Several recent articles, blogs, and even my participation in HealthTap (discussed in my last two posts) have led me to think about how psychiatry, and mental health treatment generally, are increasingly viewed as commodities. In the language of economics, a commodity is a physical good, such as food, grain, or metal, which is interchangeable with any other product of the same type. Commodities are carefully specified, e.g., “Wheat, No.1 Hard Red Winter, ordinary protein, FOB Gulf of Mexico,” but the supplier is immaterial. Everything one needs to know about a commodity is in the specification. Based on that alone, a smart buyer seeks the lowest price.
Much has been written lately about the psychiatric “med check,” a 10 to 20 minute encounter every few months for patients who take psychiatric medications. A New York Times profile of one such high-volume practice generated notoriety for this approach, well deserved in my view. Even the profiled doctor had reservations, but succumbed to the lure of higher income as compared to the traditional model of one patient per hour.
Although psychiatric medication management can be done well, the “med check” is often critiqued as an assembly–line approach that treats collections of symptoms, not people. The assembly-line metaphor highlights the commodification of both parties. On an assembly-line, each “part” moving down the line can be treated as any other. Likewise, each worker is interchangeable with any other having the same qualifications. In commodity psychiatry, any fully specified “Major depression, single episode, moderate severity” can be treated as any other. Mental health workers of a given specification (psychiatrist, nurse, counselor) are interchangeable as well. The only thing left is to let the marketplace (or government) set the price of this commodity transaction.
While commodity treatment is easiest to recognize in the stereotypical “med check,” it is rampant in the rest of the field as well. Suicidal patients should immediately be sent to the ER, yes? Because all patients who declare themselves suicidal are the same, just like “Wheat, No.1 Hard Red Winter, ordinary protein, FOB Gulf of Mexico.” Well, no. In supervising residents and talking with colleagues, I’m amazed how often patients cool their heels, and spend thousands of dollars, in three-day inpatient stays triggered by a threat of suicide. I claim no magical gift for curing depression or suicidal urges, and I’ve had my share of patients who scream, “I’m heading for the Golden Gate Bridge right now!” Nonetheless, I can’t recall the last time I hospitalized anyone for suicide risk, and I’ve never had a patient die by suicide. Why? Because it means something when someone threatens suicide, and that meaning varies from person to person. “Suicidality” isn’t a commodity specification, and it should not be treated as such.
Nor is psychotherapy immune from commodification. “You have social anxiety? We offer a 16 session cognitive-behavioral treatment for that.” As though people who are anxious in social situations are interchangeable — and as though any practitioner who conducts a brand-name 16 session intervention is the same as any other who offers that brand. The specification is all that matters, the supplier is immaterial. Perhaps the ultimate example of therapy as commodity is when there is no therapist at all, as in this recent article about a smartphone app designed to decrease social anxiety. Here, however, the app really is a commodity: Every copy of the app works the same, and it treats all users exactly the same as well.
With an ever-expanding diagnostic manual, and with a pharmaceutical, electronic, or scripted cure for every ill, psychiatry speeds toward a future where it no longer matters who has symptoms, it only matters what the symptoms are. Likewise, practitioners are interchangeable and thus should be chosen for the lowest cost, just as a buyer spends the least possible on a certain grade of wheat. It makes no sense to pay for an expensive psychiatrist or psychologist to perform psychotherapy, when psychotherapy is a commodity that can be supplied by people who charge less, or perhaps by a computer program, website, or smartphone app.
To be sure, there are areas of medicine well-served by rote protocol. Thankfully, no one stops to “customize” CPR during a cardiac arrest. But in most health care scenarios, treating patients as commodities is dubious. And in the subtle realm of emotional health it’s tragic. As I wrote in my post about nomothetic versus idiographic thinking in psychiatry, western medicine derives its considerable power from lumping patients into a disease category, and then applying statistically proven treatment to members of that category. For example, in psychiatry we are not forced to approach a new case of bipolar disorder in complete ignorance; among other things, we know lithium is apt to relieve the signs and symptoms. But if we stop there, at the nomothetic level of knowledge, we are treating the bipolar disorder, not the patient. The “supplier,” the person suffering the disorder, is immaterial. We are doing commodity psychiatry.
The alternative is not to abandon the hard-won knowledge of western medicine and nomothetic research. It is to acknowledge that every person sharing a diagnostic category is unique — that no individual experiences major depression or bipolar disorder in quite the same way as anyone else. Understanding and enhancing each patient’s unique experiential reality is the essence of psychiatric practice, and mental health care generally. Since these nuanced goals cannot be accomplished without considering the “supplier” — the person with the disorder, as well as the person offering care — the commodity model will forever shortchange psychiatrists and their patients.