Saturday, February 27, 2010

Psychiatric Diagnosis: The Shorter Version?

If you believed half of the contradictory and baseless assertions of Edward Shorter (Why Psychiatry Needs Therapy, Wall Street Journal Feb 27-28, 2010) you might envision hundreds of thousands of healthy and symptom-free Americans flocking to psychiatrists after seeing themselves described in the new DSM-V and demanding treatment with expensive drugs. And continuing to take these drugs even when they reap no benefit from them.

Nothing could be further from the truth. In fact Shorter should know that many individuals that need help and might seek it, do not, in part because of the stigma that he perpetuates with his pejorative view of mental illness. And like other critics of psychiatry who see the APA's effort to improve on DSM-IV TR as an opportunity, he has failed to offer a better system of categorizing a very real group of individuals who suffer very real symptoms. Few patients continue taking medication unless they feel a definite benefit. And many improve with psychotherapy, ECT, and other treatment modalities.

I will start with the catchy photos at the bottom of the page under the heading "The New Abnormal."

Hoarding: The definition may be new, but the problem is not. What would Shorter have us do with those who want help for this problem?

Mixed Anxiety-Depression: He says himself this combination has been recognized for years. The only new thing about it is its addition to the Manual. Make up your mind, Shorter.

Binge Eating: New? Not! Shorter, you can tell people who want help with this to stop complaining, just control yourself and go away. I can't.

Minor Neurocognitive Disorder: He calls this a commonplace occurrence for anybody over 50. We should not diagnose and treat that which is commonplace? Like the common cold? Like buponic plague? malaria? TB? Last I heard most people in the world suffered from parasitic illness, that's pretty commonplace. Shall we forget about them, too?

Temper Dysregulation Disorder with Dysphoria: He says it's a new way to diagnose fewer kids as bipolar. That's wrong? Perhaps he would have us believe the problem doesn't exist.

Shorter seems to like diagnoses in use in the 50's and 60's he relates to the European scientific tradition, but offers no support for his suggestion that they might have been more "accurate." In fact the diagnoses prior to DSM-III were based largely on very UNscientific psychoanalytic theory, and did not include "nerves" or "nervous breakdown" as he would have us believe. These ill-defined terms from popular language are almost meaningless. Shorter implies that because lithium "sometimes" prevents depressive episodes we should not bother to differentiate bipolar disorder from unipolar mood disorders ignores evidence that some drugs do treat unipolar depressive episodes effectively, and may exacerbate bipolar disorder.

Shorter's assertion that the "new" disorders all respond to the same drugs is not only baseless, but contradicts his later statements that the drugs do not work. He claims that imipramine remains the most effective drug for what he calls "serious" depression. (It also happens to be dangerous in overdose and to have more adverse effects at therapeutic doses than newer agents, many of which cost as little as $10 for a 3 month supply.) Please note that Shorter offers no definition of this category has conjured up on his own, nor any criteria for determining whether someone suffers from it or not. Perhaps we should rename it "Shorter's Disease," but that would be yet another "new" abnormal.

Benzodiazepines: An "undeserved reputation for addictiveness"? In addiction psychiatry we call this denial. I call these drugs practice builders because patients like to keep coming back for more. Has assertion that they are "effective across the entire range of nervous illnesses" is ridiculous, made even more so by the fact that, once again this Shorterism, "nervous illness," has no definition. It doesn't seem to have occurred to Shorter that the large number of prescriptions written might support the idea that many patients become addicted to them.

Shorter would have us believe that DSM-III was a step backward for psychiatry but he fails to mention that it finally dumped psychoanalytic theory and gave us the new phenomenon of multiple psychiatrists examining the same patient actually giving the same diagnosis. This inter-rater reliability was almost non-existent in earlier diagnostic schemes.  Shorter would have us believe that "bipolar" was a new diagnosis. In fact it was just a new name for what was previously called manic depressive illness. Now he tells us what "experienced clinicians" know. And where did you get that piece of information Mr. Shorter? Did you conduct a pole? Do tell us what constitutes an experienced clinician. Would we (or they) really all agree that patients with "chronic depressive illness" (another undefined Shorterist category, thank you very much) "will have" an episode of mania or hypomania? But Mr. Shorter, "mania" and "hypomania" are both defined in the DSM's. Or would you like to propose your own criteria? Or maybe you don't like criteria at all.

Shorter's statement that "anxiety became associated with addiction" doesn't even make sense.

Shorter says that "Major depression" (Does he mean Major Depressive Disorder or Major Depressive Episode?) became the "big new diagnosis." If by this he means that the frequency with which it was diagnosed increased dramatically, I agree, but this may have resulted from changes in reimbursement by insurance companies, another factor Shorter ignores in this discussion.

Shorter assets that SSRI's "don't work for diseases that don't exist." I believe a lot of patients would say otherwise.

If Mr. Shorter this half his students exhibit "disorganized speech" he may not know what it really sounds like. As for "psychosis risk syndrome" identification of at-risk populations may lead to prevention. Shorter would have us pretend such patients don't exist. Even worse he implies that if we don't have "specific treatments" for a disease we should ignore it.

I confess I cannot make sense of Shorter's closing paragraph, but I will resist the temptation to identify it as disorganized speech. What does he mean by what patients "actually have?" Why should we believe the "European tradition" he esteems is so great? And what is it anyway?

Mr. Shorter, all of psychiatry is like drawing "lines in a bucket of water," but that doesn't mean we should give up. Your ideas must be very popular in Canada, where the idea of all these people needing help must incite fear of bankrupting your health care system, but don't you just put them all on the waiting list anyway? or diagnose them all "nervous illness" and give them all benzodiazepines.

