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Two Psychiatries

March 12, 2012

A common—and ever-increasing—complaint of physicians is that so many variables interfere with our ability to diagnose and treat disease:  many patients have little or no access to preventive services; lots of people are uninsured; insurance plans routinely deny necessary care; drug formularies are needlessly restrictive; paperwork never ends; and the list goes on and on.  Beneath the frustration (and, perhaps, part of the source of it) is the fact that medical illness, for the most part, has absolutely nothing to do with these external burdens or socioeconomic inequalities.  Whether a patient is rich or poor, black or white, insured or uninsured—a disease is a disease, and everyone deserves the same care.

I’m not so sure whether the same can be said for psychiatry.  Over the last four years, I’ve spent at least part of my time working in community mental health (and have written about it here and here).  Before that, though—and for the majority of my training—I worked in a private, academic hospital setting.  I saw patients who had good health insurance, or who could pay for health care out of pocket.  I encountered very few restrictions in terms of access to medications or other services (including multiple types of psychotherapy, partial hospitalization programs, ECT, rTMS, clinical trials of new treatments, etc).  I was fortunate enough to see patients in specialty referral clinics, where I saw fascinating “textbook” cases of individuals who had failed to respond to years of intensive treatment.  It was exciting, stimulating, thought-provoking, and—for lack of a better word—academic.  (Perhaps it’s not surprising that this the environment in which textbooks, and the DSM, are written.)

When I started working in community psychiatry, I tried to approach patients with the same curiosity and to employ the same diagnostic strategies and treatment approach.  It didn’t take long for me to learn, however, that these patients had few of the resources I had taken for granted elsewhere.  For instance, psychotherapy was difficult to arrange, and I was not reimbursed for doing it myself.  Access to medications depended upon capricious, unpredictable (and illogical) formularies.  Patients found it difficult to get to regular appointments or to come up with the co-payment, not to mention pay the electric bill or deal with crime in their neighborhood.  It was often hard to obtain a coherent and reliable history, and records obtained from elsewhere were often spotty and unhelpful.

It all made for a very challenging place in which to practice what I (self-righteously) called “true” psychiatry.  But maybe community psychiatry needs to be redefined.  Maybe the social stressors encountered by community psych patients—not the least of which is substandard access to “quality” medical and psychiatric services—result in an entirely different type of mental distress, and demand an entirely different type of intervention.

(I should point out that I did see, at times, examples of the same sort of mental illness I saw in the private hospital, and which did respond to the same interventions that the textbooks predicted.  While this reaffirmed my hope in the validity of [at least some] mental illnesses, this was a small fraction of the patients I saw.)

Should we alter our perceptions and definitions of illness—and of “psychiatry” itself—in public mental health?  Given the obstacles found in community psychiatry settings (absurdly brief appointment times; limited psychotherapy; poor prescription drug coverage; high rates of nonadherence and substance abuse; reliance on ERs for non-emergency care, often resulting in complicated medication regimens, like dangerous combinations of narcotics and benzodiazepines), should we take an entirely different approach?  Does it even make sense to diagnose the same disorders—not to mention put someone on “disability” for these disorders—when there are so many confounding factors involved?

One of my colleagues suggested: just give everyone an “adjustment disorder” diagnosis until you figure everything out.  Good idea, but you won’t get paid for diagnosing “adjustment disorder.”  So a more “severe” diagnosis must be given, followed closely thereafter by a medication (because many systems won’t let a psychiatrist continue seeing a patient unless a drug is prescribed).  Thus, in a matter of one or two office visits (totaling less than an hour in most cases), a Medicaid or uninsured patient might end up with a major Axis I diagnosis and medication(s), while the dozens of stressors that may have contributed to the office visit in the first place go unattended.

Can this change?  I sure hope so.  I firmly believe that everyone deserves access to mental health care.  (I must also point out that questionable diagnoses and inappropriate medication regimens can be found in any demographic.)  But we psychiatrists who work in community settings must not delude ourselves into thinking that what’s written in the textbooks or tested on our Board exams always holds true for the patients we see.  It’s almost as if we’re practicing a “different psychiatry,” one that requires its own diagnostic system, different criteria for “disability” determinations, a different philosophy of “psychotherapy,” and where medications should be used much more conservatively.  (It might also help to perform clinical trials with subjects representative of those in community psychiatry, but due to their complexity, this is highly unlikely).

Fortunately, a new emphasis on the concept of “recovery” is taking hold in many community mental health settings.  This involves patient empowerment, self-direction, and peer support, rather than a narrow focus on diagnosis and treatment.  For better or for worse, such an approach relies less on the psychiatrist and more on peers and the patient him- or herself.  It also just seems much more rational, emphasizing what patients want and what helps them to succeed.

Whether psychiatrists—and community mental health as a whole—are able to follow this trend remains to be seen.  Unless we do, however, I fear that we may continue to mislead ourselves into believing that we’re doing good, when in fact we’re perpetuating a cycle of invalid diagnoses, potentially harmful treatment, and, worst of all, over-reliance on a system designed for a distinctly different type of “care” than what these individuals need and deserve.

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Community Psychiatry And Its Unintended Consequences

May 10, 2011

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

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

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

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

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

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

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

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

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

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

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

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

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


Mental Illness and Social Realities

May 2, 2011

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

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

—–

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

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

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

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

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

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

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

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

—–

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

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

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


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