Tuesday, September 28, 2010

Therapists on a Plane

A triple coincidence: I am replying to the email of a family psychotherapist friend with whom I used to share an office. She told me she sat next to John Gottman on the way home from attending the recent AAMFT meeting in Atlanta. I told her of my similar experience seated next to UW psychiatry professor David Avery, MD who was flying home to Seattle after this spring's APA meeting. And my partner shows me the article "Cornered: Therapists on Planes" in this morning's New York Times.

First, I would like to point out that the author, Liz Galst, undoubtedly used that term I dislike so much, "therapist," as shorthand for psychotherapist. Amazing how some seem to forget the existence of all the other kinds of therapists. But, too, this betrays the misguided popular perception of all mental health professionals as givers of "advice," professionals with whom you just talk to feel better, rather than people who treat mental illness or family dysfunction.

Kudos to Galst for sharing with readers the very legitimate concern of Rhode Island psychiatrist Scott Haltzman, MD, that seemingly casual interactions with a fellow traveler might lead to a lawsuit. She found an opponent to this notion in Gregg Bloche, MD who labels this an "urban myth." I hope he's right, but judges and juries -- not authors -- decide such matters. The notion that the patient's perception of the doctor-patient relationship rules still holds sway in court to the best of my knowledge.

Wednesday, September 22, 2010

Guest Blog: Dr. Douglas Landy on the Crisis in Inpatient Psychiatry

Psychiatrist Douglas Landy, MD, generously permitted me to publish his thoughts about the current crisis in inpatient psychiatry, which I suspect are not unique to New York State [links courtesy of BehaveNet]:

It seems to me that over the years the face of inpatient psychiatry has been changing.  It looks like we are seeing progressively sicker patients, and violence is more common than used to be the case.  These factoids are supported by statistics throughout New York State (length of stay, violence, disability secondary to violence, etc).  It seems to me that a number of factors have brought this about:

1.      More severe psychopathology is tolerated in outpatients.  Many of the people we see on an outpatient basis, at least in mental health clinics, would have been hospitalized when I was a resident, but are now more frequently treated on an outpatient basis rather than on an inpatient basis.
2.      Many of the people who (with the above taken into consideration) are treated on an inpatient basis are harder to place owing to their penchant for inappropriate if not frightening behavior, making them personae non gratae for most placements.
3.      Many of the people that society asks us to care for are more emotional misfits (who have been acculturated to using violence as a means of expressing dominance, social pecking order, and so forth) rather than having a mental illness such as bipolar disorder, etc.  An associated problem is our societal tendency to “pathologize” behaviors that the majority culture of the location dislikes or fears.  Another associated problem is our profession’s wholesale trade of contextual diagnosis for single symptom diagnosis (i.e., racing thoughts = bipolar disorder, end of discussion).  As a result, we are in part contributing to this problem by agreeing that someone who behaves in a way that is not acceptable to the majority culture is mentally ill; and that implies we can treat that mental illness; and so forth.  This is, of course, an entirely separate controversy, but you get the idea.
4.      Because our inpatient models are based on context-based diagnosis driving treatment – as opposed to mere symptom-suppression treatment along with (generally fruitless) attempts to use a model for a problem that is generally not amenable to the inpatient model of treatment (ie, many of the people referred to in paragraph 3) – we fail spectacularly at accomplishing any kind of effective inpatient treatment in this population.
5.      As a result, the inability to place this group, along with error-driven treatment, results in many people being more dissatisfied, and that does not mean the patients alone.  Staff gets overwhelmed by this as well.
6.      Staff dissatisfaction and hopelessness (as well as fear) leads to petty tyranny or abandonment of responsibility, either of which leave the situation rife with the potential for violence and loss of the therapeutic milieu owing to patient “take-over.”  This is exacerbated by continually decreasing money for mental health resulting in lowering staffing to unsafe levels, while bloating administration to ensure that the paperwork is all in order for our “friends” at the regulatory agencies.