Thursday, February 25, 2010

Agents in the Waiting Room: To Warn or Not

Continued from: DEA Suboxone Audits: The Video

I wrote earlier in HIPAA's Gaping Loophole: A Privacy Myth about the problem of compromised waiting room privacy when non-patients appear at the doctor's office. Although we may not always know in advance to expect such and intrusion, sometimes, as in the case of the current audit of OBOT physicians by DEA, we do.

When I became aware that DEA planned to audit my records I informed all my buprenorphine patients. I also informed the psychotherapist with whom I share my office. This seemed adequate until I read notes from a physician who questioned a DEA agent about the audits. According to him agents conducting audits (investigations) of doctors treating addiction under DATA 2000 should, "provide the receptionist a card, but not flashing a badge. Agents are to conduct themselves in a low key manner and will not actively work to attract attention, other than the interaction with the receptionist."

At first I thought, "Good, they will keep a low profile." But then it occurred to me that my patients might want to know whether the person sitting next to them is another patient or a federal investigator. Then I thought about my patients who do not take buprenorphine, and about the patients (or clients) of the other professionals in my office. Maybe I should post a sign in the waiting room:

"WARNING: DEA Agents May Be Present"

I ran the idea by a friend. She said that would be a good way to get rid of patients. Seems to me that anyone in the waiting room has a right to know, and that this fact should take precedence over the possibility that we might lose a few patients. I plan to ask my office mates.

What would you want as a patient? What would you want as a professional? What would you want as a federal agent?

BTW: As of a minute ago, because of DEA's refusal to schedule my audit, I have turned away 8 patients seeking buprenorphine treatment.

Worst Experience of My Career: a Follow Up

Wednesday, February 24, 2010

Commentary on Opinions of APA Ethics Committee VI

Continued from Commentary on Opinions of APA Ethics Committee V this post focuses on opinions relating to role conflict in:

The Opinions of the Ethics Committee on The Principles of Medical Ethics

Other authors have discussed the damage that can result from role conflict extensively, primarily in the context of forensic psychiatry. For example, if a treating psychiatrist provides an opinion regarding her patient in litigation, the opinion may damage the treatment or the treatment relationship, or (less importantly) the psychiatrist may bias her opinion to help the patient.

B.4.a. (2002, page 15)

In this case it appears that action by a government agency may have appeared to create a risk to the patient. The agency has then asked the treating psychiatrist whether "it is OK to proceed." Presumably the agency, by asking whether it is "OK" seems to innocently give the appearance of valuing the patient's health interest. But in reality the agency may simply want the treating psychiatrist to assume responsibility for any adverse consequence. A treatment contract does not include providing such advice to a third party. I agree with the committee's advice to refuse to provide such an opinion. The agency always has the option to retain an independent examiner.

G.4.a. (1973, page 33)

The committee addresses this case as involving conflict of interest. The hospital which employs the psychiatrist to care for a patient also wants the psychiatrist to assess the patient's "competency" (for what?) in pursuing collection of money the patient owes the hospital. The employment situation already constitutes conflict of interest for the psychiatrist: If the psychiatrist treats more patients, the hospital makes more moneys. A similar conflict of interest occurs in all fee for service medicine: If the doctor cures the patient, the doctor loses a source of income. This fact makes professional ethics necessary. So in this case the conflict of interest differs, but only slightly . The role conflict more than any conflict of interest requires the psychiatrist to decline to offer an opinion regarding the patient's competence.

R.4.a (1977, page 80)

The committee seems to have inferred facts not presented in the question as written. A psychiatrist for a student health services inquires about ethical considerations in providing treatment to some students while "seeing others for administrative reasons." The committee seems to assume the psychiatrist might assume both roles with the same student. I see no ethical conflict provided these are different students. If, however, the psychiatrist tries to assume both roles with the same student, I agree that role conflict would create an ethical problem.

Commentary on Opinions of APA Ethics Committee VII

Tuesday, February 23, 2010

Skypiatry Update

My fourth (I'm not exactly high volume.) Skype patient contact today, first time from home, spur of the moment to accommodate a schedule change.

For the first time I tried the Share Screen feature, allowing the patient to watch as I rolled the die at for a random drug screen. If you use this feature be sure you don't show the patient your calendar or other window that might display names of other patients.

Before you use Skype away from the office look behind you. Make sure the patient won't see anything you don't want them to see in the camera field.

Saturday, February 20, 2010

Sally Satel and DSM-V

See Sally Satel's article in Wall Street Journal 2.19.2010 Prescriptions for Psychiatric Trouble

OK, Dr. Satel, it ain't perfect, but it won't get better unless we keep trying. Dr. Satel gives in to the temptation to take pot shots and gives no praise to the latest effort by the American Psychiatric Association to classify mental, behavioral, and emotional problems and offers no suggestion whatsoever of how we might do better.

She criticizes the new Psychosis Risk Syndrome claiming that "a diagnosis believed to foreshadow a full-blown psychotic illness has the potential to be highly stigmatizing." Is not prognosis a major task associated with diagnosis for physicians? And who has stigmatized "full-blown psychotic illness?" Perhaps Dr. Satel herself has done so. Society stigmatizes psychiatric diagnoses. Don't shoot the messenger, Dr. S.

Dr. Satel goes on to say it might be "especially unfortunate if the labeled individual does not even go on to develop such and illness." That's like saying it is unfortunate if someone involuntarily hospitalized because of suicide risk does not commit suicide. I say it's very fortunate if the person so labeled does not go on to develop the illness, especially if the label leads to intervention that plays a role in altering the course. And speaking of stigma, note that Dr. Satel has substituted the pejorative term "label" for diagnosis or classification. So diabetes is a diagnosis, but "Psychosis Risk Syndrome" is a label?

