1966.  Their rapid onset and calming effect—much like that of alcohol—and their ability to potentiate the effects of other drugs, like opiates, often leads to use, abuse, and addiction.

[Not to get too tangential here, but last week’s episode of “Real Housewives of Beverly Hills” (hey, it’s one of my wife’s favorite shows, and we have only one TV) featured Brandi in a Xanax-and-alcohol-fueled daze, enjoying a mai tai with her girlfriends at a Lanai resort.  Oh, and she had trouble keeping her right nipple in her cocktail dress.  Is it any wonder why people request benzos by name???]

Anyway, to get back on track:  Benzos are effective drugs.  And their utility and versatility—not to mention their street value—gives them a cachet that’s hard to exaggerate.   More importantly, the potential dangers, which are compounded in patients with a high tolerance, mean that they really should be prescribed for very short intervals, if at all.

But the responsible use of benzos requires effort on behalf of the prescriber.  It takes time to explain to the patient the risks of tolerance and withdrawal.  It also takes time to teach other methods of managing anxiety.  Doctors (and, increasingly, patients) just don’t have that kind of time—or don’t want to find it.  Moreover, they (we) find it difficult to say “no” to patients when they describe something working so well.

Hence, it’s not uncommon for doctors to see patients taking 4 mg of Xanax or 8 mg of Klonopin daily, and still complaining of anxiety or restlessness or “jitteriness” and asking for more.  Patients on these regimens rarely want to stop them (even when told of the long-term dangers), and when they do, the withdrawal process is not one to be taken lightly.  (The Ashton Manualavailable online—is the authoritative resource for managing benzo withdrawal.)

Do I believe it’s fair to sue doctors who turn their patients into “benzo addicts”?  That’s a difficult question, particularly because of the tricky nature of the word “addict.”  If we instead talk about making patients physically dependent on benzos, then the question can be reframed as:  Should we blame doctors for creating a physiological state in a patient which has the potential to be life-threatening if not managed properly?

Before answering “Hell yes!” it must be understood that just about everything we do in psychopharmacology (if not all of medicine) “has the potential to be life-threatening if not managed properly.”  The real issue is, how likely is an adverse outcome, and how well does the doctor manage it?  Of course, there’s also the question about whether the patient bears any responsibility in the overuse or abuse of the drug.  But even if a patient knowingly takes more than what is recommended and the doctor knows this, it is the doctor’s responsibility to respond accordingly.

In my book, there’s no excuse for the indiscriminate prescribing of benzodiazepines.  There’s also no excuse for abruptly discharging a heavy benzo user from one’s practice, or “dumping” him on a public clinic or detox facility.  (Trust me, this happens A LOT.)  Whether a doc should be sued for this is not my area of expertise.  However, I think it is good that attention is being drawn to what is, in the end, just bad medicine.  Hopefully the systems in place that foster this sort of care—inadequate medical education, poor reimbursement for therapy, emphasis on medication management, and arbitrary insurance-company regulations that limit access to more effective treatment—can be changed soon.

But I’m not holding my breath.  I’m calling my attorney.

Biomarker Envy VI: Therapygenetics

January 4, 2012

I enjoy learning about new developments in psychiatry just as much as the next guy.  In particular, developments that promise to make treatment more effective or “individualized.”  So I was intrigued by the title of a recent paper in Molecular Psychiatry, which seemed to herald the rise of a new use for genetic testing.  But not for a biological therapy.  No, this new use for genotyping is to predict which type of psychotherapy is best for a patient.

It even has a snappy new name:  “therapygenetics.”  The term was minted by Thalia Eley and her colleagues at Kings College London, authors of the study.  Basically, the study suggests that variation in a particular gene sequence might predict patients’ responses to a psychotherapeutic intervention.  And according to a recent editorial (pdf here) in Trends in Cognitive Sciences, this might be the first step in a new era of “personalized psychotherapy.”

Personalized psychotherapy?”  A colleague of mine happened to see the editorial on my desk.  After looking at that phrase for a moment, puzzled, he asked, “Isn’t psychotherapy personalized already?”  Good question.  After all, psychotherapy is the quintessential personalized medicine, isn’t it?  Haven’t we been criticizing “biomarker” studies because they try to personalize treatment by measuring chemicals in the blood, scanning people’s brains, and doing genetic tests?  Basically everything except talk to the person???

Not so fast.  Before long, your psychotherapist might ask you for a cheek swab or blood sample on your first visit.  And who knows—you just might thank him for it.