My own conclusion is that we need to do a couple of things, some of which are clearly easier than others.
1.        We need to have adequate staffing.
PROBLEM:  Costs money
2.      We need to help society understand that:
  a.      Not all annoying behaviors, even those that are violent, are driven by mental illness.  Even the presence of mental illness does not ipso facto make it the cause of the unwanted behavior.
  b.      With mental illness in general (such as the major mood and thought disorders) and the “softer” diagnoses of personality disorders, impulse control disorders, etc, treatment is not always successful.  In such a case the questions for society are:
    i.      Do we block up the hospital system with people who don’t need to be/shouldn’t be hospitalized?
    ii.      In the case of a criminal act, should such a person be restored to health and then sent back to prison for the remainder of their sentence (ie, guilty but mentally ill)?
    iii.      What should we do with dangerous people who don’t, won’t or can’t respond to treatment and victimize peers and staff in the hospital system where their current lack of criminal behavior precludes incarceration?  Why should the mental health system be responsible for this group (I suppose that you can correctly infer that I object vehemently to the idea that sex offenders who have finished their criminal sentence can be sent to a psychiatric hospital for an indefinite period of time afterwards).
  c.       PROBLEM:  It’s like changing the course of a river.  It can be done but it takes considerable time, energy, and a lot of money.
3.    We need as a profession to be clearer about diagnosis, remembering that symptoms are contextual and not independent phenomena.  The current craze (and I use that word pointedly) for single-symptom diagnosis is merely a rationalization to use medications that perhaps needn’t or shouldn’t be used, considering the ramifications of so doing.  Additionally, the current diagnostic patterns make us all look like fools.  I’m sure that many of have heard (or even said) about a colleague something like, “It’s curious how all his/her patients are Bipolar.”

PROBLEM: It is not clear if the pharmaceutical companies promote this kind of diagnosis/treatment strategy because it’s good for the bottom line, or if their speakers promote this (I can’t say more for fear of libel) to boost their own earnings from the companies (doubtless in which they have already invested as well).  Additionally, we tend as a profession to use medications more than non-pharmacological treatment options, and as a result think more in that way.  I would love to see psychiatric training spend an additional year or so on how effectively to do combination treatment – psychotherapy and psychopharmacology together, which is something you don’t see any more.

Douglas A. Landy, MD
Chief of Psychiatry
Rochester Psychiatric Center

The opinions expressed above are those of Dr. Landy, and do not necessarily reflect the mission or opinions of BehaveNet, Rochester Psychiatric Center or the New York State Office of Mental Health.

Thursday, September 16, 2010

Washington's Narcotic Analgesic Prescribing Rules

The State of Washington, plagued by record opiate overdose deaths, drew  national attention recently with the announcement of an initiative to address the problem by formulating guidelines for physicians treating pain. I offer my comments on the August 26, 2010 draft proposed rules submitted to the Pain Management Workgroup by the Medical Quality Assurance Commission's subcommittee on pain management as an outsider with no direct stake since I do not treat pain.

In fairness this is only a draft, so perhaps we can excuse the duplications, typos, and misplaced items. But better writing will not make for better policy, nor will more documentation by doctors, which seems to be the goal. Overall the effort is misguided and constitutes a waste of state funds during a budget crisis.

Risk Factors
One rule requires the provider to "screen for risk" by looking for history of addiction, "aberrant behavior and underlying psychiatric conditions." Aberrant behavior could cover a lot of territory. Without a definition this requirement fails to advance the cause. I find the term "underlying" psychiatric condition offensive and stigmatizing. Absent evidence that any psychiatric condition causes chronic pain or addiction the committee should substitute co-morbid or coexisting.

Informed Consent
Another rule addresses informed consent. This rule states that the provider should discuss with the patient the "risks and benefits of the use of controlled substances." Providers should probably discuss the risks and benefits of any treatment, certainly any drug, even if it is not a controlled substance.