Dr. Satel calls "stunted sexual development" a Freudian concept?  Does she mean "psychosexual development?" Even Freud did not refer to it as "stunted." Freudian theories have certainly failed to meet scientific muster, but Dr. Satel seems to miss the point that before DSM-III there were no diagnostic criteria based on phenomena, just descriptions. And terms like neurosis implied unproven Freudian causes.

Major depressive disorder is not, as Satel claims, the sole designation for "pathological depression," which in fact encompasses numerous disorders such as Dysthymic Disorder, Adjustment Disorder with Depressed Mood, and others. She asks, "How do we know it is not a normal reaction?" Read the criteria doc. It's spelled out clearly. Dr. Satel may also have failed to read the Cautionary Note at the beginning of the DSM. I guess if you're suffering but she doesn't "know it's not a normal reaction" Dr. Satel will refuse to help you.

Dr. Satel rightly suggests that the "causal mechanisms" of mental illnesses might be staggeringly complex, but she fails to state that such mechanisms have yet to be defined at all. Would you have us wait until we know the mechanisms before we classify the disorders -- or treat the patients who suffer from them?

Dr. Satel criticizes the manual for failing to divide the diagnoses "as tidily as the manual implies,"  because, for example, the same patient might suffer from bipolar disorder and ADHD. Perhaps she would have us give up. Just call them all crazy and lock them away. Why might someone not have 2 or more psychiatric disorders? You can have fleas AND lice.

So Dr. Satel, we might take a few steps back, but DSM-V will very likely move us forward at least a little.

Friday, February 19, 2010

Medical Staff: Active but Inactive

A few weeks ago the hospital where I hold "active" privileges sent me the usual form where I must fill in the names of other physicians who can vouch for my competence. Did I say active? I have not admitted, managed, or consulted on a case there in years (decades?).

What better way to determine the quality of a doctor’s work could there be than the repeated and collective observations of other doctors, nurses, and even administrators, in the hospital where he or she works day in and day out. Little wonder that many health insurance companies require doctors to declare their active hospital medical staff status contracted as providers in order to contract a preferred providers.
But doctors in private offices (like myself) practice almost in secret. Even their colleagues in the same office may have scant opportunity to observe the quality of their work. Only their patients may really know how they work, but patients often appreciate doctors doing the wrong thing or shun doctors who do the right thing, to obtain drugs for example.

So active membership on the medical staff of a hospital would seem to almost guarantee quality. When most doctors followed their patients from office to hospital and back again, you could rely on that system. But today hospitals hire “hospitalists” who work only in the hospital and only for the hospital, usually for a salary, and doctors who work in their offices rarely if ever care for hospital patients. How does the hospital determine that these doctors still deserve “active” privileges without the opportunity to observe their work directly? They require the doctors to provide references from their colleagues. Doctor A says Doctor B does great work. Doctor B says Doctor A does great work. And neither has more than a vague idea of the quality of the work of either. You scratch my back, etc.

Most of those doctors probably justify our faith in the quality of their work, but why do we allow this sham conspiracy of insurance companies, doctors and hospitals to continue? Health insurers need panels of doctors willing to reduce their fees in exchange for access to larger numbers of patients, and hospitals want those office based doctors to refer their sick patients to them.

I do not mean to suggest that hospitals should not allow doctors who do not admit patients some kind of affiliation. For myself I am grateful for the opportunity for continuing education and (almost) free lunches with colleagues as well as an opportunity to serve the community by my activity on committees. And the medical staff lounge provides opportunity for discussing specific cases as well as medicine in general, sometimes enhancing collaboration on cases or referrals back and forth.

Historically hospitals have classified staff privileges as active, courtesy, and consulting. Usually hospitals grant courtesy designation to physicians who can prove active status at another hospital. Physicians with consultant status are allowed to provide consultation only; they are not allowed to admit patients or manage their care.

When hospitals allow insurers to exploit there reappointment process it only serves to weaken the house of cards of our health care system by creating an illusion of quality where it may not exist. It should be abandoned in favor of a valid method of determining how well doctors care for their patients when they cannot be observed directly. Instead the insurers should find ways to assess physician competence, and I hope hospitals will find a way to encourage physician affiliation that benefits all. JCAHO should give its blessing.

Wednesday, February 17, 2010

Commentary on Opinions of APA Ethics Committee V

The Opinions of the Ethics Committee on The Principles of Medical Ethics

Continued from Commentary on Opinions of APA Ethics Committee IV where I reviewed opinions related to uses or publication of psychiatric case information which seem to require the ethical psychiatrist to obtain patient authorization for release of information unless the information is disguised. The committee also asserts that "the problem of disguising cases is not always easily resolved" and that consent for release should be "freely" given, but that "there is no way to assure that the patient does not feel coerced into giving consent." This detour into a case I filed addresses these apparent contradictions.

In September of 2008 I submitted an ethics complaint related to three psychiatrists whose cases were described in an article published in the NY Times, to the New York District Branch of the American Psychiatric Association. In my letter I pointed out that the article included no indication that the cases were fiction or even disguised, and in fact the NY Times is known for carefully confirming the veracity of information contained in articles. Neither was there any indication that patients described had consented to publication of their cases.

