Like Water

The flustered mother told me this about how difficult it was to get her school-aged son to do what she wanted: "He's like water. Whatever I try to do, whatever rules I set up, he finds a way around them."

I said, "Well, that must be very frustrating."

Here's what I wish I had been clever enough to say to her instead: 

"You're right. Kids are a lot like water. The harder you try to grab them, the more they slip through your fingers.

Like water, kids can mirror their surroundings. They are given shape by their environment, while over time they are also shaping the environment.

Similar to water, kids can exist in different states. Too much heat or too much cold, and they may become explosive or get more rigid and brittle.

Water is very resilient. Most of the time, like water, kids can return to their previous state after a perturbation if the environment allows it.

It always takes energy to change the flow, the direction, the trajectory of water. Otherwise it just follows the path of least resistance.

Just as you can make water move against gravity through capillary action, giving the right scaffolding for a child can make all the difference. 

While water running rampant can be destructive, water put to purpose can do immeasurable good.

So you're absolutely right: your child is very much like water. Now what shall we do about it?"

Why I Love Wall-E (and Question the ACA)

Spoiler warning: If you haven't seen Wall-E yet, why not? See it first before reading this post if you don't want certain aspects of the plot revealed.

Let me tell you why Wall-E is my favorite Pixar move. The title protagonist begins the movie as a humble robot, programmed with a very specific purpose: to pick up garbage, compress it, and stack it in neat, towering piles. In Wall-E's world, man-made trash overwhelmed the earth generations ago, smothering all plant life. The humans escaped in giant spaceships, leaving robots behind to clean up the mess. Over time, all of the other robots broke down, with Wall-E the sole survivor living a repetitive, lonely existence. Yet Wall-E somehow transcends his programming and develops a sense of curiosity about the world. What were those humans like? What are these relics that they left behind? What's that green thing growing amongst the trash?

After a series of improbable but exciting events, Wall-E finds himself on board one of those giant spaceships. There, he encounters real, live humans and the robots that serve their needs. The people were uniformly plump with adiposity, reclining comfortably on mobility chairs while sipping futuristic Big Gulps™ and fixated on screens. Wall-E was aghast, eventually discovering that the villainous AI of the ship was trying to keep the humans confined to their blissful but vacuous existence. Wall-E finds a way to rally the other robots and spread the news that plant life was growing on earth once again. The movie ends on a hopeful note, with the ship returning home and the humans taking small, earthbound steps that feel like giant leaps. I love that Wall-E acted in humanity's long term interests instead of either rejecting these disappointing humans or attending only to their short term comfort.

Recently, I was reminded of Wall-E when I attended a session at AACAP's Annual Meeting in San Diego titled: "The Affordable Care Act [ACA] and How We Think About Systems, Care, Quality, and Ethics." The discussants covered various aspects of the ACA (for an overview of the ACA, see this recent post from Psych Practice). What interested me most was the talk by Dr. Michael Houston on how the ACA relates to child and adolescent psychiatrists. Dr. Houston discussed the ethical underpinnings of the ACA, namely how it seeks to institute a more egalitarian and less libertarian health care system. The law lays the groundwork for transitioning us from a fee-for-service system in which doctors have a financial incentive to do lots of procedures to a system in which both patients and doctors have a responsibility to society to contain costs.

Clearly, one of the goals of the ACA is to make doctors provide more efficient care. One of the justifications for why we need this is the chart above (from this HuffPo article) showing how, despite spending way more than any other country on health care per capita, the U.S. trails most other developed nations in life expectancy. The logic seems to be that since we're not getting good bang for our buck, the health care delivery system must be streamlined.

This focus on efficiency would have an especially high impact on child psychiatrists, given how relatively few of us there are compared to the high numbers of patients. Here's an old article from 2006 about the shortage, and not much has changed since, except that even more children are being diagnosed with conditions like ADHD and taking multiple medications, putting further strains on the health care system. Last year, AACAP published a document describing how the ACA will impact the practice of child and adolescent psychiatry. More mental health care will be delivered by pediatricians and care managers, with psychiatrists overseeing cases but not seeing patients directly unless they were especially complicated.

To me, this seems like a herculean effort to create ever more efficient Wall-Es, without trying to address why there was so much for Wall-E to clean up in the first place. Instead of just focusing on the shortage of child psychiatrists, why are we not doing more about the over-abundance of patients? After the session, I asked one of the speakers this very question. Her answer was sobering: she had thought about this issue herself, but when she tried to a submit a paper on the prevention of mental disorders in children, no child psychiatry journal would accept it. She thinks that is just not our mindset, just not what we are trained or paid to do. It reminded me of the old adage by Upton Sinclair, "It is difficult to get a man to understand something, when his salary depends on his not understanding it."

Don't get me wrong, I believe in universal health care. I just don't think that the ACA is going to successfully address the mental health issues of children in this country, just as it won't address the obesity epidemic by making obesity treatment more streamlined. For example, today's NYTimes article that I linked to earlier profiled a California mother who has a child with ADHD and severe behavioral issues. Here's the crucial paragraph:

Some would consider Matthias a textbook candidate for combined treatment. His rages have overwhelmed schools and child care programs for years, and he is already struggling in first grade. He and his mother — a medical technician whose typical workday drawing blood lasts from 7 in the morning until 4 p.m. — share a cramped and clamorous three-bedroom ranch house with her sister and brother-in-law and their spirited children, ages 3 and 6 months. Matthias is having nightmares and bladder-control issues.

I'm not sure that any amount of meds or access to a child psychiatrist would help this child as much as having a less stressful home environment. I don't claim to know what the best solution for our society as a whole would be, but I do think we need to put more effort into investigating what can be done to better support children and families, and not just from a medical/health care system point of view.

I hope that more of us in the child psychiatry field can be a bit more like Wall-E: a bit more curious about the world we find ourselves in and how it became that way, a bit more willing to ponder what can change things for the better. Let's not continue to just put our heads down in order to squeeze ever more efficiency and productivity out of our days.

Boyhood Movie Review

Putin. Gaza. Ebola. ISIS. Ferguson. Robin Williams. This has been one of the more unsettling summers in recently memory. However, as we head towards Labor Day and I look back on the last couple of months, what I recall most clearly and fondly (besides some personal and family matters that are irrelevant here) is watching Boyhood, by director Richard Linklater.

The film stars Ellar Coltrane as Mason, who is 6 at the beginning of the story. We watch as he grows year by year into an 18 year-old young man. Forget all those gimmicky 3D movies; this is a 4D film, where the genuine passage of 12 years of time adds an extra dimension that cannot be faked by CG.

Boyhood succeeds in capturing something about the essence of our times when it comes to parenting and childhood. The parents have split, and the dad, played by Ethan Hawke, is barely around initially, only occasionally swooping into his kids lives like a tornado of fun. Meanwhile, the mom (Patricia Arquette) struggles to raise her children while trying to go back to school so her family could break free from the struggles of low-wage America.

Amazingly, the director found a young actor in Coltrane who was able to deliver a consistently convincing performance from childhood to adolescence. The film opens with him lying on the grass staring into the sky, leaving us to wonder what he makes of life. Coltrane was able to project this introspective nature throughout, and as a young man engages in the kind of philosophical discussions that Linklater's characters are known to do.

However, Boyhood is as much a coming of age movie about Mason's parents as it is about Mason's own journey. I found it interesting that the adults seemed to be engaged in a search for identity as much or more so than the children. The character who evolves the most over the 12 years is Mason's father, who becomes a minivan-driving, church-going actuary in middle age. Mason's mother ends up as a somewhat tragic figure who has to balance her career with parenting while dealing with a string of bad relationships. Our culture really is harder on women, and this film reflects that reality.

Boyhood has been the best reviewed movie of the summer and deservedly so. One may look at the box office receipts for the latest Transformers assault on the senses ($243.8M) vs. Boyhood ($16.3M) and despair; I choose to see the fact that this movie was made at all as a sign that there is still hope.

The Limits of Big Data in Psychiatry

While browsing The Atlantic earlier this week, I came across this:

Yes, I was tempted to click on the article involving electric shocks, but it was the ad "Rising Mental Health Issues Facing Our Children, in Five Charts" that caught my attention. The colorful charts show some alarming-looking numbers that most readers of this blog are probably used to seeing by now: that there is a large increase in children receiving mental health diagnoses, that ADHD is diagnosed at very high rates (especially in the South), that children on Medicaid are more likely to receive a mental health diagnosis than children with commercial insurance, etc. The data for the charts were gathered from pediatrician visits across the country by athenahealth (apparently they're too cool for capital letters), the electronic health record (EHR) company who paid for the ad.