One Provider, One Pharmacy
This rule goes on to suggest the patient should "receive prescriptions from one provider and one pharmacy" if possible, a nice idea but hardly within the control of the prescriber. I am not sure I see the connection to informed consent. Another loosely related rule suggests that the provider should document indication for opioid usage on the prescription. Perhaps this is so the pharmacist will know that the patient wants that OxyContin for pain rather than to get high. It will not prevent overdose deaths.

Patient Responsibility
Also included under this section is the suggestion of use of a written agreement "outlining patient responsibilities." I welcome this wording as in medicine in general I believe there is far too little focus on the responsibilities of the patient and too much on the responsibilities of the physician. Ultimately overdose death results when a patient takes too much drug on a single occasion. The physician cannot prevent such an occurrence. However, the committee could do us all a great service by providing at least a prototype agreement. Such agreements often fail to live up to their promise and frequently add to confusion. For example, the committee suggests requiring the patient to agree to "medication levels screening when requested." This may work well if the sample is collected when the patient is already in the office, but if the patient must provide a sample when ordered to do so at a random time between office visits, the physician must assume the role of arbiter when the patient delays appearance at the lab or office, forced to make judgments about the validity of the excuse. This is not an appropriate role for a physician.

The committee suggests a requirement that the patient provide consent to allow coordination of treatment between the prescribing physician and local emergency departments and pharmacies. Such authorizations, however, expire in 90 days in the state of Washington, so when such communication is required the physician must have access to the date of the authorization in order to confirm its continued validity in order for this provision to work. This problem also makes for difficulty and adherence to another provision of the proposed rules. In this provision is suggested that the patient must consent to reporting by the physician of "concern" that there may have been "illegal activity." Again, vague language limits usefulness.

Of course such an agreement or contract must specify consequences, most likely discontinuation of the drug, when the patient fails to adhere to its terms. The proposed rules also alludes to "tapering" before discontinuation, but this implies control over what the patient takes when the physician can only control what she prescribes, and, other than the unenforceable "one prescriber" notion nothing prevents the patient from seeking another physician.

Safekeeping of Drugs
The suggestion that responsibility for safekeeping of the drugs rests with the patient admonishes the patient to use "discretion" and keep medications in an "inaccessible" place. The only feasible way of addressing the issue of potential theft is to make it clear to the patient that replacement prescriptions will not be issued when the patient claims to not have enough to last until the next planned refill, regardless of the reason given, except perhaps if the drug has been confiscated by law enforcement and the patient can provide a receipt proving this to the physician.

One proposal suggests that the provider should be "willing" to refer to the patient. I can imagine a prescriber documenting his "willingness" in a progress note. Willingness alone will not help. Not only must the consultation actually take place, but patient and prescriber must alter the treatment in response to the consultants recommendations.

Episodic Care
The draft discourages provision of narcotic prescriptions for chronic noncancer pain without objective evidence of acute injury. I applaud this principle as well as inclusion of the statement, "The treatment of patients with chronic pain is not considered an acute health service." I believe emergency physicians far too readily prescribe controlled substances.

Photo Identification
The suggestion that providers should write prescriptions for controlled substances "to require photo identification in order to fill" should apply to all controlled substance prescriptions, not just those for pain. But the best way to effect such a change should start with pharmacies, not physicians.

Reportable Acts
The committee suggests that physicians may have "an obligation" to report illegal acts by patients to law enforcement. The committee should also however admonish providers to do this only consistent with applicable statutes and ethics guidelines relating to confidentiality.

Opiate deaths result from too much drug not from too little documentation. These new rules will likely discourage many doctors from prescribing for pain, and will make it easier to discipline doctors who ignore them.

Overall these guidelines will likely fall short. There is little real substance here but much to make the prescribers who care want to avoid treating this population with narcotics. Perhaps most unfortunate is the fact that we have in buprenorphine a much safer drug which the committee does not even mention, perhaps only because the FDA has approved no oral formulation for treating pain. (Treat Physical Pain Safely with Buprenorphine) The committee, rather than demanding more documentation, should encourage prescribing of safer drugs like buprenorphine.