After more than a year passed without a determination I asked about the status of the investigation. I received a letter from the District Branch Ethics Chair, Henry Weinstein, MD, dated November 10, 2009 indicating that the committee had deliberated and "acted accordingly" but could not tell me "either the processes or the substance" of the committee's work. However, the committee was more forthcoming with the NY Times. In an enclosed letter dated October 15, 2009 addressed to the Public Editor a Dr. Kevin Kelly wrote on behalf of the NYDB that the named psychiatrists "were scrupulous about either obtaining consent from their patients before publication or disguising the material in such a way that the patients could not be identified." The letter went on to express concern that lay readers might not understand that consent must have been obtained, and that this might lead them to "avoid needed treatment." The letter concluded that a psychiatrist should only allow such material to be published or to write an article including such material if a statement that the material was disguised or that the patient consented accompanies the article.

In spite of the above the Oct. 20, 2009 New York Times included an article by psychiatrist Richard Friedman, When Parents Are Too Toxic to Tolerate, describing two cases in which he struggled, apparently in his role as a psychotherapist, with how to handle the dilemma some of us face in deciding whether (or how much) to distance ourselves emotionally from troublesome parents. As in the former article this article contains no mention that the author disguised the cases or that the author obtained authorization for publication, freely or otherwise, from his patients or the several other individuals mentioned.

Did I expect the NY Times to, "Stop the presses!" to make sure the more recent article would conform to the NYDB letter's requests? Not really. The NY Times has no obligation to comply with ethical guidelines suggested by NYCDB, or even APA. Journalistic ethics no doubt apply. Although the letter to the Times was a nice gesture it was Dr. Friedman was responsible for compliance. Furthermore, the Time represents only one of thousands of publishing organizations who could potentially impact the problem.

The NYDB ethics committee disappointed me, though. Having served on the ethics committee of a state psychiatric association myself I have some familiarity with the procedures. For the committee to provide information about the determination to a public newspaper while withholding it from the complainant defies belief. Also, I have understood that Ethics complaint procedures require the local committee to indicate in the final letter that the complainant can appeal the determination to the APA committee. In this case the committee  informed me neither of a determination nor of the right to appeal. I wrote (December 11, 2009) both Dr. Weinstein and the APA ethics committee indicating I wanted to appeal the determination as expressed to the NY Times, pointing out that neither of the letters mentioned whether the committee considered the issue of whether it is possible to obtain freely given informed consent for such an endeavor (which is unlikely to benefit the patient at all) or attempted to address the question of what might constitute adequate disguise of such information.

Having never received even an acknowledgment of either letter from APA or NYCDB I contacted APA to inquire as to the status of the case. In an email communication from APA dated February 11, 2010 (two months after my letter) I was informed that APA had requested the case file for review by APA Ethics Committee. For a response to my question about adequate disguise I was referred to the British Journal of Psychiatry Instructions for Authors (viewed 2.16.2010):

"If an individual is described, his or her consent must be obtained and submitted with the manuscript. Our consent form can be downloaded here. The individual should read the report before submission. Where the individual is not able to give informed consent, it should be obtained from a legal representative or other authorised person. If it is not possible for informed consent to be obtained, the report can be published only if all details that would enable any reader (including the individual or anyone else) to identify the person are omitted. Merely altering some details, such as age and location, is not sufficient to ensure that a person's confidentiality is maintained."

I might wish the NY Times would adopt such a policy, but there are a number of problems with BMJ's approach, not the least of which is that by providing a copy of the consent the psychiatrist reveals the identity of the patient to the publisher. The suggestion that the patient read the report before submission raises further questions. Can the psychiatrist presume that the patient possesses the necessary skill, knowledge and judgment to assess the potential for damage? Will this task take away time from a psychotherapy session for which the patient must pay? Will the psychiatrist attribute some kind of therapeutic value to the exercise? Will the patient feel pressured to give consent to please her physician? The BMJ guideline suggests use of disguise only if "it is not possible for informed consent to be obtained." But this could include situations in which the patient refuses to consent. What then? The guideline does provide a standard for judging adequacy of disguise, but how can we apply this standard? I confess that I cannot offer a better solution.

As for my letter to the NYCDB, as yet I have received no acknowledgment.

For myself I lean toward the practice of fabricating all cases for publication and clearly stating that the cases are fabricated. Because I do not believe that patients possess the capacity to give truly informed consent or that consent can be freely given, to release information that will not benefit the patient in any way, I believe no patient should be burdened with a request for consent to publish.

In the next installment I address opinions related to role conflicts: Commentary on Opinions of APA Ethics Committee VI

Saturday, February 13, 2010

Skypiatry, Emergencies and Offices

Yet another patient contact via Skype reveals new questions and possibilities. So far I have not even mentioned the option to all of my patients, since there are some with whom I only want to visit the office. On the other hand a few patients have made it clear for a variety of reasons that they do not want to use Skype. Couple that with what has become a major pre-Skype hassle: getting a signed copy of the agreement under which I conduct these contacts. This convinces me that, rather than only asking select patients to sign the agreement, I plan to ask all to sign it next time they visit the office, so we will have that out of the way just in case we decide to use Skype on the spur of the moment.

Over at Shrinkrap a rich debate over what constitutes a psychiatric emergency raged last week. Of course I remain clear that emergencies demand 911 and emergency rooms, but occasionally psychiatrists and patients will want to get together sooner than they might have planned in non-emergent situations. My office lease ends in November. Even pre-Skype I try to avoid going to the office when I can, preferring to work on BehaveNet and forensic projects from home. With the advent of teleconferenced patient contacts I will need the office even less. So I started thinking maybe I can do with a part-time space. But this means I will have less flexibility for face-to-face visits in an office even though there will be more flexibility for Skype contacts. Suppose I only have the office Mondays and Tuesdays, it's Tuesday evening, and I want to schedule a patient ASAP. We will have to wait five days, unless we make do with Skype. This points to some kind of shared office space where practitioners can schedule 15 minute slots any day as most cost effective. I started getting the word out to colleagues. No idea where this will lead, but I'm thinking the schedule should be online and accessible from a smart phone.