They helpfully included a video at the bottom of the ad so we can get "perspectives on these trends from top health care leaders." Take a look:



Watching this video, I was struck by the words of Kurt Newman, M.D., President and CEO of Children's National Medical Center:

"These graphs are just probably the tip of the iceberg. The directional trend is very disturbing, but also the magnitude is disturbing, and these pediatricians are swamped.
[…]
That's why we need to do more research, we need to have a better system in terms of more providers, we need to be able to pay the providers a reasonable amount for the care they're giving. But I think if we do all that, we're going to have a huge impact for these kids and families."

Classic. There's an epidemic on, doctors are swamped—we need more funding so we can provide more treatment! No wonder he's the CEO. And like many other CEOs, he oversells when talking about the future:

"We're on the cusp of something really huge there. It's kind of like big data and big analytics that are gonna really revolutionize how we can identify these trends or get specific about certain diseases […] Autism might be a hundred different rare diseases that are all rolled up into one. We won't figure that out unless we have the analytics, all of the the really sophisticated capability of probing into: is that patient like that patient, is that child like that child, what made them more similar?"

Perhaps I'm too dumb to comprehend big data/analytics, but I fail to see how information mined from an EHR is going to shed light on the etiology of autism. Also featured in the video is Angela Diaz, M.D., Director of the Mt. Sinai Adolescent Health Center, who seems to have a more common sense take on the data:

"We need to figure out what is leading to these kids…30% of U.S. students to feel sad and hopeless for the last 12 months, and of those, 40% of the girls? What is going on? So we need to get to the root causes of these things, and try to identify and then figure out, how to prevent?"

I certainly agree with Dr. Diaz on the importance of trying to determine the root causes of the rising rates of these conditions. However, having the raw data and figuring out causality are two very different things. I would argue that in psychiatry we already have access to tons of data, but unfortunately much of it is interpreted through a very narrow, biologically-oriented lens. Having faster access to bigger pools of data is not going to help. Example in point: the January 2014 JAACAP article that described rising rates of ADHD in the US, which I had previously blogged about. That article was accompanied by an editorial by Drs. Walkup, Stossel, and Rendleman that essentially heralded the findings as good news and a sign that ADHD is being increasingly recognized and treated, which is desirable from a "public health" point of view.

In the June 2014 issue of JAACAP, Dr. Jonathan Posner wrote a very reasonable letter to the editor (subscription required), pointing out that other, more rigorous studies (relying on both parent and teacher report instead of parent report only) have found rates of ADHD closer to 5-7% instead of the 11% reported in the JAACAP article. He concludes that the reason for the rapidly increasing rates of ADHD diagnosis in the community may be "that a substandard approach to diagnosing ADHD has become the norm." Drs. Walkup and Rendleman wrote a reply (subscription required); here's the first paragraph of their response:

Thank you very much for your comments. Your position is one that we believe is shared by many, which is why we wrote the piece. Although we respect your and others’ opinions, we find it difficult to support the statement that rising rates are due largely to substandard assessment of ADHD—it is just too simplistic an explanation. The solution that you allude to is likely not tenable for a high-prevalence condition such as ADHD, because there just aren’t enough child psychiatrist providers to do it all. We are not advocating poor-quality diagnosis or inappropriate treatment; rather, the goal of the editorial was to understand the role of advocacy and education in rising rates, the importance of a public health approach to high-prevalence conditions, and to help child and adolescent psychiatrists come to terms with the fact that our traditional model of care, which is time intensive and highly personalized, is not likely to be able to address the public health burden of ADHD. We certainly do not want to inhibit the pediatric prescriber from taking on the challenge. They need our support to do it well.

So the assumption they make is that cases of ADHD reflect a biological disorder and that increasing awareness of the condition amongst the population, diagnosing it, and treating it with medications is good and proper.

Imagine, for moment, something like this happening with the obesity epidemic. The maps of child obesity in the U.S. look suspiciously like those of the ADHD epidemic, with the highest rates in the deep South. Sure, there are drugs to treat obesity, but would anyone talk with a straight face about a "public health" approach to obesity consisting of identifying the cases and then treating them with medications? Wouldn't a better (and true) public health approach be to ensure that children can get adequate exercise, good nutrition, and that people aren't incentivized to buy the cheap calories and processed "foods" that are making them obese?

Thus, as long as the prevailing view of psychiatric conditions is a narrow one, the data will be used for narrow purposes, such as academic leaders/CEOs arguing for more resources, or to justify the high rates of psychiatric medication prescribing. Here, I'm not even going to get into some other questions I had about the athenahealth ad, including who its intended audience is and what it is trying to achieve. Most doctors recognize that EHRs do not help them care for patients. These systems mostly appeal to large clinics and hospital organizations, for reasons that I will let Dr. George Dawson's recent blog post explain.

The Impact of False Diagnostic Labels

Back in April, an extraordinary article was published by Dr. Peter Parry, an Australian child psychiatrist, about his correspondence with an American adolescent who had been diagnosed with pediatric bipolar disorder (PBD) during the PBD craze in the early 2000's. I had linked to the article on Twitter, but I haven't had a chance to write about it until now.

The power of this article comes from the fact that it includes a detailed first-person account from the patient "Adam." He comes across as an extraordinarily thoughtful young man, who had a tragic but far from uncommon encounter with psychiatry. Here's what Adam had to say about being diagnosed with PBD and treated:

I was 12 when first diagnosed. I had suffered depression and anxiety including severe OCD, which has since disappeared. It should also be mentioned I come from a screwed-up family and was physically abused by a sibling. Parents divorced young. My mother had a lot of issues, etc. So it goes without saying there was a lot the psychiatrist should have asked if he was ever so inclined. But unfortunately, he holds a faculty appointment at [edited—A PBD oriented child and adolescent psychiatry clinic].

Within about three months, I was on 8 different medications at one time. Very scientific treatment—all the best—several anticonvulsants, several antipsychotics, a couple of antidepressants and lithium too.

Things got so bad, that I ended up being referred to the neurology department, for different opinions about strange symptoms I began having on this cocktail. Which resulted in their giving me a working diagnosis of some kind of mitochondrial myopathy. "Bipolar plus mitochondrial disease" as it went. Which I have been told only recently could have been precipitated by the huge amounts of divalproex I was taking. The symptoms quickly disappeared when I coincidentally stopped the drug for unrelated reasons. Oh well, but it is a clear illustration of what one of the "best" academic medical centers in the world has to offer a struggling young boy.

And here is Adam's perspective on how the diagnosis and treatment affected him:

But the worst part of this, which I have only been recently able to shake within the last year (2008/9), is the defectiveness I felt. Just kind of in some core way. Like I'm totally different. When I was younger, that feeling was a lot stronger and more prominent. Now I feel like a fool for even having given thought after eight years to the question of whether I might go to sleep one night and wake up manic. I decided with my (new) psychiatrist's support a year ago to stop my medicines. I’m not doing especially well now, but I have at least been able to shake the feelings the diagnosis itself carved into me. The same can’t be said for its physical and social effects though.

It's not just children and teenagers who are vulnerable to being misdiagnosed with bipolar disorder; it can even happen to an NBA millionaire. A couple of weeks ago, I read one of the best articles that I've ever encountered on mental health in professional sports, titled "Why Isn't Delonte West in the NBA?" As a casual basketball fan, I knew that West had been a part of the Cleveland Cavaliers during the LeBron James years. I've heard that he struggled with mental illness and had been diagnosed with bipolar disorder. I recalled that he had been arrested after being found driving around with multiple weapons, and there were even rumors that he had slept with LeBron's mother. But this article provides the inside story of what actually happened, and the facts were deeply unsettling.

Delonte West grew up without a stable home, with a single mother who worked multiple jobs just to keep afloat after his parents divorced.

West has an older brother, a younger sister, and a vast extended family that he refers to as "a village." He stayed with many of those relatives growing up. "I lived off of every exit," he says, rattling off 11 specific ones from memory. "I lived in so many apartments … with cousins, uncles, and aunts, just making it."