In this prospective, observational study, Eley’s group studied 359 children in the UK and Australia who enrolled in a cognitive behavior therapy clinic for treatment of an anxiety disorder.  Before starting therapy, the children underwent genomic testing, specifically for the genotype of the 5-HTTLPR, the promoter region of the serotonin transporter gene.  They found that children with SS genotype (i.e., two copies of the “S” allele) were more likely to respond to cognitive behavior therapy (CBT) than the other children.  It wasn’t an absolute benefit, but the data looked pretty good, particularly after six months of follow-up:

The above results may be reminiscent of some earlier work.  The 5-HTTLPR has become the “workhorse” of psychiatric pharmacogenetics, ever since the publication by Caspi in 2003 (pdf here) that the SS genotype predisposes people to depression if they also experience stressful life events.  That result was challenged in 2009, however, by larger studies showing no effect.  Then, this result was overturned again by an even larger analysis (pdf here) showing that, indeed, the S allele might in fact mediate the stress-depression relationship.  Confused yet?  I agree, it’s enough to make one’s head spin.  Or, at least, to make us conclude that we don’t really know whether it makes people more susceptible to depression.

But maybe Eley’s finding can lead us in a slightly different direction.  Maybe the 5-HTTLPR genotype may make one more responsive to treatment.  Maybe the S allele makes a person not just more sensitive to stressful life events (and therefore more likely to become depressed or anxious), but also more able to overcome them through therapy?

It’s an intriguing suggestion, but easy to dismiss.  After all, who’s to say that another group won’t overturn this result and lead us right back to square one?  And does this mean that we should test all our patients before subjecting them to CBT?  Who’s going to do that?  (And pay for it?)

Personally, I don’t believe Eley’s paper should be casually tossed aside.  First of all, anything that improves patient outcomes (yes, even pharmacogenetics) deserves study.  And while it’s probably premature to use genetic tests to assign people to psychotherapy interventions, it is encouraging to see this work.  Specifically, this is a first attempt to take an endophenotype and use it to enhance treatment response.

An endophenotype is a heritable feature—biochemical, anatomical, psychological—that is simpler than a “diagnosis” like a depression or anxiety disorder, but which can be readily observed and measured.  (See excellent review here.)  In this case, the S allele of 5-HTTLPR might bias one’s attention toward emotional stimuli, an endophenotype that has been found in other research.  (Note: in a previous naturalistic study of bulimic patients, the S allele was correlated with greater novelty seeking and insecure attachment.)  If such an endophenotype can be found in other subgroups of depressed and anxious patients, then it makes sense that we might be able to employ treatment strategies that exploit this psychological feature.

This is purely theoretical, of course, but the beauty is that this theory is entirely testable, and the Eley paper is the first attempt to do so in a non-pharmacological setting.  Behavioral and psychological endophenotypes offer a perfect opportunity to test the efficacy of psychosocial approaches, which, by definition, target patients’ behavior and psychology.  Biological phenotypes can also be tested (e.g., with different pharmacological interventions), but there are always several steps between a change in biology and a person’s subjective report of effect—this is the bane of psychiatry.

In other words, using psychobehavioral endophenotypes to enhance treatment offers face validity.  It just makes sense to both the clinician and patient.  Most patients would willingly submit to a genetic test (or, for that matter, a battery of psychological tests — maybe a “psychomarker” is on the horizon?) to match them with a psychotherapeutic treatment.  However, using a CYP450 genotype, or brain scan, or quantitative EEG, to predict which drug is best for them, just seems, well, weird.

In conclusion, I’ll quote a passage from the Trends in Cognitive Sciences editorial:  “Genetic variation can (and should) be incorporated into psychosocial treatment research…. Doing so promises to deliver a fuller, more nuanced understanding of psychopathology which, in turn, could enhance the ability to tailor treatments to individuals based on genetic profile, increase the effectiveness of psychosocial treatments, and ultimately alleviate substantial suffering associated with psychiatric illness.”

Hopefully, this will turn out to be true.  It seems like the best way to harness the inevitable (and money-driven) push toward genotyping, but to use such data in a way that maximizes patient response, rather than simply make our treatment more automated and algorithmic (the psychiatric industry’s version of “personalized”) than it seems to be headed right now.

Is the Criticism of DSM-5 Misguided?

December 15, 2011

In 2013, the American Psychiatric Association will publish the DSM-5, the next edition of its diagnostic manual.  Public reaction has, thus far, not been favorable.  Critics decry the lowering of diagnostic thresholds in existing criteria; the conception of new diagnoses seemingly “out of thin air”; the radical overhaul of entire sections (like the personality disorders); and the secrecy under which many of the earlier planning stages were held.

Much of the criticism, including that from its most vocal critic, Allen Frances (lead author of the current edition, the DSM-IV), laments the expansion of diagnostic criteria.  They argue that this may increase the number of “mentally ill” individuals and/or pathologize “normal” behavior, and lead to the possibility that thousands—if not millions—of new patients will be exposed to medications which may cause more harm than good.