Thursday, February 11, 2010

Cell Phones and Emergencies Don't Mix

Cell phones work so well, most of the time, and afford such convenience in casual use, that we risk failure to recognize their substantial limitations, especially when used in conjunction with voice mail, for communicating with patients in critical or emergent situations when 911 services might serve them better.

Use of any kind of telephone may be inadequate for even routine psychiatric care and psychotherapy, much less for the difficult and critical task of emergency assessment and intervention which demand face to face communication. The physician responding to a phone call from a patient after hours might be enjoying the effects of a second glass of wine, embroiled in conflict with a teenage child, or otherwise in flagrante delicto. Voice mail allows you to delay contact with the patient until you can focus your full attention on the call, and your surroundings will not distract you.

Caller ID adds to the complexity: If the patient has set her phone to block unidentified callers, the physician must choose whether to expose his cell or even home telephone number.

Cell phones can easily be carried in pocket or purse. They can also easily be dropped, drowned (Web pages instruct us how to revive a phone dropped in the toilet.), borrowed, broken, forgotten, hidden, hurled, left, lost, silenced, stolen, stepped on, turned off, and ignored. Their batteries can die. The signal can be distorted, unintelligible, interrupted by a second call, or dropped completely. You may forget to switch the phone back on after leaving a place where cell phones must be switched off. You may not hear the ring tone because of ambient noise or feel the vibration if the phone is not next to your body. You may forget to switch from one alert mode to the other after changing modes, in a meeting or theater. As I write this a cell phone belonging to I know not whom rings in vain on a desk in my office suite, probably forgotten by a patient. In poor coverage areas the phone may not ring at all. Bluetooth headsets and other hands-free devices can further complicate matters, and, contrary to myth, may not improve safety when used while driving.

If your patient calls, and you do get both the message and the call back number, but cannot use your cell phone, do not count on using a pay phone. The number of pay phones in the United States diminished by about two thirds between 1998 and 2007. You may not know the location of a pay phone, and finding one in an urgent situation could take an hour or more. If you borrow someone else’s cell phone your lack of familiarity with its operation could compound the problems, and the phone may retain a record of your patient’s number.

Voice mail, too, can compromise communication. The message may be interrupted or unintelligible. The caller may not leave the correct call back number, or any number at all. Some phones will tell you the caller’s number but only if it is not blocked. The caller may not finish recording a critical message, interrupted by a limited recording time, or you may stop playback before you have heard the entire message, thus failing to hear critical information. The caller who just leaves a message for you to call them back may decide to stay off the phone awaiting your return call instead of calling 911. Whether this means a few minutes for you to pull your car to the side of the road or 50 minutes to finish a psychotherapy session, the resulting delay in seeking immediate help from another source may result in disaster. In theory “call waiting” features should help, but either doctor or patient might accidentally drop a call, particularly during a crisis. You may try to leave a message only to hear, “I’m sorry, but the person you have called has a voice mail that has not been set up yet. Good bye.” or, “This mailbox is full.”

Some cell phones may alert you only to the first voice mail message leaving you unaware of messages recorded subsequently. Even when returning a call to a patient claiming to need an urgent response the physician may encounter the patient’s outgoing message. His voice mail may or may not accept a message, and even if you can record your message, phone tag and repeated delays may ensue.

In contrast to cell phones the use of 911 is straightforward, consistently and rapidly accessible, and its reliability may be limited only by that of the caller’s phone. Regardless of the time of day the 911 operator is likely alert and focused on the job. Enhanced 911 services can even tell emergency personnel the location of the caller, critical information if the patient has reported a dangerous act or intent or in any situation where the patient needs assistance but cannot provide his or her location.

Psychiatrists should afford their patients limited telephone access outside of normal business hours, but not for emergencies. If you do use a cell phone to talk to a patient, do not do so while driving or where others can hear your conversation. When retrieving voice mail always finish listening to each message before you end the call. Do not delete messages until the next business day. Preserve your professional boundaries and keep your cell number private by forwarding to your cell phone calls directed to your office number.

Unless you can return every emergency call within a few minutes let 911 handle them, and add to the outgoing message on your office voice mail a warning to hang up and dial 911 for all emergencies (not just medical emergencies) so your patients will know not to wait for your return call.

(This is a considerably shortened and toned-down version of an article I wrote in response to a piece by Robert I. Simon, MD that appeared in the February, 2008 Psychiatric Times. In his article he criticized the use of "hang up and dial 911" messages and extolled the virtues of the cell phone. One wonders if he ever actually used one himself. Interestingly, too, Clinical Psychiatry News declined to print the article after I explained what prompted me to write it. Thank heaven for blogs.)

Commentary on Opinions of APA Ethics Committee IV

Continued from Commentary on Opinions of APA Ethics Committee III:

Several opinions address questions related to release or publication of information, what HIPAA calls protected health information, obtained by the psychiatrist during treatment. What I find particularly troubling is the recurrent publication of case information in a variety of media with no indication that the patient has authorized release and no indication that the information is fiction. Even if the patient has authorized release of the information I believe the patient may have felt coerced to do so or that at best responding to such a request places an undue burden on the patient.

