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.

Prove That You Need Me

December 11, 2011

I’ll confess, sometimes after I see a patient I ask myself, “was that really necessary??”  That’s not to suggest that the interaction was a complete waste of time, or that I regularly provide treatment that is excessive or harmful, but I am frequently reminded of an observation I first made many years ago:  we in psychiatry provide a lot of “care” that might be considered unnecessary and, in the long run, wasteful and inefficient.

(Note: I am specifically referring here to certain aspects of outpatient mental health treatment.  The same might occur in other medical specialties, but those aren’t my areas of expertise, so I can’t comment.  Furthermore, I am NOT referring to regular health-maintenance visits to one’s primary physician, pediatrician, or OB-GYN, in which the “care” consists of an examination and, if necessary, screening tests or preventive measures.)

Consider the following examples of wasteful, inefficient care in psychiatry.

I see many patients (particularly in the community setting) who have been “treated,” often irregularly and infrequently, by a variety of psychiatrists or other physicians who have doled out a half-dozen psychiatric diagnoses and a laundry list of medications.  When I see patients like these, their complaints are usually vague and nonspecific, adherence to past treatments has been questionable, and a substance-abuse component is often present.  While these patients may indeed suffer from mental illness (or, in many cases, simply face profound psychosocial stressors that the system allows us to call mental illness), it is unlikely that these patients will receive the resources they truly need from conventional psychiatric practice.  However, it’s convenient—for us as a society—to shunt them into the psychiatric juggernaut, where they often lose any hope for lasting recovery.

Another example is the patient living in difficult, stressful circumstances who is referred to a psychiatrist by a social service agency or by the criminal justice system “for an evaluation.”  Again, these individuals may face huge psychosocial stressors—and may indeed benefit from professional assistance of some sort—but psychiatric care?  It’s hard for a psychiatrist to say no.  Instead, we give a diagnosis, frequently an “NOS” diagnosis, which, in practice, means “he sort of looks like he might have depression or an anxiety disorder or psychosis, but we’re not sure yet.”  This may be justifiable at first, but unfortunately these diagnoses tend to stick—and, interestingly, patients are rarely undiagnosed—locking the patient into a neverending roller-coaster of medication trials and, not uncommonly, a lifetime of psychiatric “disability,” at great expense to all.

Finally, there are those individuals who see a psychiatrist at the urging of their primary doctor or a family member.  They may complain of very legitimate symptoms of irritability or mood lability, guilt or sadness over a recent loss, sleep disturbance or anxiety, or chaotic personal relationships—phenomena which we have all experienced to various degrees.  Sometimes these symptoms are incapacitating; sometimes not.  But we psychiatrists are good at making square pegs fit into round holes; through our DSM-tainted lenses, we give whatever diagnosis “fits best”—often the dreaded “NOS,” discussed above.  Furthermore, because many of us are loath to send a patient home empty-handed—and ill-prepared to do anything other than diagnose or prescribe— we give a medication which we think might “work.”  (And if it does, we see it as affirmation of our diagnosis, but that’s material for another post.)

These three situations are common in psychiatry.  I’m absolutely not saying that patients like these should be denied treatment, “shown the door,” and asked never to return.  As a mentor taught me many years ago, no one sees a psychiatrist when everything in his or her life is perfect.  But sometimes we fail to recognize that the psychiatrist may approach the patient and his or her complaints in the wrong way.

I believe that, when evaluating patients, psychiatrists should use the tools of scientific investigation:  an open mind (although we can use our past experience and intuition, as long as we search for data to support it, too), deep interest and curiosity, a systematic method of analysis, and, most importantly, the lack of bias or predetermined outcome.  A significant aspect of this “data collection” is an accurate assessment of the patient’s resources and ability to overcome his symptoms; if his resources can be augmented by psychotherapeutic intervention or by medication, fine, but if not (or if an accurate assessment of his strengths shows that such intervention is unnecessary), then we must have the willingness to say no and back out.

Let me emphasize once again, I am NOT saying that we should be skeptical of patients, or ignore their complaints.  But we need to acknowledge we are predisposed (as a result of our training, the nonspecificity of the DSM-IV, and the current treatment paradigm in psychiatry) to see “mental illness” where it may not exist, and prescribe drugs in response.  As a result, patients sometimes feel that their complaints “aren’t heard” or are “misunderstood.”  Alternatively (and worse, in my opinion), some patients may actually buy into the diagnosis (when in fact it may just be a figment of the doctor’s—or the APA’s—imagination) and use it as an excuse or a rationale for not taking other measures to engage in lifestyle change.  To provide truly compassionate and patient-centered care, we must act differently.

