The Good Med Check IV: Getting Physical

(Continued from The Good Med Check III: Time Is Money)

Critics of the med check often equate the abandonment of psychotherapy by psychiatrists with tragic abandonment of the biopsychosocial model, viewing psychotherapy as a necessary ingredient of every patient encounter (if only for psychiatric patients). You might think they were invoking the bio-psychotherapy-social model. But in fact when psychotherapy in the form of psychoanalysis stuck it's foot in the psychiatric door a hundred years ago was it not the "bio" that was abandoned? Back then  few drugs competed with non-"biological" treatment modalities, but as the model of psychiatrist as psychotherapist (or just "therapist") evolved psychoanalysts pronounced the physical examination, so long an integral part of patient-physician encounters, incompatible with analysis, and eventually any psychotherapy, citing potential boundary violation: talk, but don't touch. (Thankfully, we do not hear protests that psychotherapy should accompany electro convulsive therapy.)

To be sure physicians of many specialties have abandoned the physical exam in favor of laboratory tests and imaging studies. If your non-psychiatrist physician lays hands on you at all, she will likely limit or direct the examination to only that which relates directly to your complaint or diagnosis. Admittedly, at least at first look, few aspects of the physical (other than the mental status exam) seem directly related to psychiatric complaints or disorders, unless the psychiatrist assumes the role, as some do, of primary care provider. But a psychiatrists probably could do a better job by attending to a few physical findings, whether part of a med check or a psychotherapy session. A few examples follow:

• Monitoring blood pressure in patients taking venlafaxine, and some other drugs
• Weighing eating disorder patients or patients taking drugs that affect weight
• Pupil diameter when you suspect unadmitted drug use
• Examination for cogwheel rigidity in patients taking dopamine antagonists
• Neurological examination to rule out neurological causes for psychosis or conversion

One could argue that the psychiatrist needs to "see" the patient more than the patient needs to see the psychiatrist. In some ways physical examination of a psychiatric patient stands at the opposite end of the spectrum of clinical tasks from psychotherapy, but it is at least as legitimate.

Next to Normal: Is Bipolar a Dysphemism for Life?

If you thought this Broadway musical was just about Bipolar Disorder, I won't spoil the surprise. It is a tribute to the strength and resilience of patients and families who must cope as best they can with serious mental illness on top of everything else life can throw at us. And with less help from psychiatry than we would like to offer.

I found the view of modern psychiatry balanced and accurate. Broadway has finally moved past it's obsession with psychoanalysis, but still seems stuck on individual psychotherapy. How might this story have unfolded with a family psychotherapist? There was one glaring omission: How might this story have unfolded under managed care?

Take heart psychiatrists. As Diana tells her Dr. Madden, "You're not a scary rock star anymore."

Next to Normal

Why Psychiatrists Should Enter the Blogosphere

A few weeks ago Shrinkrap Dinah posted Why Shrinks Don't Blog, quoting my earlier comment:

"The fact is, though you claim your blog is for psychiatrists, my impression is that few of us participate in any blog. What stops them? Snobbery? Hubris? Ignorance? Apathy? Fear?"

Despite a lively conversation I'm not sure we ever answered the question, but it occurs to me, now that I've been doing this since August 2009, to put the hard sell on my colleagues who have not yet jumped in.

Doctor, you are in control. You do not have to start your own blog and post to it every day. Just read someone else's when you get the urge. Read a few comments, too. Most of us isolate ourselves pretty completely. We put together a pretty narrow view of psychiatry. Reading blogs will not provide a complete psychiatry world view, but it will expand your horizons.

You will discover how some of your colleagues think and practice. Once in a while you may incorporate some of these ideas in your own approach. Better yet you will discover what some of our patients think about us, especially what they may not feel free to discuss during a visit. You will become more sensitive to their concerns.

Enter the fray by posting a comment. Most blogs allow you to post anonymously, so you need not worry that your patients or colleagues will discover your innermost secrets and opinions. Your opinion matters to the rest of us, and we want to learn from your experience. You can influence psychiatric thinking. Test your own ideas by provoking disagreement from others. It is not so terrible to discover that you were wrong. I know from experience.

Starting you own blog may be easier than you thought. Decide whether you want to remain anonymous or  use your blog as a vehicle to increase exposure for your professional identity, even to market your practice. You can make a commitment or not. Write as little or as much as you want. You will not spend every waking moment screening comments.

To paraphrase, "Doctor, blog thyself." You will make psychiatry better.

Psychiatric Ethics of Publishing Cases

Publication of psychiatric cases in the media can benefit the public, patients, and psychiatry in general. It can also benefit the author and the publisher, but such publication raises the question of whether, and how, we can ethically make patient treatment information public.