A.1.c. (1993, page 6)

In this case a former patient has joined a group to which the psychiatrist already belongs. The committee advises the psychiatrist to ask the former patient whether it might "be troublesome" for them to belong to the same group. This situation presents a real world dilemma where I see no perfect answer. Often with such situations it seems that ethics committees want us to believe there are ethical and unethical ways to proceed. But here if the psychiatrist leaves, the patient may feel responsible. The psychiatrist could ask the patient to leave, but the patient would have every right to stay in the group. The proposal of asking the patient, however, may unduly burden the patient, who might feel compelled to assent to the psychiatrist remaining in the group even if he does find the situation uncomfortable. We can argue that the psychiatrist should make the decision. If both remain, further awkward situations might develop over time. No mention is made of whether this is a psychotherapy patient. Should that make a difference? Regardless, the patient might never feel free to return for more treatment in the future. And in a small community few other psychiatrists might be available. If this occurred during treatment, one might expect a recommendation that this might become a matter for discussion in sessions, but I can argue that the patient pays for treatment of the patient, not for discussion of situations to a degree created by the psychiatrist.

I would make the same argument in A.2.d. (1989, page 9) which involves a similar relationship where the repercussions for the psychiatrist to escape the situation would be prohibitive. In this case the psychiatrist's landlord sells the building to a former patient. Here the response rightly states the purchase is "between your landlord and your former patient," however I disagree with the recommendation to "explore distortions" in the relationship if the patient returns to treatment. This kind of recommendation should only apply to psychoanalytic/psychodynamic treatments, and is inappropriate in the context of general psychiatry.

A.2.e. (1989, page 9)

In this case the psychiatrist wants to take patients on a book promotion tour. The opinion correctly discourages the practice while wrongly attributing the response to "tranference", but by placing the word "freely" in quotes referring to the giving of consent, correctly implies that consent may be anything but "free."

D.2.b. (1993, page 22)

Here we have a question of use of video of psychotherapy session for professional workshops or national television. The opinion indicates the practice would be acceptable for the workshop provided there is "informed consent," but discourages the practice for national television, supporting the latter recommendation with an unacceptably vague reference to the public's perception of psychiatry. Again, I challenge the notion that such consent can be "freely" given. However, the consideration of the public's perception of psychiatry is absolutely legitimate. We as a profession hold an ethical interest in ensuring that members of the public will feel confident that when they seek treatment the psychiatrist will ask for nothing other than money in return. No sexual favors. No permission to publicize the case.

D.4.g. (1990, page 24)

This case again relates to use of a video record of a session for a workshop, but with the requirement of free consent more rigorously stated: "fully informed, uncoerced... not obtained by an exploitation..." I believe this is impossible.

L.1.a. (2003, page 53)

In this case the psychiatrist wants to allow a "drug sales representative" to attend a visit with a patient. The opinion this time states, "there is no way to assure that the patient does not feel coerced into giving consent." I agree, but how is this different from the situations described above? It is my contention that the patient must never be deemed to have given free consent except when the release of information will directly benefit the patient as for transfer to another provider or for consultation.

R.4.a. (1977, page 80)

This case involves a role conflict, where the student health psychiatrist's employer wants an administrative assessment of the patient. Affirming the above, the ethics committee warns against releasing a report of such an assessment, "since the consent may not be freely given but coerced."

R.4.b. (1993, page 80)

The opinion in this case seems to contradict those above: We are told trainee psychiatrists do not need to obtain informed consent to present the patient's "therapy" (whatever that means) in class discussions and in supervision groups. What makes this situation different?

Q.4.c. (1993, page 76)

Here the question involves use of records possessed by a now deceased psychiatrist for research. For this "lofty" purpose however informed consent does not suffice. According to the committee one must obtain "highly" informed consent. There is no explanation of the distinction.

Q.4.a. (1976, page 75)

The questioner in this case wants advice on publication of a psychoanalytic case book. Here the committee once again, I believe improperly, burdens the patient by suggesting that informed consent include asking the patient to review the material. I argue that no patient she feel obligated to devote time to such an endeavor with no expectation this will benefit the patient, but only that it will benefit the psychiatrist. Furthermore, we cannot expect the patient to possess the knowledge, skill or experience to make such a decision. However, I do agree with the committee's statement that, "The problem of disguising is not always easily resolved." Here we need more guidance from the committee. Case information will be published. Disguise may occur on a spectrum. I can surely say, "I treated a man with olanzapine" without fear of violating confidentiality, and hopefully with having to obtain consent (informed, highly informed, or otherwise) from every patient about whom that statement might be accurate, or about a particular patient I might have in mind while making the statement. But gradual addition of details, and a host of other factors, moving toward the other end of that spectrum will inevitably lead me across the ethical line. We need guidelines to help us avoid this, and it is not fair to our patients to ask for consent in an effort to shift responsibility away from ourselves.

In the next installment I will address the question of consent for publication of psychiatric cases from after the fact: Commentary on Opinions of APA Ethics Committee V

Wednesday, February 10, 2010

DSM-5: Initial Impressions Positive

After a quick look I see nothing I do not like:

Substance Use Disorders:

Substance "abuse" always had too much of a moral connotation: Bad people abuse things. Having a substance use disorder does not make you bad.

Substance "Dependence" should have been Addiction all along. We usually mean physiological dependence as distinct from addiction.

Getting rid of both Abuse and Dependence is good.

Speaking of addiction, I'm glad "internet addiction" was NOT included as a behavioral addiction. For one thing, internet is not a behavior. Gambling is a behavior, but I'm glad they don't classify it as an addiction either.  More later.

Asperger's: Colorful as they are, naming diseases after people has no descriptive value, and if there's no bright line between Asperger's and the rest of the autism spectrum, so much the better. Good riddance.

Substituting "Intellectual Disability" for "Mental Retardation": We should probably incorporate "developmental" to distinguish from dementias, but even a small step toward ridding our language of the derogatory "retard" is good.

Tuesday, February 9, 2010

Good Health, Bad Health, Telemental Health?