In the NBA, he had several outbursts of anger, which led to him seeing a psychiatrist.

West was diagnosed as bipolar by a D.C.-area specialist. He says that when he saw the doctor, he’d been feeling down, having days when he was sad and tired and didn’t want to get out of bed. But he told the specialist that there were also times when he "might just go out and buy a car. Or go to the mall and spend 25 grand." West doesn't think the doctor took into consideration that such behavior might not be unusual for a professional athlete with a big paycheck. He now thinks that he was suffering a temporary bout of depression, not exhibiting symptoms of a chronic disorder.

Another part of the article provided additional context for West's inner struggles:

As a kid, moving from school to school, he often found himself the target of playground taunting. "I was real funny-looking," he says, with big ears, a mole on the back of his head that he had removed once he got to the NBA, and a birthmark below his lip that he's also had partially removed. His light skin and red hair stuck out, too. "I was made fun of a lot growing up, but I just knew the basketball court was the place where you couldn’t make fun of me, you had to respect me." He says he always had "more jokes for me than you had," but that he internalized the cruel things kids said to him. Last year, West told an interviewer that he believed his real problem was not bipolar disorder, but "self-loathing."

This was what actually happened in the weapons incident that contributed to derailing West's NBA career:

It was the offseason, and a few of West's cousins had come over to his house with their children. West's mother was looking after the kids while he slept and the other adults went out. At some point in the evening, West's mother woke him up. She said the kids had gotten into a closet in his small, in-home music studio, where he stored guns that he had bought, legally, in Cleveland. He needed to do something about those weapons, she told him.

With the driveway crowded by his cousins' cars, West got on his motorcycle so he could bring the guns to another residence. Earlier in the evening, he'd taken Seroquel, which is often prescribed for bipolar disorder. Seroquel makes you drowsy, and as he headed out on the highway, he found that he was dozing in and out. After he felt himself drifting off, West was pulled over for making an unsafe lane change, and he told the officer that he was carrying weapons. The day after the arrest, a police spokesman said that West was "very cooperative the entire time."

After his arrest, West played for the Cavaliers for another season, but the article makes the plausible argument that because West had been labelled with a mental illness, people were willing to believe whatever crazy things they heard about him, including the false rumor that he had slept with his teammate's mother. Undoubtedly, taking Seroquel contributed to his arrest. Without the "bipolar disorder" label, if instead the narrative had been that West had emotional issues due to childhood stresses, he may well still be in the NBA.

Earlier this week, Dr. David M. Allen had a blog post on misdiagnosis: "Is Your Psychiatrist Committing Malpractice Even if Doing What a Lot of Other Psychiatrists Are Doing?" (The short answer is "yes.") However, according to Dr. Parry's article, when Adam looked into his legal options, he was told "his treatment would be deemed 'standard practice' where he lived," which is a big deterrent for the lawyers when it comes to medical malpractice lawsuits. What a sad irony: the crappier the standard diagnosis and treatment becomes, the more the practitioner is protected by the herd.

When I was in medical school at a very biological psychiatry-oriented institution, the psychiatry professors made sure to educate us on the past evils of blaming refrigerator mothers for schizophrenia. And yet, as Dr. Parry pointed out, we have gone from the "brainless psychiatry" of the psychoanalysts to today's symptom-focused "mindless psychiatry" that tends to ignore the patient's inner life and the developmental biopsychosocial context. Here is my favorite section of Dr. Parry's article:

In addition to being a method of inquiry, science is a social process and there is a vast research literature concerning the sociology of science. Scientific disciplines do not build on knowledge in a purely linear fashion, but at times undergo dramatic upheavals according to paradigm shifts. The dominant paradigm governs what is acceptable to study, research, publish and practice. Softer sciences like psychiatry can be more susceptible to extreme paradigm shifts. The history of psychiatry reflects this. 

One of my biggest frustrations while reading Dr. Parry's words is that his wisdom is relegated to an opinion article published in a little known open-access journal, while the leading child psychiatry journal, which claims to be "advancing the science of pediatric mental health and promoting the care of youth and their families" [emphasis mine] would never permit such a sharp critique within its pages.

Psychiatry's Low-Tech Advantage

The other day, I received this in the mail:

It's a 57-page booklet/brochure ("bookchure"?) filled with professional photos designed to tug at the heartstrings, minimalist typography, and colorful charts highlighting the awesomeness of Akron Children's Hospital. All I could think of was, "How much money did they waste on this?" Living nowhere near Ohio, I will never have the chance to refer a patient to them. Pages 51-53 list 6 names on their Board of Directors, 26 Directors, 3 Directors Emeritus, and 5 Honorary Directors. This many Directors, I presume, are needed to oversee the 4751 employees and 703 medical staff (p. 50), as well as $1.06 billion in gross patient services revenue (p. 56).

And this wasn't the first such bookchure I've received. I've gotten similar mailings from the Mayo Clinic, the Cleveland Clinic, and probably other places that I've since forgotten. This is what our health care industry has become: Specialty centers who vie for clientele by boasting about the high-tech procedures and treatments that they offer. It reflects a system where about 20% of the population take up 80% of the costs (and even more damning, 5% of people account for 49% of spending).

At its core, Psychiatry is a very low-tech specialty, perhaps the one least reliant upon machines and specialized equipment. That's not to say there's no technology in the field, since knowledge constructs such as CBT are also forms of technology (and let's not forget Big Pharma), but psychiatry today is generally not what anyone would call "high-tech."

The leaders of academic psychiatry and the director of NIMH certainly view the low-tech nature of psychiatry as a huge disadvantage, a travesty that they are doing everything in their power to try to rectify. Hence the ever-greater emphasis on higher-tech ways of studying and manipulating the brain, whether it's optogenetics or connectomes.

However, I view psychiatry's low-tech nature as a huge advantage, at least when that advantage is embraced. A psychiatrist can easily start a practice due to low capital costs and enjoy low overhead since there is no need for a huge support staff. This keeps the focus on the relationship between the doctor and the patient, rather than having some other intermediary like an insurance company or a managed care organization extracting profit. Patients get to spend more time with their psychiatrist, and the psychiatrist has to see fewer patients, resulting in a win-win scenario. Especially if you believe, as I do, that a good therapeutic relationship can lead to positive changes.

Rather than embrace these advantages, the leaders of our profession have done all they can to minimize them, by advancing and supporting a biomedical model of psychiatry where psychiatrists are turned into prescribers doing brief med checks (or into consultants to other doctors). Since drugs are one of the few high-tech (and expensive) things in psychiatry, this of course serves the interests of pharmaceutical companies and the researchers that they support.

Last week, 1 Boring Old Man wrote about new APA President Paul Summergrad's plea for psychiatrists "to put aside internecine battles":

What [Summergrad's] predecessors have failed to notice is that a growing number of psychiatrists refuse to operate in the world created for them by Managed Care and insurance reimbursement, and that’s not all about money. […] A lot of it has to do with being unwilling to have practice dictated by excel spreadsheets in the offices of bureaucrats, the marketing departments of a corrupt industry, or the moguls of the APA and NIMH. Many avoid the APA like a plague. And many who still work in that system would be glad for a chance to change it into something more compatible with the real reasons they chose this specialty in the first place.

I really like the above paragraph from 1BOM since it captures the essence of the problems within our profession, but I would say that it's very hard to be a part of "that system" without being subject to general economic trends affecting all of healthcare. Most other specialities are not quite as low-tech as psychiatry, but the ones that rely on talking to patients and examining them using very basic equipment, such as internal medicine and pediatrics, certainly have similar dynamics.

With all that said, I am by no means anti-technology, as long as the technology is serving the patient. For example, a recent San Francisco Chronicle article highlights one entrepreneur's efforts to create "a website for a health care model in which members pay monthly fees for primary care." If that works, it would help remove primary care physicians from the grind of being in the current insurance reimbursement-based system, which has led to high rates of burnout. Also promising are the health initiatives of companies like Apple, which have the potential to empower individuals to keep better track of their own health (and allow doctors easier access to that information), which hopefully will someday decrease society's reliance on the high-tech specialty hospitals with their fancy publicity materials.