Do we as psychiatrists want prospective patients to wonder whether they might end up in the same positions as Dr. Spork and his patient Barbara?:



In the past week or so two psychiatrists appear to have described real cases in national media. In neither was there any indication that the author had made up the case; in neither was there indication that the psychiatrist obtained permission from the patient; and in neither was there any indication of the extent, if  any, to which the author might have disguised the case. In both the level of detail seemed sufficient that the patient might be identified:

Depression On The Rise In College Students
In fairness to the Dayton, Ohio psychiatrist, Jerald Kay, MD, who did not author the story, I can find only one sentence in which he seems to have supplied the information. Perhaps the author obtained the story elsewhere and Kay just added to it.

When Self-Knowledge Is Only the Beginning
New York psychiatrist Richard A. Friedman, MD authored this story.

In each of these articles:

• Does potential benefit to the public outweigh risk of damage to the patient?
• What constitutes adequate disguise?
• Can a psychiatrist ethically ask a patient to allow publication without damaging the treatment relationship?

An author can attempt to disguise patient information, but what constitutes adequate disguise? In a private communication a chair of the American Psychiatric Association ethics committee pointed me to the standard used by a professional journal. The sole criterion was whether the patient herself could recognize her case. But, in my opinion the most critical piece of information in determining whether a case describes oneself is the name of the treating psychiatrist who will generally be the author. Regardless of the criteria used, the author should make note of the fact that a case has been fictionalized or disguised.

When it seems likely that any reader can identify the patient from published information, and even perhaps when there seems to be little such danger, one might consider obtaining the patient's consent to publish their case. However, this raises the additional question of whether a patient can freely consent. In most situations where it is desirable to release patient information the patient benefits directly, and often the patient initiates the request. In this case however the author, publication, and perhaps the public -- not the patient -- stand to benefit. The physician asking for consent risks placing the patient in a difficult position where he might feel pressured to consent against his will, damaging the treatment relationship. If the patient did consent to publication, the author should state this fact in the article.

Relevant sections of the APA Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry:

Section 1.1 “A psychiatrist shall not gratify his or her own needs by exploiting the patient. The psychiatrist shall be ever vigilant about the impact that his or her conduct has upon the boundaries of the doctor-patient relationship, and thus upon the well-being of the patient.”

Section 4.11 “It is ethical to present a patient or former patient to … the news media only if the patient is fully informed of enduring loss of confidentiality, is competent, and consents in writing without coercion.”

From an APA Ethics Opinion:

Section 2-RR “Their consent, while ‘freely’ given, is likely to be heavily influenced by their transference feelings, the need to please you… suggests an exploitation of your patients for your personal gain that outweighs the potential benefit of public education.”

Short Psychotherapy

No, not "short term," short, as in short sessions.

Who says psychotherapy requires 45-50 minute sessions and a formal commitment? Although I cannot claim to know the history I suspect the almost-an-hour session originated with psychoanalysis, and the 45' session allowed psychotherapists to pack more patients into a day, and make more money. Modern psychiatric visits started out as psychotherapy sessions. The medication management piece snuck in slowly and now threatens to take over entirely. Despite the numerous advantages of independent provision of medication management and formal psychotherapy a compromise model offers a few advantages that might quiet some of its critics.

Since I ostensibly stopped offering psychotherapy I have noticed that the patient and myself often wander off the subjects of symptoms, medications and side effects, and almost as often I yield to the temptation to offer a systemic intervention, even when I know the patient is "in" psychotherapy in the more formal sense with a non-physician professional.

When I reflect, I realize this is nothing new. My family systems perspective lends itself to this less rigid approach to psychotherapy. I have done this all along. There is no real contract. Patients appreciate it, possibly partly because it's one-stop shopping and I charge no more for the added time.

There's always that dilemma over whether to charge a flat fee whether the visit lasts only five minutes or requires twenty five. The payer, whether a third party or the patient herself, likes to know in advance how much any visit will cost. I don't like to have to worry about whether the patient can afford an extra ten minutes with me. Besides, my fee always covers much more than actual time with the patient: office rent, staff, billing services, postage, telephone calls, malpractice insurance, contacts with other treating professionals, writing medical records, copying medical records, reading some other provider's medical records, ordering prescriptions, etc, ad infinitum.

CBT, which can be directed at specific symptoms and disorders also may lend itself to this model. Read High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide or the article in the October, 2010 issue of Psychiatric Times.

Pitfalls do exist:

• The psychiatrist risks working at cross purposes to the independent psychotherapist treating the patient formally.
• Without a contract patient expectations may exceed reality.
• It's a lot easier to say "time's up" when you both see the minute hand on ten. In this model you decide when to stop based on when you want to go home or how many patients are in the waiting room. There's no entitlement to the full 50'.
• Some patients may not feel permission to bring up a matter they want help with.
• That matter the patient wants your help with might require referral for formal psychotherapy. But you can figure that out with the patient and steer them in the right direction.
• Some interventions benefit from follow-up within a few weeks, but for medically stable patients the next regularly scheduled appointment may be months away.