(Thanks to Dinah at Shrinkrap for pointing me to

Let me start with "health." Good word. Wrong context. We are talking about psychiatry here. Mental ILLNESS, not mental health. Doctors treat diseases, illnesses, sick people. They're already off on the wrong foot -- or word.

Telemental. Define it, please. You can't, can you? Used as "telemental health" telemental is an adjective. It modifies health. So telemental health is a kind of health, right? Apparently not. What is it?

Whoever came up with this travesty has butchered the English language. We could try application of algebra:

Tele (mental health)

or Tele Mentalhealth, Tele Mental-health?

Face it. It does not work. Even if telemental can be defined, which I doubt, the term fails to name what it is intended to name and should be abandoned forever in favor of something like telepsychiatry.

Yes, in my grandiose moments I aspire to be the William Safire of psychiatry.

Bipolar: Overdiagnosis or Misdiagnosis

When I ask a patient psychiatric or substance use disorders in blood relatives, Bipolar disorder increasingly comes up. I think, "Yeah, right." This is just one of many adverse consequences of the Bipolar overdiagnosis epidemic.

So I was glad to see in JCP I received yesterday:

Psychiatric Diagnoses in Patients Previously Overdiagnosed With Bipolar Disorder (Zimmerman et al J Clin Psychiatry 71:1, January 2010)

However, I will quibble with the terminology: One cannot "over" diagnose a patient. Then it becomes misdiagnosis (which my spell checker recognizes, unlike overdiagnosis). One can certainly overdiagnose 2 or more patients, while one can misdiagnose any number of patients.

Sunday, February 7, 2010

DEA Suboxone Audits: The Video

Continued from: DEA Suboxone Audit: Worst Experience of My Career as a Physician

Read the script below.

Hello. I’m the owner & editor of

Today I want to talk to you about an initiative by the Drug Enforcement Administration that threatens patient access to buprenorphine, also known by the Trade names Suboxone and Subutex.

These drugs were made available in the US, as an alternative to methadone, for treatment of addiction to heroin and pharmaceutical opiates like Oxycontin early in 2003.

Starting as early as the summer of 2009 DEA agents started making unannounced and unscheduled visits to physician practices to audit records related to prescribing and dispensing buprenorphine.

These audits needlessly disrupt medical practices, threaten patient privacy, and waste taxpayer money and the agents’ time which could be better devoted to investigating diversion and illegal prescribing of dangerous opiates like Oxycontin.

I don’t object to the audits themselves which may result in stopping inappropriate practices by some physicians.

But physicians qualified to treat addiction with buprenorphine know to expect the audits, so DEA will not likely catch anyone red handed. I have already heard stories of agents wasting their time – and taxpayer money.

In one case agents appeared at a doctor’s office 3 times when they could not perform the audit because the doctor was absent.

In another case agents appeared at a doctor’s office when a staff Halloween costume party was in full swing but the physician was absent. I can just imagine the agent’s response at the reception desk:

"No, this is not a costume. I really am a DEA agent."

Surely agents have better things to do with their time. And taxpayer money.

If you are a patient, even if you are not treated with buprenorphine, you may find yourself sharing your doctor’s waiting room with a DEA agent who lives or works in your community and may recognize you.

I wrote a letter to my local DEA field office offering a time when I would be available for my audit. No one even responded.

Doctors have to jump through too many hoops already to provide this life-saving treatment. The disruption of practices that results from unscheduled audits will discourage physicians from providing buprenorphine treatment, resulting in increased illicit drug use. Maybe it is not just a coincidence that this will also increase job security for DEA employees.

I hope you will join me in demanding that DEA immediately begin scheduling all buprenorphine audits. In protest I have also made a decision to stop accepting new patients for buprenorphine treatment in my practice until my audit is completed. I hope other physicians will do the same and let it be known.

Contact your elected representatives, local medical associations, your local DEA field office, the Substance Abuse and Mental Health Services Administration, Dr. Westley Clark at the Center for Substance Abuse Treatment and Gil Kerlikowske at the Office of National Drug Control Policy. The American Civil Liberties Union may also be interested in your privacy concerns.

Physicians can coordinate efforts at the CSAT buprenorphine forum and the Behavenet opinion blog. Just search for “DEA Suboxone audit.”

Thank you, and stay clean.

Agents in the Waiting Room: To Warn or Not

Friday, February 5, 2010

Flush the drugs, man! The feds're comin'.

Expired drugs in the office? How do you get rid of them correctly before those nasty DEA agents invade your office looking for contraband buprenorphine?

"I emailed a local agent who replied thus, " are allowed to  dispose of the controlled substances yourself - with at least one witness.   This activity must be recorded on a DEA Form-41."

This sounded good, particularly after the aspersions I have cast at DEA in the past few months, but then I read Form 41, and I wrote back:

"Form 41 is confusing:

Signature of applicant or authorized agent: Who is that?

"Destroyed by": Is that me, or does someone at DEA sign that after destroying the drug?

The instructions imply I should send the drugs to DEA rather than destroy, except one indication of "destroyed as indicated and the remainder forwarded tape-sealed after verifying contents." What does that mean? This comes after the blank for how many packages have been received. Received by DEA? by me?

I have 56 tabs of 200 mg modafinil. Please advise. Is the form correctly completed?"

So should I put the pills in a bottle full of wet coffee grounds or mail them to the DEA field office. Has anyone done this and avoided the gas chamber?


Another med management visit today. This is like a virtual house call. I actually did a couple real ones when I practiced in Manhattan in the 80's. You get a little more feel for the patient, and you may get to meet the pets when you see the home, even the office.