Assimilation vs. Independence

Last week, I got the chance to have dinner with a friend who is a businessman and one of his acquaintances, a cardiologist. My friend asked the two of us what we thought of the state of medicine, and what it was like being a doctor these days. It was interesting to hear what the cardiologist had to say. He had been part of an independent medical group, which was recently bought out by a large hospital system. He talked about all the additional rules and regulations that he had to follow and how burdensome they were. Then he had this to say:

"Basically, the problem is that doctors have no power or control over our own profession. The reimbursements rates and policies are determined by the government and private insurers. The doctors who are older can tell themselves they only have to stick with it a few more years before retiring, while younger doctors are too busy trying to establish themselves and pay down medical school debt. Doctors can't unionize or go on strike. It's hard to organize them because it's like herding cats. Therefore, we just have to accept the system and work within it."

I thought it was a very good summary of the present situation facing most medical specialties. It was a nice coincidence that the following day, 1 Boring Old Man wrote wrote this post highlighting some of his reactions to recent articles on psychiatrists & insurance panels, as well as whether psychiatrists who do psychopharmacology vs. psychotherapy will eventually split into different professions. He began:

I went into practice around 1986. If patients used insurance, that was fine with me, but for two simple reasons, it never occurred to me to take insurance. First, I would’ve had to have a staff to file it and keep up with it and I didn’t want to pass on those costs. Second, that would’ve required me to be on insurance panels that would’ve prescribed how I practiced, meaning becoming a psychiatrist who primarily prescribed medications – the kind of psychiatrist people rave about in the blog comments, on Mad in America, or on the steps of the APA Meeting in New York.

Dr. Dawson wrote the following in response to 1BOM's post:

We will all remain in the limbo of politicians telling us we need increased access and insurance companies decreasing access in order to increase their profitability.  And that has nothing to do with the fact that psychiatrists need to be trained in neurology, neuroscience, medicine, and psychotherapy.  Not accepting insurance is the ultimate affirmation that business does not define medicine or psychiatry.

In a comment on 1BOM's post, Dr. Reidbord had this to say:

It appears many of us psychiatrists simply got the memo a little earlier. Psychiatry, like primary care medicine, is fast becoming two-tier: practiced at the level of professional excellence when business does not define it, and something tragically less when it does.

What I wonder is, why don't more psychiatrists speak out about the state of things? The difficulty in spurring practicing clinicians to action is vexing, since I believe that the majority of psychiatrists enjoy spending time with patients and did not go into the profession to become 15-minute med checkers or care team consultants who do not directly see patients.

Of course, I think the cardiologist's explanation above is a good one, but additionally, I believe that ideology and zeal are two primary factors that give psychiatrists of the key opinion leader (KOL) variety a disproportionate amount of power. 1BOM has written before about the dangers of therapeutic zeal, while I've written about the NIMH's techno-utopian vision. The problem here is that ideology and zeal are unifying forces that rally people to a cause, allowing them to dictate the course of events even when they are in the minority. It is much harder to get people to rally around the banner of multi-disciplinary thought ("psychiatrists need to be trained in neurology, neuroscience, medicine, and psychotherapy") or the biopsychosocial model. As David Brooks wrote in a recent column on threats to the international system of liberal pluralism:

It was barely possible [to defend the system] when we were facing an obviously menacing foe like the Soviet Union. But it’s harder when the system is being gouged by a hundred sub-threshold threats. […]

Moreover, people will die for Mother Russia or Allah. But it is harder to get people to die for a set of pluralistic procedures to protect faraway places. It’s been pulling teeth to get people to accept commercial pain and impose sanctions.

Can there possibly be a solution? Well, it is fortuitous that at least for psychiatrists, independence is still an option. Unlike many other medical specialities, we don't have to buy expensive equipment or hire an extensive support staff. Solo office-based practice is still possible. In certain parts of the country, people are willing to pay $250 per hour for a psychiatrist who is good with both medications and therapy, though if you're like 1BOM and don't care about income maximization, you can probably work anywhere.

And perhaps some day, enough doctors will tire of the "long train of abuses and usurpations, pursuing invariably the same Object evinces a design to reduce them under absolute Despotism," and declare independence en masse. That'll be an interesting day.

What It Will Take to Decrease ADHD Rates, Part 2

In my last post, I enumerated some of the reasons why I thought the high rates of ADHD diagnosis and treatment were not about to fade. Here, I will discuss several steps that I think would need to take place in order to quell the ADHD "epidemic" in America.

Education Reform

Back in October, the New York Times published a very interesting article examining possible causes behind the rising rates of ADHD diagnosis:

Hinshaw, as well as sociologists like Rafalovich and Peter Conrad of Brandeis University, argues that such numbers are evidence of sociological influences on the rise in A.D.H.D. diagnoses. In trying to narrow down what those influences might be, Hinshaw evaluated differences between diagnostic tools, types of health insurance, cultural values and public perceptions of mental illness. Nothing seemed to explain the difference — until he looked at educational policies.

The No Child Left Behind Act, signed into law by President George W. Bush, was the first federal effort to link school financing to standardized-test performance. But various states had been slowly rolling out similar policies for the last three decades. North Carolina was one of the first to adopt such a program; California was one of the last. The correlations between the implementation of these laws and the rates of A.D.H.D. diagnosis matched on a regional scale as well. When Hinshaw compared the rollout of these school policies with incidences of A.D.H.D., he found that when a state passed laws punishing or rewarding schools for their standardized-test scores, A.D.H.D. diagnoses in that state would increase not long afterward. Nationwide, the rates of A.D.H.D. diagnosis increased by 22 percent in the first four years after No Child Left Behind was implemented.

And now, with the implementation of the Common Core, things may get even worse. As the philosopher-comedian Louis C.K. tweeted:

My kids used to love math. Now it makes them cry. Thanks standardized testing and common core!
— Louis C.K. (@louisck) April 28, 2014

A huge amount of my third graders time is spent preparing for and answering questions like this. pic.twitter.com/WU5tEo8JRO
— Louis C.K. (@louisck) April 28, 2014

I am no education specialist, but it's fairly obvious that our education system is not working, and things like NCLB and the Common Core do not address the most pressing need, which is better teachers. This is a problem that is parallel to the emphasis in my profession on useless things like "quality of care", maintenance of certification, and patient satisfaction surveys, rather than increasing professionalism and training better clinicians.

Changes in Professional Training/Culture

Speaking of training better clinicians, blindly applying diagnostic criteria without regard to context is one of the biggest problems in American psychiatry. It leads to situations like this one noted by Dr. Allen Frances on Twitter:

#DSM5 changes increase #ADHD by 50%-a simply crazy expansion when 6% kids already get stimulants http://t.co/6gCcn23xjX
— Allen Frances (@AllenFrancesMD) May 2, 2014

In that study, parents completed a structured interview, designed to cover all of the ADHD diagnostic criteria. This approach is the gold standard in research, yet if you look at the document I linked to, there is no mention of the word "sleep" at all in there. So if a teenager is up all night playing video games and then struggles with focusing at school and doing homework, this approach would flag that teen as having ADHD. Sadly, many doctors, especially those with limited time to spend with patients, use a similar approach when they give parents a questionnaire like the Vanderbilt and then diagnose the child with ADHD if enough 2's and 3's were circled.

If a child does get diagnosed with ADHD, both the American Academic of Pediatrics and the American Academy of Child and Adolescent Psychiatry have published guidelines that say first-line treatment is medication "and/or" behavior therapy. Yet it is very hard for most families to actually find someone who offers this type of therapy; plus, behavioral therapy is much more demanding of parents' time and effort than simply medicating a child, a point I'll address in the next section. Still, increasing access to behavioral therapy can potentially help reduce the reliance on meds. I'm not sure how this is going to happen, but obviously we as a society would have to make it a priority to increase the numbers and the quality of training of those therapists.

As another example of the lack of holistic thinking, there are multiple studies showing a link between certain artificial food colorings and hyperactive behavior in school-aged children. During my child psychiatry training, I heard about these studies from a lecturer who emphasized that the effect size was small. However, a small average effect can mask large effects in individuals who are susceptible to certain insults. Or it may slowly lead to larger effects over long periods of time. In Europe, foods containing those dyes are required to have a warning label that they "may have an adverse effect on activity and attention in children," so most manufacturers have switched to using natural colors so they don't have to show the warning label. Not surprisingly, the FDA decided not to act, citing the need for more research.