I know some psychiatrists will respond, “I always see my patients with an open mind, I’m fair and honest, and I give the patient the benefit of the doubt.”  Of course, there are exceptions, but as a product of psychiatric training within the last decade, I can attest to the fact that this approach is rare.

Psychiatrists are taught to look for pathology, not health.  And as they say, “seek and ye shall find.”

A more life-affirming and empowering strategy might be for the psychiatrist to (a) first evaluate a person’s strengths and assets, (b) carefully assess the patient’s goals or desires, (c) determine what prevents him or her from achieving those goals, and, most crucially, (d) determine whether the psychiatrist has the means to help the patient achieve those goals (not necessarily to “correct a symptom” or “treat a diagnosis”).  Then and only then can treatment commence.  Otherwise, we’re spinning our wheels, misleading our patients, wasting our time, and serving no one.

We Do Not Know What We Cannot Know

December 5, 2011

Who provides the best mental health care?  I’m not referring to the relative merits of psychiatrist vs. psychologist, academic center vs. private practice, or meds vs. therapy.  No, I’m referring to the actual individuals providing the treatment, and the background that they bring to the therapeutic interaction.  We like to talk about education and degrees, publications and professional designations, but to the patient, do these really count for anything?

Why do I ask?  Readers of this blog are aware that I do some part-time work in community mental health, and while I feel that I have a good rapport with most of my patients there, they couldn’t care less about where I went to school or how many publications are on my CV.  By the same token, I cannot relate with much of what they experience in their day-to-day lives.  The symptoms they report almost surely have a very different meaning to them, than the same symptoms would to me or to someone in my family.

I also work on an inpatient psychiatric unit where, again, we doctors are on a different plane than the patients we treat.  In fact, I’ve been impressed by the degree (and duration) of peer interaction, even in these acutely ill patients, and wonder whether this may be a significantly therapeutic component of their hospital stay.  I regularly see groups of two or three patients sitting together, discussing medications, family or relationship problems, legal issues, or—as I experienced just the other day—simply singing or dancing with each other.  It seems as if patients can trust their peers far more easily than their providers, who aren’t in their shoes.

And in the addiction field, “mutual support” (12-step meetings or other group therapy), in which the “therapeutic breakthroughs” come not from professional staff but from the influence of peers, provide the foundation of most of our treatment approaches.  Having had my own experiences as a patient, too, I can attest to the fact that my peers often “got” me far more effectively than those I was paying to do so.

Is this necessarily a problem?  After all, a surgeon doesn’t have to experience colon cancer to perform a bowel resection, an internist doesn’t need to be diagnosed with diabetes to understand its management, and a man can be an excellent obstetrician even though he’ll never give birth to a child.  Even in mental health, professionals can be quite astute and eminently capable, even without a history of mental illness themselves (even though we’re often accused by our colleagues as selecting this profession to cure our own problems!).

But it might be time to reevaluate this.  As a psychiatrist, I may understand the neuropharmacology of SSRIs and antipsychotics, the (supposed) biological basis of depression, and the foundations of cognitive behavior therapy more deeply than any of my patients, but in the long run, does any of this matter?  It’s bad enough that we lump together all sorts of symptoms as “major depression”; it gets infinitely more complex when we consider the vast range of circumstances that give rise to a person’s symptoms, and only the patient—or someone who shares the patient’s experience—can truly understand this.

Sometimes I feel like a fraud.  I’m expected to be objective and detached when, in fact, I’m dealing with subjective, emotional, and sometimes existential anguish that simply cannot be shared or felt by someone on my side of the couch (or desk, as it were).

How to remedy this?  For me, the best approach is not to view patients through the foggy and distorted lens of the DSM-IV, or with a narrow-minded focus on symptoms and medications, but rather to get to know them as I might wish to know a new friend.  I want to listen to their needs and desires, their intrinsic weaknesses and strengths (in a way, to not even see them as patients) and then provide whatever help or structure that they need—if I can.  Perhaps that type of engagement is not the standard of care, but patients seem to prefer it.

A very practical solution might be to rely on peer support more frequently than we do.  That is, ask patients to advise and connect with each other, rather than rely on ‘professionals’ like me.  (BTW, I’m not wishing my way out of a job; I truly believe that there will be a need for trained professionals to facilitate or oversee this process.)  We already know that the most effective non-pharmacological treatments for mental illness (e.g., the Soteria project) rely heavily on peer support.  The rise of social media has also empowered patients like never before.  Some of the most insightful (and respectful) information I have learned in this field comes from patient-oriented websites like Surviving Antidepressants, Beyond Meds, Holistic Recovery from Schizophrenia, and many others.  (In fact, I think it’s incumbent upon doctors to pay close attention to what’s written on sites like these—because these are the people who ask for our help!)