Thursday, September 9, 2010

Taking Insurance

Surely one of the most ubiquitous euphemisms in medicine today.

Another professional (William Shryer at Diablo Behavioral Healthcare) subscribing to a listserv I read inspired me to write this with his comment on a frequent type of post: "Need psychiatrist in Omaha who takes Aetna [or some other brand of payer]." He advances this quaint idea that, rather than basing a referral on who "takes" which insurance, one should base referral on the qualifications of the provider and the clinical needs of the patient.

I imagine myself ordering two hamburgers, fries and a soda, and asking, "Do you take insurance?" like I might ask whether they accept checks or credit cards.

I imagine myself answering, when a prospective patient in our first telephone contact poses the same question, "I take money."

Insurance is definitely not money.

Taking insurance is a gamble. When the insurance company pays the provider, it is entitled under federal law, and some state laws, to say, "Gosh we didn't mean to send you that money after all. Please send it back now." And you have to send it back. I call it funny money. That applies even if the provider has not signed a contract with the payer. It's even stickier if the provider has agreed to the terms of the contract. Like the professional I mentioned above I contract with no payers, including Medicare. So I have not read one of those many paged contracts in some time. My objection arises from the fact that most of them appear to lead to the provider working, not for the patient, but for the payer, what I see as a conflict of interest.

But here's the catch: most patients cannot afford to pay our fees out-of-pocket, and many of those who can feel entitled to get something back for all those dollars they spend on premiums. I have to sympathize.

And which provider is most qualified? The provider who "takes insurance" from whomever offers it may have a very busy practice indeed. This may translate into lots of experience. Are quality and quantity necessarily at opposite ends of the spectrum? Would you rather have your appendix removed by a surgeon who does the procedure once a year or one who does it four times a week? Experience is not the only consideration though. The provider with the less busy practice may take more time and provide a more individualized approach. She may also have more time to return phone calls or schedule early appointments. Insurers usually verify credentials, attempting to guarantee at least a minimal level of competence, but providers who do not contract with insurers may stay busy enough to avoid contracting by virtue of referrals from other providers and patients who respect them.

That referral should take qualification and the clinical needs of the patient into consideration, and reimbursement may be necessary, but more patients might benefit from reading the provider's contract with the payer rather than pretending the provider answers only to the patient. Providers who complain about insurers but sign those contracts have no business complaining. They are enabling them.

Wednesday, September 1, 2010

Guns and Psychiatry

What comes to mind when you think of guns and psychiatry? Probably the Army psychiatrist at Fort Hood, or maybe the Virginia Tech student with psychiatric problems who went on a shooting rampage. Next you may think of the obligatory removal of access to firearms when you send home a patient at risk for self harm. Then there are the myths about violence and mentally illness.

But millions of Americans own firearms, so it should not surprise you that other considerations abound. How do you, the psychiatric provider, feel about the fact that a patient or family member might bring a concealed weapon into your office? Do you have a policy? signs on the waiting room wall? How many psychiatric providers themselves might keep firearms in the office? Would you ask a patient to leave if you discovered she had a revolver in her purse?

What about your patient with PTSD who has himself been a victim of violence and may want a weapon for protection? Would you argue against such a practice on principal? Maybe he's physically disabled as well, making him even more vulnerable.

Have you, the mental health practitioner, ever conducted a background check on a patient to determine whether there might be a history of criminal conviction? Possession of a permit to carry a concealed firearm can provide you with strong evidence that the individual has never been convicted of domestic violence or a felony in many states?

How important are leisure activities to a patient struggling with anxiety or depression? If your patient's favorite pastime relates to gun-smithing, collecting or hunting, do you want her to abandon an activity that contributes to self-esteem and possibly social connection during a time of crisis?

Most of us in the helping professions, especially medicine, are all too aware of the devastation wrought by violent death or serious injury, but do you want a patient who likes, owns, or even carries guns to feel judged by the very person to whom he has come for help?

Even if, like me, you do not believe in "transference," know where you stand with your feelings about people and firearms, and take care not to let them interfere with your work.