Societal/Demographic Changes

One of my previous posts examined the geographical differences in the distribution of ADHD in the U.S. Clearly, societal factors like higher rates of single parenthood, lower social mobility, etc. have an impact on which children get diagnosed with ADHD.

One of the biggest issues I come across is how everyone is super-busy all the time, especially parents with young children who have to juggle their jobs and child-raising responsibilities. Not surprisingly, given how exhausted many American parents are, it is easy to give in to the temptation of having television or an iPad be a babysitter/pacifier. This of course comes at a huge cost to the relationship between parents and their children. Child in Mind is an excellent blog that has many posts on how parent-child interactions are critically important for the development of self-regulation skills in children, which significantly impact emotions, behaviors, and the ability to concentrate. There is also evidence that parents and schools can effectively teach self-control to children in ways that do not require harsh treatment or bribery.

Thus, measures that take stress off parents and increase the time that they can spend with their children is something that our society needs to invest in. Universal daycare/preschool is just one example. According to this article, "the U.S. ranks third to last among OECD countries on public spending on family benefits." If you don't think that has anything to do with why we lead the world in ADHD, then I'd love to hear your explanation.

In conclusion, there are no easy fixes to the problem of ADHD over-diagnosis/treatment in America, because it is in large part a reflection of some thorny societal/cultural problems. But that doesn't mean there are no solutions. The problem does require addressing issues on multiple levels, and not simply prescribing more pills.

What It Will Take to Decrease ADHD Rates, Part 1

I have nothing but respect for Dr. Allen Frances, who has done as much as anyone to raise awareness about the dangers of over-diagnosis and medicalizing normality. He had written extensively about the causes behind the rising rates of Attention-Deficit/Hyperactivity Disorder (ADHD). His recent blog post, My Prediction: The ADHD Fad Is About to Fade, surprised me with its optimistic tone.

First, Dr. Frances points out some of the forces that have led to the excessive diagnosis of ADHD and its treatment with stimulants, including big pharma with their lobbyists and deep pockets, perfectionistic parents, recreational users, chaotic schools, and ADHD experts who see only the benefits but not the risks of treatment. He then goes on to list his reasons for "making the long-shot bet that [the ADHD fad] will now begin to fade":

• The percentage of kids being diagnosed (11 percent overall, and 20 percent of teenage boys) is so absurdly high that reasonable people can no longer accept that the label is being applied with anything approaching sufficient care and caution.

• The astounding rate of stimulant use (6 percent overall, and 10 percent in teenage boys) shocks us into the realization that we are creating a generation of drugged kids.

• Studies show that stimulants are much less effective than we originally thought in improving long-term school performance.

• Some of the leading experts who developed the concept of ADHD and did the best research are speaking out about their surprise and dismay at the way it is now being misused.

• The press is now on the case, with frequent exposés of careless ADHD diagnosis and stimulant misuse. Alan Schwarz of The New York Times deserves special mention (and a Pulitzer prize) for his vivid, in-depth reporting, but this story is now receiving extensive international coverage and has long legs.

I hope that Dr. Frances is right. However, I am not nearly as hopeful as he is "that parents will now play an active role in curtailing the ADHD fad, protecting their kids from unwarranted diagnosis and potentially harmful medication treatment."

I certainly agree with Dr. Frances's first two points about the "absurdly high" rates of diagnosis and "astounding rate" of stimulant use. However, I am not convinced that statistics like this will lead to people clamoring for change. As the saying (apocryphally attributed to Stalin) goes, "A single death is a tragedy; a million deaths is a statistic." For example, the U.S. locks up far more of its adults than any other developed nation. Yet I do not detect much outrage, except among the minority populations that are disproportionately incarcerated. Even liberal Americans who are upset by the high rates of incarceration would probably not mind if someone who burglarized their house got the maximal sentence. Similarly, the average person reading about the skyrocketing rates of ADHD might be taken aback, but that feeling is unlikely to translate into action, especially if this person's child is falling behind in school or not behaving, and the doctor offers a pill as the standard treatment.

In my own experience, the rising rates of ADHD treatment have just made it a more acceptable topic of everyday conversation, so I sometimes have parents come to me saying that the child of an acquaintance of theirs was transformed by a medication, and now they want the same pill for their child as well. The parents I meet who would prefer not to have their child on a medication by and large know nothing about the rates of ADHD diagnosis and treatment; they just think it's wrong to give their child a brain-altering pharmaceutical.

As for the third and fourth points, I think the experts who are dismayed by the high rates of ADHD are still in the minority, while most ADHD experts tend to have views similar to those expressed in a recent JAACAP editorial:

Importantly, although rates of medication use have increased in the past decade, approximately 70% of children and teens with current ADHD are receiving medication treatment (6.1% divided by 8.8%). Although not every child or adolescent with ADHD requires medication treatment, the study documents a pattern of undertreatment. Because stimulant medication is the core evidence-based treatment for ADHD, undertreatment is an important take-home message from this study.

When academics such as these discuss the studies showing lack of long term benefit from stimulants, they tend to emphasize that that the children and adolescents studied were on too low of a dose (usually blamed on pediatricians and PCPs), or did not take the medication for long enough.

As for Dr. Frances's last point, I hope the media keeps up their coverage. However, I think back to circa 2008, when Senator's Grassley investigations put many big-name psychiatrists on the hot seat, and I wonder how much lasting change resulted from those news reports. It seems that the news cycle moved on, and unethical behavior and conflicts of interest continue to be pervasive amongst the top echelons of medicine and psychiatry.

While I may come across as quite pessimistic here, in a future post I will outline some things that I do think can eventually help decrease the over-diagnosis and treatment of ADHD.

On Integrated Mental Health Care

The American Psychiatric Association sure seems to be pushing hard for integrated (a.k.a. "collaborative") care these days. They even commissioned a report on how integrated care would save the system billions, which the Psych Practice blog recently dissected. APA president Dr. Jeffrey Lieberman, who is nearing the end of his term, recently published this piece in Psychiatric News. The attitude is one of "change is coming, so we'd best prepare." In this post, I'd like to take a critical look at various aspects of integrated care, based on my own (admittedly limited) experience.

First, why is integrated care a good idea? Where I work now, many psychiatrists do not accept insurance, and it can take patients months to get in to see a psychiatrist. When they do see a psychiatrist, the psychiatrist and referring physician are often too busy to communicate with one another. In some places, primary care doctors are forced to handle psychiatric patients with severe illnesses like schizophrenia, as highlighted in this post by Dr. Maria Yang. With children, pediatricians with very little psychiatric training often end up counseling parents about behavioral issues and prescribing medications, due partly to the severe shortage of child and adolescent psychiatrists.

Just as the American health care system is not just one system, but a patchwork mostly local systems, integrated/collaborative mental health care is not one thing; it can be done in many different ways. Several years ago, I experienced integrated care first-hand when I worked as a consulting psychiatrist in several primary care clinics that mainly provided care for underserved populations. Not surprisingly, most patients I saw were over 40 and had multiple medical problems. Most were referred to me because of depression or anxiety, though a significant number had a personality disorder, bipolar disorder, or schizophrenia. I got to spend an hour for each new patient visit and 30 minutes for each follow-up. In some of the clinics, I was told I should try to refer the patient back to their primary care physician (PCP) after 6 visits with me, though they were generally flexible about that.

I have to say, it was overall a good experience for me. I got to focus on providing patient care and did not have to deal with insurance companies or pharmacy benefit managers, since the clinics mostly used a generic formulary for medications. I was also glad that I helped not only the patient, but fellow physicians as well. The primary care doctors were uniformly and sincerely appreciative of having a psychiatrist that they could quickly refer patients to, or quickly consult with on a "curbside" basis. The patients tended to show up consistently for their appointments and liked having more time to talk with me compared to their brief PCP appointments. In one of the clinics, where the patients were mostly refugees and immigrants, few of them would have sought out a therapist or psychiatrist on their own, but they were more comfortable going to their doctor's office to meet with me. This all seems to concur with the APA's view of things.