But maybe the most important thing we can do as professionals is to heed the advice shared by our patients and peers in the recovery community, which is to practice humility in our daily affairs.  We must acknowledge what we do not know.  And the most important information we do not have is what it’s like to spend a day in our patients’ shoes.  While we can share our expert knowledge with patients—and sometimes order treatments with which our patients disagree—we must ultimately respect the fact that our patients know themselves—and others like them—far greater than we do.

I Really Need To Lighten Up

December 1, 2011

Reading back over my last few blog posts, I realize I’ve done absolutely nothing to make psychiatry fun or interesting.  In fact, dear reader, you might think I’m a pretentious pedant, obsessed with irrelevant details that have nothing to do with what my patients really need.  And you know what?  You might be correct.  Treatment of depression by family practice docs?  BORING!!  A possible biomarker for cocaine relapseWho cares????  A new insomnia medication?  A real sleeper…

I realized today that I’m doing it all WRONG.  Not only can psychiatry be fascinating, but it can be cool.  As cool as a rap video.  Because that‘s what matters nowadays, right?  Don’t believe me?  Take a look at Steve Stahl’s DLPFC Rap:

No wonder I find psychopharmacology so dry.  It’s because I don’t realize how BADASS it can be!!!  I’m sitting here in my office, questioning antidepressant mechanisms, poring over datasets and p-values, and reading up on esoteric new interventions like concreteness therapy for mood disorders.  In the meantime, Steve Stahl and his NEI Global crew are partying on the beach in San Diego, rapping about the DLPFC.  It’s true.  I’m a loser.  Lame.  A real D-bag.

The DLPFC, for those “in the know,” is the dorsolateral prefrontal cortex.  I used to know it as Brodmann area 46, a cortical area responsible for executive function, planning, organization, and working memory.  But that’s boring sh*t for old farts like me, I guess.  After watching the NEI Global clip, I now know it as “all I need to know.”  That’s pretty tight.  It’s also “where the money is,” which is even more badass.  Dollar bill, y’all.

Why are those old, gray-haired APA dinosaurs spending all their time writing the new DSM-5???  Why do the guys in the journals recommend brain scans and genetic screens and personality tests and long-ass interviews???  Yo, get it together, Steve Stahl has already figured out that the DLPFC is responsible for “executive function, attention, concentration, impulses, emotions, obsessions, compulsions, motor [?], fatigue, ruminations, worry, pain, negative symptoms, guilt, and suicidality.”  What more do you need to know, bro???

So now, when a psych resident asks me what causes obsessions or suicidality, I can just answer, “Yo, homeboy, it’s the DLPFC.”  Then I can tell him to find a drug that acts on the DLPFC and say, “prescribe that sh*t!”  Even better, when a patient comes to my office and complains of pain or guilt or concentration problems, I can just whip out one of Stahl’s epic pix and say, “Chill out, sister, homey’s got yo back” and write a script for something that works on the DLPFC.  As the video says, “most of the symptoms are in the PFC!!!!”  Bitchin’!  Another satisfied customer!

Of course, I am kinda pissed off now because my med school profs and residency mentors made me study all that stuff about brain development, cognition, behavior, PLUS all that neuroanatomy sh*t not involving the DLPFC.  WTF???!!!!  Major waste of time, LOL!!!!!  ‘Cuz the DLPFC seems to be where it’s at (where’s this Beck Depression Inventory?).  All I need to do now is grab Stahl’s book or attend an NEI Global conference—or, better yet, look for drugs that affect the DLPFC—and I’m good to go!

Hey, mental illness is no laughing matter.  But learning about the part of the brain that causes mental illness can be LMFAO, can’t it??

[Thanks to the Neurocritic blog for the link to the DLPFC rap.]

“We’re Doctors. We Prescribe Drugs. That’s What We Do.”

November 29, 2011

One of my most vivid memories of medical school was during my internal medicine rotation, when it had become apparent to me that, despite spending my pre-clinical years studying complex pathophysiology and pharmacology, and the fine art of history-taking and the physical exam, the actual clinical work seemed to be more like a numbers game.  I felt like I was always responding to a data point:  a blood pressure reading, a glucose level, a WBC count.  And the response always seemed to be the same:  I prescribed a drug.

To my immature medical mind, it seemed almost too simple.  I thought a computer could do it just as well.  When I commented to my attending physician that we seemed to be emphasizing medications over lifestyle changes, alternative therapies or preventive measures a patient might take, he responded, “We’re doctors.  We prescribe drugs.  That’s what we do.