The notion that psychotherapy must be an all or nothing proposition may prevent you from providing the best treatment to your patient. If you the psychiatrist include a psychotherapy intervention now and then, you may increase efficiency, cost-effectiveness, and your chances of success.

Unhinging Dr. Carlat

No, this is not a review. I have not read the book, and I don't entirely disagree with Dr. Carlat's ideas.  I did, however, read a review, which I cannot now locate, but which included a short case said to have come from the book. A brief look may demonstrate the extent to which a different perspective can influence a psychiatrist's approach and challenge the notion that psychiatrists prescribing medication should also provide psychotherapy to most patients. (Let's not blame Dr. Carlat for any of this. The reviewer may have misread Carlat, and I may have misread the reviewer. If I didn't get it right, apologies to Dr. Carlat.)

As I recall the case involved a patient prescribed zolpidem for insomnia. Because of oversedation he nearly or actually wrecked his car. The patient had not been able to muster the courage to contact the doctor about the sedation because of his reluctance to confront authority figures, such as physicians. According to the reviewer Dr. Carlat argued that had he been treating the patient with psychotherapy the patient might have overcome his reluctance, telephoned the physician, and avoided the accident.

Here's how I would approach the case: First, I never prescribe zolpidem. Even if I prescribe a drug for insomnia I prefer melatonin, gabapentin, or a very sedating antidepressant like mirtazapine or trazodone. But before prescribing I want to know the source of the insomnia, and in some cases will recommend a sleep medicine consultation. I also like to address sleep hygiene (behavior) before resorting to a drug. Why would I want to prescribe a drug like zolpidem that can lead to dependence and has been associated with patients eating a buttered cigarette or driving while asleep?

But suppose, against my best professional judgment, I do prescribe zolpidem. I would do so only after warning the patient about the risks involved. And in fact the pharmacist would probably offer the same warnings orally and in writing when dispensing the drug.

But let's say it still boils down to that problem of psychological reluctance to call the authority figure. Successfully addressing such a problem in psychotherapy could take months or years, and there's no reason to believe it would happen any faster if the psychiatrist were providing the psychotherapy rather than a non-physician. Furthermore, we should not assume that psychotherapy would address said reluctance. Many kinds of psychotherapy don't address such problems at all, at least not directly. What would make a difference, however, is how often the patient visits the physician, even for a short visit to talk about medication effects, wanted and unwanted, and even with no psychotherapy.

This case also begs the question of whether psychiatrists should provide psychotherapy so patients can muster the courage to call between appointments about a side effect. I argue that psychotherapy should address a diagnosable mental disorder (however we choose to define it).

And wait. Suppose a sleep medicine physician, or heaven forbid an orthopedic surgeon, prescribed the zolpidem. Would we want all physicians to provide psychotherapy? Orthopods don't even do physical therapy.

This case provides little or no support for the position that psychiatrists should provide psychotherapy. It does underscore the importance of careful selection of medication, avoidance of medication when possible, and adequate patient education. In some cases there may be advantages to one-stop psychiatric shopping, but in this case the frequency of contact, rather than overcoming a psychological problem with psychotherapy might have made the difference.

The Best Treatment or Just the Most Expensive?

$600 an Hour for Treatment

No, $600 for a 45 minute psychotherapy session.

On July 7, 2008 The New York Times published an article (Age of Riches: Challenges of $600-a-Session Patients by Eric Konigsberg) describing the psychotherapy practices of psychiatrists Michael Stone and Byram Karasu.

At first read this looks like another story about the wealthy getting the best treatment. Not necessarily. This article tells us a little about what is probably a very unrepresentative sample of the rich and famous but raises many questions about the practice of psychiatry, or at least the practice of some forms of psychotherapy.

The article begins with an example in which Dr. Karasu criticizes a “therapist” for encouraging a patient to go ahead with an expensive purchase despite his misgivings rather than “explore” the patient’s anxiety. He labels the purchase as a manifestation of an “addiction” involving “excesses and consumption.”

The average psychiatrist today may charge more than $100 for a medication management visit that may last five minutes. Cram 12 of those into an hour and you easily exceed Dr. Karasu’s fee. Of course it takes many more patients to fill your practice. Or fewer psychiatrists can treat the same number of patients, depending on your perspective. The $600 fee is exorbitant, and indeed few can afford it, especially twice a week, but the economic law of supply and demand determines how high a fee such a professional can command.

Regardless of fees much of importance is conspicuous by its absence. There are references to treatment, neurosis, patients, doctors, and psychoanalysis, but there is no mention of illness, of mental disorder. The rich “patients” described in the article seem to want only help for life problems, for “unhappiness or emotional anguish,” or just someone to talk to.