That being said, my experience with integrated care was far from perfect. I thought that the vast majority of patients I saw would have benefitted from psychotherapy, yet very few of the clinics employed therapists, and none had access to more intensive treatments like dialectical behavior therapy. Even in the clinics that did have therapists (usually LCSWs), they were usually full and could not readily see new referrals. Because of the therapist shortage, I often ended up prescribing a medication by default. And of course, other forms of integrated care may be much more compromised than what I experienced. For example, managed care organizations seem to focus much more on cost containment, screening using rating scales, and then using medications to get those numbers down. To quote Sandra Steingard's comment last month on the 1Boring Old Man blog:

I was at a conference where a psychiatrist enthusiastically described her experience with collaborative care. Every morning, the treatment team would get together (the “huddle”). She gave an example of why this was so helpful. One day, someone mentioned that someone’s PHQ-9 had gone up by a few points (this is a nine item screening for depression). The presenter said something like, "So we agreed to increase the fluoxetine from 20 to 40 mg and we were all set to go!"

I also get quite concerned when I read things like Dr. Lieberman's article, which reflects the thinking of the APA leadership. From his closing paragraphs:

The difference between challenge and opportunity is often one of perception. Psychiatrists can view health care reform as leading to an inevitable change from the status quo and worrisome loss of autonomy. Alternatively, they can recognize that psychiatrists are well positioned to participate in and direct new health care initiatives—to become leaders of change, rather than siloed providers outside the mainstream of modern health care. We are the most highly trained, knowledgeable, and best positioned of all health care specialists to determine and provide (or at least oversee) the care of people with mental disorders. We are also mental health advocates who can identify gaps in service, educate others on the role of psychiatry, and offer concrete ways to better serve those within our communities.

There is a historic and exciting opportunity for psychiatrists to influence the future of medical care and occupy our rightful position in the field of medicine. Our nation is still at the beginning of the reform process, and we have the ability to influence its direction, but not if we choose to sit on the sidelines. It is important for psychiatrists to stay involved, not only in practice settings, but as APA members at the local and district branch levels. Step up and make your thoughts known to health care and government leaders; most are willing to listen if we offer ideas and solutions.

Is the focus on improving patient care, or something else? I believe that most psychiatrists are secure with their professional identities, and it is the more biologically-oriented psychiatrists who feel that we must claim our rightful place amongst other medical professionals. It's clear that they fear that psychiatrists would just opt out of the system entirely and remain in solo practice or collaborate mostly with independent psychologists and therapists. This would open the door for people like prescribing psychologists or nurse practitioners to fill the unmet need of psychiatric prescribers in medical settings. So on some level, this is a political battle as the APA fights to retain the mantle of mental health leadership. Why else do you think they have prominent politicians like Bill Clinton and Joe Biden opening the APA annual meetings?

In my mind, the biggest unmet need in mental health right now for the insured population is increasing the numbers of providers of effective therapies like CBT, DBT, PCIT, and so on. Of course, the APA does not address this at all. Instead, what the biological psychiatrists tend to emphasize is that primary care doctors don't diagnose enough, don't use the right dosage of medication, and patients do not stay on medications for long enough. Thus, the relentless push for diagnostic inflation, mass screening so cases are not missed, medication algorithms so that doses are optimized, and tracking patients like they're widgets in a factory. If psychiatry changes in accord with this vision, it would profoundly alter who enters this profession (if it continues to exist at all). Most psychiatrists I know went into this field because of a desire to treat the whole person rather than just symptoms, not to "or at least oversee" treatment provided by someone else. This type of system would favor those whose interests lie primarily in numbers, charts, "huddling" with a team. Is this really what anyone other than the APA wants business interests of managed care want the future psychiatrist to be?

This post was edited to more accurately reflect what I meant to say. Thanks, Dr. Dawson!

Book Review: Slow Getting Up

Over the weekend, I read Nate Jackson's Slow Getting Up: A Story of NFL Survival from the Bottom of the Pile in almost one sitting, a rare thing these days with my attention span getting ever shorter. Jackson was an unlikely success story, someone who beat the odds by making it to the NFL and playing for six seasons despite not being drafted after playing for a Division III college.

Jackson very vividly captures the bravado of the professional athlete: the pride in his extraordinary physical prowess, the adrenaline rush of stepping onto the field, the agony of being in the purgatory of NFL Europe, the fear of appearing weak, the drunken cash-burning Vegas partying, the frenzied testosterone-fueled cracking of helmets.

The book is wickedly funny in parts, such as when Jackson described having to be at practice early because he was part of the special teams unit:

Forty-five minutes later the rest of the team shows up. Starters don't come to special teams meetings. They're happy not to play during the ritual sacrifice of kickoffs and punts, but maybe they're also a bit envious. We're a tight-knit group. We know things the other guys don't. We know about fifty-yard dead-spring head-on collisions. We know about snot bubbles. We look at the game differently. [p. 101]

The gallows humor pervades much of the book, but the most jarring passages are when Jackson quotes from his own extensive medical record. The dry technical language belies the horrible ravaging that his body has suffered. From one of his later injuries:

MRI findings:

High-grade complete tear and stripping of proximal left adductor longus and brevis, with distal retraction and about 5cm tear defect gap with intervening edema and hemorrhage. Strain of the adjacent pectineus and obturator externus and gracilis muscles and attachments.

Moderate proximal hamstring tendinosis and/or strain and scarring are seen, with longitudinal thinning and possible tearing of the proximal deep margins at the ischial tuberosity attachments bilaterally. [p. 185]

From my viewpoint, Jackson's interactions with the team doctors take on a surreal quality. They ostensibly warn him of the risks and benefits of procedures such as steroid or NSAID injections, but it's a foregone conclusion that he would do whatever might get him back onto the field the fastest. Of course, the doctors were serving the team more than the players: one passage describes how Jackson's injuries were first reported to the team's management and the coach before he himself found out what was going on. The long-term health of the player did not factor much into the equation.

Ultimately, what I got out of the book is that the NFL is a profit-generating industry, which like all others, seeks to maximize its profits. It treats the players as replaceable cogs in a machine, parts that can easily be replaced when broken. Sure, coaches and general managers are frequently hired and fired as well, but it is the bodies and minds of the players that pay the ultimate price for our entertainment. Yet at the same time, players enter into this arrangement willingly (at least in the beginning), attracted by the money, the glory, the desire to be compete with the best in the world.

And that brings me to perhaps why I wrote this post today. There was an article in The Daily Beast making the rounds: How Being a Doctor Became the Most Miserable Profession. The article highlights a litany of woes, including the high suicide rate amongst doctors, the fact that 9 out of 10 doctors would discourage others from joining the profession, and how doctors have to see so many patients now that "the average face-to-face clinic visit lasts about 12 minutes."

Just as the NFL uses its players for profit maximization with little regard for their well-being, the healthcare system uses doctors in the same way. I tend to believe that what keeps most doctors in the profession is not the quest for money or status, but a sense of duty, of wanting to help patients and not abandon them. So in this way, doctors might actually be worse off than NFL players. There's no collective bargaining agreement. Doctors – in the U.S., at least – don't go on strike. The associations that are supposed to represent doctors often seem to collude with the business forces of medicine rather than look out for the interests of practicing clinicians. Doctors are not so easily replaced, and since there's already a big doctor shortage in the U.S., we've been sucking up physicians from the rest of the world's supply.

Compared to primary care, psychiatrists have it relatively good. Many are still in solo private practices, not on insurance panels and seeing a manageable number of patients per day. Others work in public-sector roles. Yet with every passing year, the system creeps closer to requiring psychiatrists to participate, ostensibly to help contain costs with measures like integrated care. What can be done to change it for the better? The current path is clearly not sustainable. Cost containment is clearly being targeted at the wrong level. How about containing costs here, or here? Now that would be a great start!

Losing the White Coat Part 2: Residency

This is part 2 of a series on the evolution of my approach to psychiatry. Part 1 was about my medical school experience, and A Most Influential Professor described a key experience I had in college.

I went into psychiatry because I was fascinated by the variety of human emotions, behavior, and psychopathology, and I wanted to explore the plethora of influences (cultural, social, psychological, and biological) on those aspects of humanity. My medical school emphasized the biological approach, so I decided to continue my training elsewhere for residency.

At my residency program, while there was more of an emphasis on psychotherapy compared to my medical school, the biological psychiatrists still reigned supreme. The university had some well known psychotherapists, but they tended to have titles such as "emeritus professor" or "clinical professor," meaning that they were not around very much. And I doubt they would have felt welcome, with the residents' main jobs being completing paperwork and adjusting medications during the majority of their rotations, rather than running groups or conducting therapy.