Fast forward about 10 years.  I now work part-time in teaching hospital.  One of my responsibilities is the supervision and training of psychiatric residents and medical students.  Recently, one of the students asked whether her final exam for the psych rotation would include questions about psychotherapy, to which my colleague responded (and yes, this is a direct quote), “No.  We’re doctors.  We prescribe drugs.  That’s what we do.”

The echoes of medical school resounded loudly.  But the words from med school professor had had a very different impact on me a decade ago than those spoken by colleague just last week.  While I accepted my professor’s words as the insight of a seasoned expert about what really matters in medicine, my psychiatrist colleague’s comments rubbed me the wrong way.

It made me wonder, has medicine changed?  Or have I?

I (and numerous others) have written extensively about how psychiatric drugs don’t work nearly as well, or as frequently, as advertised.  Others have written eloquently about the inherent dangers of psychiatric medication—a viewpoint which has been, at times, exaggerated, but to which I have become more sympathetic over the years.  These are two reasons to shudder at the fact that psychiatrists-in-training are being taught to emphasize the pharmacological approach.

But more important to me is the fact that, with comments like these, we psychiatrists are actively positioning ourselves to rely on a treatment philosophy that may well have run its course at some point in the not-too-distant future.  (Will today’s psychopharmacologists face a fate like those of the psychoanalysts of the 1950s and 60s?)  If students and residents increasingly see psychiatry as a pharmacology-oriented specialty, they will be less likely to explore other interventions that may ultimately prove to be more helpful to their patients.

Psychiatry is already ceding territory to other professionals.  Psychotherapy is taught in most psychiatric training programs, but few psychiatrists are paid (or choose) to do therapy.  Understanding how to provide systems-based care, or integrate psychiatric care into a patient-centered medical home (PCMH) model, is not something psychiatrists are trained to do, despite the obvious drift of American medicine in this direction.  Even some areas that could arguably be considered areas of unique psychiatric expertise— developmental disorders, addiction treatment, child development, geriatric neuropsychology, psychosomatic medicine, integrated pain management, trauma recovery, to name a few—aren’t a major part of the psychiatric curriculum.  Why not?  There are no drugs that we can prescribe (and, similarly, no drugs approved by the FDA) to treat these conditions.

This gradual erosion of psychiatric training has two consequences.  First, it opens the playing field to other mental health professionals who can generally provide their services more cheaply than psychiatrists do.  While most of these specialists perform their jobs quite admirably (making the psychiatrist irrelevant, by the way), the prioritization of cost over quality may result in patients getting worse care over the long run, especially if rigorous standards are not upheld.  Secondly, because meds are still where the money is, more non-psychiatrists are getting into the psychopharmacology game.  Psychiatric nurse practitioners (who have prescribing privileges), physician assistants, family practice docs, Suboxone jockeys, psychologists (in some states), and many others see psychopharmacology as a way to keep their customers patients satisfied and to keep their offices full.  When, in the end, the data show that these patients fare no worse (or, sadly, no better) than those seen by psychiatrists, then the writing will really be on the wall for most of us.

Some readers, particularly those working in a private practice setting, might respond, OK, I see your point, but some psychiatrists really do provide comprehensive, thoughtful care to their patients.  To which I would say, yes, but they are truly in the minority.  My own career trajectory (as well as my personal life) has taken some unexpected turns, and these turns have taught me how psychiatry is practiced among the masses in “the real world,” not in the Ivory Towers of Cornell, Stanford, or UCLA.  For the majority of patients and providers, psychiatric treatment is a numbers game, and the numbers are easy to follow:  More patients + More appointments per day + More medications prescribed = Everyone wins.

I believe that not only can psychiatrists provide better care than the medication-laden treatments we dole out today, but we have a responsibility to do so.  Four years of medical school and four years of residency provide plenty of time to learn about human behavior, emotions, the roots of motivation, child development, family systems, learning theories, interpersonal skills, coping strategies, evolutionary psychiatry, ego psychology, personality theory, human sexuality, spirituality, existentialism, psychodynamic principles, and basically everything else that makes a person tick, in addition to the basic biology of the disorders we diagnose and treat.  To dismiss this in favor of a medication-oriented curriculum that could be obtained in a weekend seminar or in an industry-funded CME course, is an insult to our intelligence, and, potentially, the downfall of our profession.

When the prescription pad becomes a hammer, then every symptom starts to look like the proverbial nail.  Perhaps it’s time for psychiatrists to dust off some other tools before it’s too late.

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