I recommend routine "visits" to very stable patients the first time you try this, and this kind of visit serves another needed purpose. Many patients I treat have been and will be taking the same medication for years. As far as I'm concerned I one visit per year should suffice, but my malpractice risk managers recommend more frequent visits. For example, you should always make sure to have patients come in the day before a suicide attempt. This really is risk management mentality, and of course in an ideal world we would do that, but the patients I describe will not likely try to hurt themselves, and have the sense to call if things start to fall apart, or they just want to talk about a change in treatment.

The other reason for more than once yearly visits: $. What I charge barely covers the cost of the visit, not to mention the med refills and liability that have become fixed costs per patient. My patients do not want to come see me every three months, much less pay for it, but with at least with a visit via Internet the inconvenience of the trip, and the attendant risks, disappear. I figure even after I get used to Skype I will want even the most stable patients to come to the office once a year, but if we can conduct 2 out of 4 or 3 out of 4 visits via Skype, I get adequate quarterly "dues," the risk managers can sleep at night, and I minimize inconvenience to the patient.

What were the risks attendant to office visits?
  • Cost of gas, increased carbon footprint, global warming, climate change
  • Risk of motor vehicle accident
  • Risk of running into your neighbor in the psychiatrists office: "Joe, I didn't know you were mental!"
  • Time missed from work
 I think I'm going to like being a Skypiatrist.

Thursday, February 4, 2010

Milestone: My First Patient Contact for Med Management via Skype

The connection dropped about halfway through, probably due to a connection problem for the patient's Internet, but we reconnected after a few minutes. The audio quality was excellent, video adequate.

This is good, clearly better than telephone. It may never completely replace in person contact, the advantages stack up pretty well.

Next I need to work out how to share screens with the patient. I hope this will enable us to simultaneously view while we roll the die for a random drug screen.


I'm accustomed to scribbling notes on my Tablet PC in my lap, but for Skype the computer sits on the desk in front of me under the Web cam, so I can make brief notes with the keyboard during the visit with little or no disruption. This should make ordering prescriptions online or via fax easier, too, not to mention browsing for patient information documents online.

The informal protocol cues are missing: The patient alerting me she's in the waiting room, inviting her into the office, greeting my dog, escorting the patient out of the office at the end. I imagine new rituals will evolve.

It's not for every body or for every visit, but for the right ones the only disadvantage is the patient doesn't get the healing interactions with the pup.

Tuesday, February 2, 2010

Docs. Where have you been?

Twice in the past week I have talked to orthopedic surgeons who were clueless about buprenorphine (Suboxone). Well, not actually the surgeons themselves, but their "medical assistants." (All surgeons seem to do anymore is cut.) All jokes about the intellectual capacity of doctors in that specialty aside, maybe we should not expect them to completely grasp a concept like addiction that none of should claim to have mastered, but we all learned about opiate partial agonists in medical school. Even those of us for whom buprenorphine was not around way back then there were nalbuphine and pentazocine. Almost the same idea.

And it is not just the surgeons. ED docs often seem ignorant of the drug as well. Even when the patient produces a wallet card with an 800 number (which they don't bother to call) they ignore the drug's properties. They never call me either.

What will it take to get the rest of the medical profession up to speed on this drug?

HIPAA's Gaping Loophole: A Privacy Myth

[Fiction based on fact.]

Late on a Friday afternoon a couple months ago when I heard a noise in the waiting room, I went to the reception window to see whether a patient I expected might have arrived early. A middle-aged man standing there, leaning on papers on the counter, asked if one of the psychotherapists who shares the office was there. When I responded that she was with a client, he asked me whether I would be willing to sign for a subpoena. I told him I would not and returned to my office. I called my patients to warn them with whom they might unexpectedly find themselves sharing the waiting room. They rescheduled rather than take the risk that this individual might recognize them.

HIPAA and related state statutes and case law provide penalties for unauthorized release of identifiable patient information, even, I believe, addressing the sign-in sheets some physicians used to keep at the reception window. But I know of no law or rule to prevent someone else in a waiting room from recognizing a patient.

Here's a (probably incomplete) list of people who might recognize you as you sit in my waiting room.

People who have business there:
Letter carriers, delivery people, attorneys, court reporters, people from neighboring offices, other patients and their: kids, partners, parents, friends, and other people they care for.

People who need not have business there, at least during office hours:
Cleaning and maintenance people, walk-ins, solicitors (despite the signs that tell them to stay away), the landlord.

People who need not have business there:
Process servers, federal agents.

I have visited at least one office where the exit from the solo physician 's office bypassed the waiting room. But even with this arrangement patients arriving early or on the wrong day, and many of the others listed above might see you waiting or entering. And the cost of building could be prohibitive.

Going back many years (pre-HIPAA) an agent from some federal agency or other appeared in my waiting room, showed his badge, and told me I should hand over records of a patient who apparently had applied for a job with the agency. He informed me, wrongly, that I did not need to obtain the patient's authorization to release the records. I have heard similar stories from at least two other psychiatrists, both of which took place since HIPAA took effect. In all these cases the agencies could have requested records by mail rather than sending an agent.

We will never likely enjoy complete health privacy. Telemedicine promises reduction in waiting room appearances but opens the possibility of electronic hacking or eavesdropping. But government agencies should respect privacy concerns and alter policy and procedures accordingly. We can try to schedule patients we have reason to believe might know each other when they will not present at the same time. We can try to schedule non-patients when patients will not be present. But realistically we cannot assure privacy in waiting rooms.

On the evening described above I glanced into the waiting room as I was preparing to leave. Even though my office mate had signed for the subpoena, the process server still sat reading. When my office mate asked him whether he had any further business there, he replied that he wanted to finish an article he had started to read. I thought briefly about demanding that he leave, but I was on my way out, no one else was waiting, and I figured no one really needed my intervention.