It was easy to see who the big money-makers of the department were: the researchers who focused on the neural basis of mental disorders while providing biological treatments in their clinical practice. There was a bipolar disorder expert, who once had a patient on 10 different medications, to the point that it was impossible to tell what was the patient's "disease" and what were the side effects. There was the schizophrenia expert who headed the locked inpatient unit, who frequently gave talks to psychiatrists in the community advertising the newest antipsychotic medications. She claimed that because she was on the speaker bureau for all the big pharma companies, she was unbiased in her assessment of the medications. And then there was the renowned depression expert, who once told us, "Even if the medications are no more effective than placebo, it doesn't mean that you shouldn't treat the patients." Make of that what you will.

However, the experience that opened my eyes most to the flaws of a purely biological approach to psychiatry was what I saw happening with Dr. Z, one of the psychiatrists on the electroconvulsive therapy (ECT) service. He gave great lectures, drawing up pretty diagrams of the circuits in the brain believed to underly mood and depression. Unlike most psychiatrists, he often walked around in scrubs, and he had a confident charm to go along with a cheerful disposition. Perhaps appropriately so, since he offered a treatment unparalleled in its effectiveness for patients with severe psychotic depression and bipolar disorder.

The problem, though, was that the bipolar disorder diagnosis (and its attendant "treatment resistant depression") became so loosely applied that practically anyone with mood swings was being diagnosed with "bipolar II," and Dr. Z fully embraced this trend. His evaluations for whether a patient was a good candidate for ECT were thorough, to a point. There was meticulous documentation of the medications that the patient has tried and the inadequate response to them. Mostly ignored, however, were details about what the patient's life was actually like and what factors may have been influencing their symptoms. Thus, plenty of patients who clearly had borderline personality disorder (BPD) were deemed "excellent candidates" for ECT; none of the depression medications that they had tried ever did lasting good, since their moods would turn depressed or irritable in response to interpersonal stress, regardless of what meds they were taking.

I remember hearing two stories in particular about his patients (details altered to protect anonymity). One day, a patient of Dr. Z's arrived in clinic holding a knife to her chest after her boyfriend broke up with her. She told the astounded clinic receptionist that she would stab herself if she did not see Dr. Z right away. Dr. Z was not in, and the patient ended up walking into the office of another psychiatrist, who managed to calmly talk her down while security was notified. Another time, a patient was dragged kicking and screaming into the ER after swallowing a handful of pills during an argument with her husband. She was heard yelling, "I'll only talk to Dr. Z! Where is he? I know he's coming because he loves me!" Dr. Z clearly had a profound effect on his BPD patients, even if the benefits of ECT for those patients was very temporary.

Recently, I read Dr. David Allen's post on the difference between the symptoms of major depression and the depression often seen in BPD. But even back then something felt off to me about doing ECT on patients who had "treatment resistant depression" because of a personality disorder, which brings me back to the title of this post. At the institutions where I trained, the psychiatrists who wore the white physician's coats, not surprisingly, tended to be the more biologically-oriented ones. Thus, in my mind the white coat became associated with their view of psychiatry, one that I did not share.

Thankfully, my mind was already set on being a child psychiatrist. At least in the world of child psychiatry, despite the influence of biological psychiatrists like Harvard's Biederman, many (I don't dare to claim "most," given the direction things seem to be heading) child psychiatrists still consider the influence of things like family, parenting, and developmental trauma on behavior, rather than just focusing on figuring out the black box of the brain.

There's a Pill for That…Or Not

A few days ago, I read an article by Los Angeles-based psychiatrist Joseph Pierre titled "A Mad World" (thanks to Vaughn Bell over at Mindhacks for the link). Right off the bat, I was suspicious of the SEO link-baiting done by the Aeon editors: the title that appears on the web browser's title bar is not "A Mad World," but is "Do psychiatrists think everyone is crazy?", and the URL of the article ends in "have-psychiatrists-lost-perspective-on-mental-illness." Of course, Dr. Pierre likely had no control over how the publication chose to market his article; more on this later.

He does make some good points about how mainstream psychiatrists are not as bound by the DSM as some may think:

The truth is that while psychiatric diagnosis is helpful in understanding what ails a patient and formulating a treatment plan, psychiatrists don’t waste a lot of time fretting over whether a patient can be neatly categorised in DSM, or even whether or not that patient truly has a mental disorder at all. A patient comes in with a complaint of suffering, and the clinician tries to relieve that suffering independent of such exacting distinctions. If anything, such details become most important for insurance billing, where clinicians might err on the side of making a diagnosis to obtain reimbursement for a patient who might not otherwise be able to receive care.

However, reading through the piece gave me a very uneasy feeling. After thinking about it some, I think my discomfort comes from the author's uncritical acceptance of American consumerism, as illustrated by sections like this one:

Though many object to psychiatry’s perceived encroachment into normality, we rarely hear such complaints about the rest of medicine. Few lament that nearly all of us, at some point in our lives, seek care from a physician and take all manner of medications, most without need of a prescription, for one physical ailment or another.

Now, I love being a consumer as much as most other Americans. The convenience of being able to do just about anything ("There's an app for that") on a handheld device is incredible. But what happens when you mix healthcare and consumerism? You get commercials telling viewers to "ask your doctor about" lots of different conditions, whether it's chronic dry eye, low T, or whatever. We already live in a county where the costs of healthcare far outweigh the benefit in terms of life expectancy, so isn't the over-medicalization of normality worth lamenting, even if most people don't? And certainly when it comes to healthcare, the consumer is not always right, though doctors often give in and end up doing things like prescribing antibiotics for viral illnesses.

And then there was this passage, straight out of a pharma executive's wet-dream:

Pharmacotherapy for healthier individuals is likely to increase in the future as safer medications are developed, just as happened after selective serotonin re-uptake inhibitors (SSRIs) supplanted tricyclic antidepressants (TCAs) during the 1990s. In turn, the shift to medicating the healthier end of the continuum paves a path towards not only maximising wellness but enhancing normal functioning through ‘cosmetic’ intervention. Ultimately, availability of medications that enhance brain function or make us feel better than normal will be driven by consumer demand, not the Machiavellian plans of psychiatrists.

SSRI's have been around for over 25 years, and where are the safer medications? Has he not been reading the headlines? He continues with:

The legal use of drugs to alter our moods is already nearly ubiquitous. We take Ritalin, modafinil (Provigil), or just our daily cup of caffeine to help us focus, stay awake, and make that deadline at work; then we reach for our diazepam (Valium), alcohol, or marijuana to unwind at the end of the day. If a kind of anabolic steroid for the brain were created, say a pill that could increase IQ by an average of 10 points with a minimum of side effects, is there any question that the public would clamour for it?

Suppose we have a pill that could take away pain but has no side effects whatsoever, including constipation, sedation, deadliness in overdose, etc. Isn't it obvious that an emergent effect (whether or not you call it a "side effect" or not) is that people would be hooked on this pill, and it would have enormous street value? Perhaps I'm just old-fashioned, but I get the sense that side effects (e.g. passing out drunk, getting jittery from caffeine, becoming duller from chronic cannabis use) are nature's way of keeping us from going overboard with too much of a good thing.

Dr. Pierre states toward the end:

In the final analysis, psychiatrists don’t think that everyone is crazy, nor are we necessarily guilty of pathologising normal existence and foisting medications upon the populace as pawns of the drug companies. Instead, we are just doing what we can to relieve the suffering of those coming for help, rather than turning those people away.

Drug dealers can make the same argument, that they're just there to meet a consumer demand, relieve suffering, and increase happiness. Of course, with drug dealers it's easy to see that their products have very short-term benefits but cause long-term harm. While not nearly as extreme, I believe that if all we're doing is relieving suffering without helping patients recognize and change what led to the suffering, we are not truly helping them in the long run; we're just turning them into repeat customers. And suffering itself is not always a bad thing. In the field of child psychiatry & psychology, for example, we are increasingly recognizing how parents' efforts to protect their children from any suffering can lead to those kids having trouble being on their own or dealing with stress later in life.