The American Psychological Association, the British Psychological Society, and the American Counseling Association have expressed their opposition publicly.  An online petition from the Society for Humanistic Psychology (part of the APA) has garnered nearly 9,000 signatures in fewer than 60 days.

I understand and sympathize with the critics, particularly against the DSM‘s emphasis on “user acceptability” over validity (and, in the interest of full disclosure, I did sign the petition).  But I wonder whether the greater outcry against the DSM-5 is somewhat misdirected. The DSM-5 may very well turn out to be a highly flawed document, but that’s all it will be: a document.  Whether it results in the “overdrugging and overdiagnosing” predicted by critics like Frances is not the primary responsibility of its authors, but of those who will use the book.  And this is where the outrage should be directed.

First of all, let’s just state the obvious:  it is impossible to write a comprehensive, scientifically valid catalog of all mental illnesses (particularly when some argue convincingly that mental illness is itself a false concept).  When we’re talking about conditions that have both biological and sociocultural origins (in fact, this has long been part of the distinction between “neurologic” and “psychiatric” disease), it seems clear that a diagnostic manual will never capture the full spectrum of psychiatric disorders.  Even if we included semi-accurate biological markers in the diagnostic criteria—a Holy Grail we’re far from attaining—mental illness will always, in the end, depend primarily upon the patient’s subjective experience.

Thus, the DSM-5, like all DSM’s before it, will be, almost by definition, incomplete or deficient.  It will be a descriptive tool, a taxonomy, a guidebook, featuring the authors’ best guess as to what might constitute a treatable condition.  For example, in real life there is no one thing called “major depressive disorder” as it appears in the DSM-IV (in fact, there are 1,497 variations).  Nonetheless, we use “MDD” to label all of our patients with these combinations of symptoms, because it’s the best fit.  But a good mental health professional doesn’t treat MDD, he or she treats the person with MDD.  Calling it “MDD” is only necessary for insurance billing, for drug companies to get FDA approval for new pharmaceuticals, and for patients and docs to give a name to (and, if necessary, demystify) their condition.

In other words, the danger lies not in the label, but in how we use it.  In fact, one might even argue that a lousy label—or a label that is so nonspecific that it applies to a broad swath of the population, including some in the “normal” part of the spectrum (wherever that may be)—may actually be beneficial, because it will be so meaningless that it will require the clinician to think more deeply about what that label is trying to convey.

As an example, consider “chronic pain,” a label frequently applied to patients and written in their charts.  (Even though it’s often written as a diagnosis, it is really a symptom.)  “Chronic pain” simply implies that the patient experiences pain.  Nothing more.  It says nothing about the origin of the pain, what exacerbates or soothes it, how long the patient has experienced it, or whether it responds to NSAIDs, opioids, acupuncture, yoga, or rest.  When a new patient complains of “chronic pain” to a good pain specialist, the doctor doesn’t just write a script; he or she performs an examination, obtains a detailed history and collateral information, and treats in a manner that relieves discomfort yet minimizes side effects (and cost) to the patient.

Perhaps this is what we can do in psychiatry, even with the reviled new DSM-5 diagnoses like “Attenuated Psychosis Syndrome” or “Disruptive Mood Dysregulation Disorder.”  Each of these new “diagnoses” suggests something about the patient and his or her behavior or experience.  But neither one should predict a course of treatment.  In fact, a vague diagnosis should actually prompt the doctor to probe more deeply into a patient’s symptoms and determine their impact on the patient’s well-being and functional status (which may actually help improve disability evaluations, too).  On a population basis, the heterogeneity of patients given a diagnosis might stimulate further research (neurobiological, psychological, epidemiologic, maybe even anthropological) to determine more specific subtypes of illness.

Will the new diagnoses be “overused”?  Probably.  Will they lead to “overdrugging” of patients—the outcome that everyone fears?  I guess that’s possible.  But if so, the spotlight should be turned on those who do the overdrugging, not on the document that simply describes the symptoms.  This may turn out to be difficult: official treatment guidelines might come out with recommendations to medicate, insurance companies may require diagnoses (or medications) in order to cover psychiatric services, and drug companies might aggressively market their products for these new indications.  And there will always be doctors who cut corners, arrive at diagnoses too quickly and are eager to use dangerous medications.  But these targets, ultimately, are where the anti-DSM-5 efforts should be placed, not on its wholesale rejection.

In the end, one could argue that the DSM-5 is unnecessary, premature, and flawed.  Unfortunately, it simply reflects our understanding of mental illness at this point in time.  But is it a “dangerous public health experiment,” as Allen Frances has warned?  Only if we allow it to override our eyes and ears, our hearts and minds, and what our patients truly need and want from us.   In the end, it’s just a book.  What really matters is how we use it.

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