If this is not just an example of the richest patients buying the best doctors, we need to look further for an explanation. Perhaps it is the rare wealthy narcissist (Narcissism also afflicts the poor and can lead to failure.) who gravitates to a treatment that is expensive, if easily afforded, and makes him feel special. Perhaps these doctors are no better than the next “therapist” at helping them, but they may become skilled in attracting them to and keeping them in “therapy” even when they fail to “make progress.”

Sometimes many of us like to think all that money and success would not have made us happier anyway, and indeed the wealthy suffer from many of the same mental disorders as the rest of us. Antidepressants and other medications, and psychotherapy methods like cognitive behavior therapy, effectively treat most mental disorders today. The notion of “neurosis” was long ago abandoned by the diagnostic manual of the American Psychiatric Association, but psychoanalysts, Freudian and otherwise, cling to it stubbornly. The few who seek psychoanalytic psychotherapy from the likes of Drs. Stone and Karasu may be less ill and more in search of someone to listen. They may even like the idea of a “treatment” that can go on for years, regardless of whether it is effective.

Ambivalence about whether to bid $8 million for a painting is not likely a manifestation of a mental disorder, nor is the success of “treatment” likely to hinge on whether to give the patient permission to buy rather than force him to explore his anxiety. The mentally ill, wealthy or not, deserve effective treatment. The worried well are all too happy to pay someone with lofty status to listen to their complaints. Psychoanalysts like Drs. Stone and Karasu need only a few such patients to fill their practices.

If you are wealthy and need treatment that works, find a family or cognitive behavioral psychotherapist, or take psychiatric medication. They work just as well for the wealthy as for the rest of us.

No, Dr. Moffic, That Is Not the... Answer!

In his article “To Drive or Not to Drive? That Is the…” (The Ethical Way, Clinical Psychiatry News, Volume 35, Issue 10, Page 41 (October, 2007), Dr. H. Steven Moffic has established a new duty of treating psychiatrists to evaluate the “fitness to drive” of each patient, and a new exception to physician patient privilege “…when you are reasonably sure of potential danger” arising from psychiatrically impaired ability to drive.

Dr. Moffic has paid scant attention to the damage such a conflict of role or interest might have on the treatment relationship. He also failed to reference any ethical precept, including the most relevant: “A psychiatrist who regularly practices outside his or her area of professional competence should be considered unethical.” (American Psychiatric Association, The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry, 2006 Edition http://psych.org/psych_pract/ethics/ppaethics.cfm; accessed November 5, 2007). Instead, he takes the position that the treating psychiatrist should perform even a questionably competent evaluation because “practically speaking, such information usually is difficult to obtain.” He described this difficulty in one case as arising only from the fact that the patient “lived alone.” Regardless of whether a patient lives alone, a forensic psychiatrist can answer questions about disability, competence or capacity, and fitness with little or no conflict of role or interest, leaving your relationship with your patient unharmed.

The duty of a clinical psychiatrist is to diagnose and treat mental illness. The only well-accepted exceptions are the Tarasoff duty to protect, the duty to report physician misconduct, and the duty to notify authorities of child abuse. There is no duty to “fill out forms.” There is no duty to ensure that a patient can obtain a license to drive a motor vehicle, to practice medicine or to fly an airplane. There is no duty to obtain insurance money for a patient. If a duty to protect the public from drivers impaired by their medications or mental disorders has been established, Dr. Moffic should cite applicable statutory or case law.

Treating psychiatrists are no more qualified to perform "clinical assessments" of fitness for driving than to determine whether their patients should or should not be permitted to own or use firearms, return to work, be considered disabled, be considered competent to make a will, or to stand trial. They are not qualified to determine whether a patient is fit to procreate, raise children, or ride a bicycle. All such assessments result in a conflict of role, if not a conflict of interest, which will probably interfere with the physician’s care of the patient.

Dr. Moffic recommends that we “Do receive informed consent” but fails to specify to what the patient must consent. The need to obtain authorization to release information is obvious. The clinician who follows this recommendation should also, however, advise the patient of the limitations of the psychiatrist’s ability to perform a “clinical assessment of the patient’s driving” and the potential adverse effect on the treatment relationship. He should also warn the patient before undertaking a psychiatric evaluation that he might determine that the patient is unfit to drive and that he might report this to “authorities” whether the patient wants him to or not.

As long as psychiatrists like Dr. Moffic find it more expedient to “just sign the form,” attorneys, insurers, bureaucrats, and a host of other third parties will exploit this free and easy alternative to forensic evaluation with no regard for the resulting damage to the doctor-patient relationship or for the quality of the assessment.

Dr. Moffic asks, “What is the clinician to do?” when your patient asks you to “fill out a form.” The answer: Focus on treating the patient to the best of your ability and to follow your instincts and the admonition of Nancy Reagan and, “Just say no.”