I don't advocate turning people away, but I often emphasize to patients that feeling better is going to take significant time and effort on their part, and is not something I can just give them, which may not be what a good consumer wants to hear. Which brings me back to my first paragraph. I not only pointed out the methods Aeon used to market the article to consumers, but I also mentioned that Dr. Pierre works in L.A. This is not a coincidence, as L.A. is one of the epicenters of American consumerism. This article is emblematic of how consumerism operates and is a defense of it, by someone who may be too immersed in a consumerist culture to see its follies.

Insel's Techno-Utopia

In a recent post, 1BOM likened the key opinion leaders (KOLs) in psychiatry who gathered at two glitzy meetings to fashion commentators at the Oscars:

It was Dr. Schatzberg’s comment at the end, "More needs to be done now if we are to have new treatments in the next decade..." It sounded to me like those dress designers thinking about what new innovations they could muster for the coming year. It has to be something new – novel, innovative, a new look, a new material, a new something to drape the pretty ladies with on the red carpet next year. […]

The psychopharmacology era from 1987 to the recent past has been like that. The next wonderful new antidepressant has to be more desirable than the last one. The novel way of accessorizing [sequencing, combining, augmenting] has to be value added. Without a pipeline producing something new periodically, the shine wears off of the old drugs and their foibles begin to show. So we need a new design, a new line [as they say in the garment industry], something to keep the momentum flowing. But our KOLs haven’t been like the dress designers, they’ve been more like the Red Carpet commentators who talk about other peoples’ designs – giving talks like recent advances in …, or neurobiology of ..., or writing review articles, or signing on to the industrial clinical trials – more groupies than stars. That must be why they’re so frantic. Commentators with nothing to comment about.

I think that's an interesting analogy, but for me it doesn't quite hit the nail on the head. To me, a more apt analogy is along ideological lines. Lately I've been reading Steven Pinker's The Better Angels of Our Nature, a very detailed and data-driven book about why violence has declined over time. I was struck by the following passages about the roles of utopian ideologies in promoting violence:

Institutionalized torture in Christendom was not just an unthinking habit; it had a moral rationale. If you really believe that failing to accept Jesus as one's savior is a ticket to fiery damnation, then torturing a person until he acknowledges this truth is doing him the biggest favor of his life; better a few hours now than an eternity later. And silencing a person before he can corrupt others, or making an example of him to deter the rest, is a responsible public health measure. [p. 16-17]
[…]
Revolutionary and Napoleonic France, Bell has shown, were consumed by a combination of French nationalism and utopian ideology. The ideology, like the versions of Christianity that came before it and the fascism and communism that would follow it, was messianic, apocalyptic, expansionist, and certain of its own rectitude. And it viewed its opponents as irredeemably evil: as existential threats that had to be eliminated in pursuit of a holy cause. [p. 239]

Of course, none of these KOLs are like Napoleon, Stalin, Mao, etc. Thank the deity of your choice that they do not have that much power, and that we live in a much more peaceful time. These days, scathing editorials questioning a person's integrity are as dirty as the KOLs get.

But just like those utopian movements, much of academic psychiatry (especially the KOL segment) is driven by an ideology: the tenets of biopsychiatry, which the 1 Boring Old Man blog has described in detail. This ideology is assumed to be correct, and because its believers think that this system will result in a huge amount of good (i.e. "NIMH envisions a world in which mental illnesses are prevented and cured"), then people who seem to oppose this ideology are at best deeply misguided, at worst causing irrevocable harm. Furthermore, anything short of this grand vision is deemed not worth pursuing.

In my mind, this is the best explanation for why things like Paxil study 329, or the Markingson case, or problematic conflicts of interest, or millions of mentally ill being locked up in jails and prisons, get ignored by the leaders of academic psychiatry. They're seen as relatively insignificant bumps in the road in the grand utopian scheme. Last year, I wrote a somewhat tongue-in-cheek post about what if the NIMH succeeds in its utopian vision. With the recent news that the NIMH will only fund treatment studies that also examine biological etiology, things are much more serious than I thought.

Why Aren't Mental Conditions Like Physical Ones?

Earlier this week, Dr. David Rettew tweeted me his article on Psychology Today, "What If We All Got Mentally Ill Sometimes?" I thought it was well reasoned and thought-provoking. Here's the last paragraph, which summarizes his argument:

What I am really trying to say here, I think, is that scientifically there is very little to go on to help us figure out where the lower thresholds of psychiatric disorders actually exist. To deal with this reality, we can either reserve the term mental illness for those with the most extreme levels of pathology or admit that the brain, the most complicated thing that has ever existed on this planet, gets a little off track once in a while for most of us and needs a little maintenance.  This maintenance does not and should not be confused with prescription medication or five times per week psychotherapy for all.  There needs to be some productive middle ground between a response of, for example, “It’s ADHD and you need this medication” and “It’s not ADHD (or there is no ADHD) so go home and fend for yourself.” 

My quick response was:

@pedipsych I'm sympathetic to your POV, but in our current culture, more diagnosis = more meds. So better to tackle 15 min med checks 1st.
— Psycritic (@psycrit) March 11, 2014

Here, I'd like to expand on my thoughts a bit more.

In an ideal world, everyone would recognize that the brain is the most complex organ that we have, indeed the most complex object that we know of in the universe. Thus, it would not be surprising that it does not function perfectly all of the time, and putting a label on what (we think) is going on would be as unremarkable as calling an upper respiratory viral infection "a cold." Just as most people get sick with colds twice a year, or suffer multiple orthopedic and soft tissue injuries throughout their lives, shouldn't mental conditions be as commonplace and non-stigmatized?

The problems, though, are many-fold. The first is what happens when someone shows up at the doctor's office looking tearful, depressed, or anxious. The majority of psychiatric medications are already being prescribed by primary care providers. As a medical student, I got to see many general internists rushing from one patient to another, spending 10-15 minutes on each encounter. These doctors had very little time to spend delving deeply into their patients' lives (this answers 1boringoldman's question, "what's the hurry?"). The more patient docs would listen empathetically for a few minutes, and then offer an SSRI or benzodiazepine, letting the patients make the choice as to whether they would like to try medication. So if more people thought that they had some kind of mental condition, more would probably opt for the meds. Psychiatrists, of course, should know better, but we are often just as culpable in taking a "medication-first" approach to treatment, especially when working in settings where we function as little more than medication prescribers/consultants. As the saying goes, if all you have is a hammer…

Dr. Rettew tweeted the following response:

@psycrit In our child psychiatry clinic, 15 minute med checks are banned. It is possible.
— David Rettew (@pedipsych) March 11, 2014

I think it's wonderful that his clinic doesn't do 15 minute med checks. Most child psychiatry clinics at least acknowledge the importance of parents in a child's life, so the minimum is usually 30 minutes to allow time for a psychiatrist to work with the whole family. Unfortunately though, that method of practice is not the default for most mental health care that takes place in this country, and I worry about what will happen with the increased adoption of collaborative care models (nice anecdote here).

What Dr. Rettew proposes requires an adequate framework to provide checks and balances, i.e. using a true biopsychosocial model so that what is happening in the brain is not the only point of emphasis. A (very) rough analogy would that the use of needles to inject medications directly into the body can be a good thing, but it requires a framework of basic sanitary practices like sterilization of used needles and/or disposal, without which the technology could actually cause more harm than good. In The Hot Zone, for example, Richard Preston described how re-use of dirty needles led to ebola outbreaks in Africa. Another example, detailed by Steven Pinker in The Better Angels of Our Nature, is that when democracy replaces autocracy in places that don't have a culture that values pluralism and human rights, the result is often even more chaos and bloodshed.

Additionally, the effect on people of telling them that they have a brain condition is vastly different from telling them that they are suffering from indigestion or hypertension because of the stigma associated with mental illness. I don't think that labeling a significant proportion of the population with a mental illness is a good way of overcoming this stigma, especially when most doctors do not have time to explain the nuances behind psychiatric diagnosis to their patients. To the average patient, a diagnostic label implies a level of knowledge that we do not have. I have seen multiple cases where after receiving a diagnosis with inadequate explanation, patients have felt that there was something wrong with their brains, which for many resulted in more harm than good.

Overall, I agree with Dr. Rettew's message that there should be some middle ground between "diagnose + medicate" vs. "no diagnosis + no treatment." However, I don't think that the medical model is well suited for much of mental health since what contributes to both mental anguish and well-being is so multifactorial. That is why I love NOS/NEC, and I often find myself using "no specific diagnosis + multimodal treatment."