July 31st, 2009  The recent debates over U.S. healthcare reform are long overdue, yet still sadly inadequate. (The discussion is about health insurance, actually, not the care itself. But I titled this post “healthcare reform” since that is what everyone is calling it.) There is no need to rehash the plentiful evidence that the current system is broken: millions of uninsured, job lock to maintain health coverage, unwarranted claim delays and denials, whole industries devoted to medical paperwork and reimbursement, and the near impossibility, given a pre-existing condition, of purchasing non-employment based insurance at any price. Hardly anyone across the political spectrum argues for the status quo.
The national debate centers on how to provide universal, or universally available, coverage to all Americans. Some argue that with proper incentives, private insurers could cover everyone. Similar to health coverage in the Netherlands, this proposal aims to preserve the private insurance industry and competition in the marketplace. Others argue that health care does not follow classic supply-demand principles, and that competition among private insurers has not controlled costs. A publicly funded, government-sponsored option is preferred to remove the profit motive and gain efficiency through standardization.
Universal health coverage is the norm in virtually all developed countries. I believe Turkey and the U.S. are the only remaining exceptions. Some nations, Britain for example, have nationalized health care — doctors are government employees. Others, like Canada, use public funds to pay doctors in private practice, much as Medicare currently operates in the U.S. These systems are not perfect. In particular, there are longer waiting times for elective procedures, sometimes on the order of months. But surveys repeatedly show that citizens (and doctors) of these countries are happier with their health services than Americans are with ours. And studies also show their health outcomes are the same or better than ours, for far less money.
There are many places to read about health insurance reform that do a better job than I can (e.g., here). From my reading, I believe a single-payer plan such as those in Australia, Canada, and Taiwan would greatly improve health care in the U.S., while preserving patients’ ability to choose their own doctors, and also doctors’ ability to work in the private sector. It’s a pity this option, so popular across the globe, is a political third-rail here. In my view, publicly funded health insurance (think Medicare) is no more “socialist” than the public funding of highways, police departments, and firefighters.
In a nutshell, that’s my view of publicly funded health insurance in general medicine and surgery. But what about psychiatry in particular?
Universal coverage would be a boon for the seriously mentally ill. Schizophrenia and severe chronic mood disorders render many sufferers unemployable and ineligible for private insurance. Some eventually qualify for Medicare and/or Medicaid, the limited forms of public health insurance that already exist. The additional stigma attached to using public programs due to severe disability would abate if public health insurance became a mainstream reality. Others with debilitating but less severe forms of mental illness do not qualify for Medicare or Medicaid, but cannot maintain private insurance due to frequent job loss, chaotic lives, depression, and so forth. The affordability of care and treatment is a constant stress atop an already stressful existence.
Universal health coverage would change all that (see this report from the California Endowment). Canadians talk about their comfort in knowing their friends, acquaintances, coworkers — fellow citizens — have access to health care regardless of circumstance. Healthy Americans might feel this way, too, when the chronically mentally ill among us are assured access to care.
At the other end of the psychiatric spectrum are relatively healthy individuals who seek psychotherapy for help in living a life that is basically stable, but is unfulfilling, frustrating, anxiety-laden, or sad. In the U.S., most health insurance, private or public, limits coverage for this type of treatment. Many private plans cap the number of treatment sessions to 20 or fewer per year; Kaiser Permanente additionally requires that a mental health professional “believes the condition will significantly improve with relatively short-term therapy.” Medicare does not cap the number of visits, but covers only half its “allowed fee” — the patient or supplemental insurance pays the other half.
It should be noted that traditional dynamic psychotherapy, the kind I do, considers it beneficial when the patient pays for therapy himself. Directly paying for therapy focuses the dynamics between patient and therapist by excluding distracting intermediaries. It matters more (to both parties) that the patient gets what he or she is paying for. Sometimes patients express unstated feelings toward their therapist in how they pay their bill; this can be interpreted as transference, moving the treatment forward. Moreover, dynamic psychotherapy is an intensely private undertaking: Many patients choose to forgo insurance coverage even if they have it, to avoid a public record of the treatment, or the need to document it with third parties.
All that said, many more people can benefit by psychotherapy than can afford to pay for it directly. A universal health plan that covered therapy in a substantial way (say, as Medicare does now) would make this service available to many who could not receive it before. Third-party payment issues are handled all the time in dynamic therapy even now. And not all therapy is psychodynamic; I know of no concerns regarding CBT (cognitive behavioral therapy), for example, being paid by third parties.
In short, U.S. healthcare — more accurately, health insurance — reform that universally covered mental health treatment would revolutionize care of the mentally ill in this country. Benefits could be as visible as fewer homeless on the streets and in the jails, as subtle and pervasive as a comforting sense that Americans care about each other both in body and spirit. I hope we have the will and the wisdom to make it happen.
June 28th, 2009  In my last post, I highlighted diagnostic challenges related to borderline personality disorder (BPD): Sometimes dramatic, self-destructive behavior leads to reflexive, inaccurate use of this label, while other times eagerness to diagnose a medication-responsive illness such as bipolar disorder can lead to overlooking BPD. Naturally, this barely scratches the surface. Thousands of books have been written about BPD. This editorial from the May 2009 issue of the American Journal of Psychiatry provides a concise summary of controversies surrounding the diagnosis. Even the Wikipedia entry on BPD has extensive useful information. Today I’ll focus on another central feature of BPD that has proven challenging to residents I’ve supervised (and me): parasuicide.
Parasuicide refers to self-harming behavior identified by the patient as suicidal but unlikely to actually result in death. Sometimes termed a “suicide gesture,” typical examples include taking a handful of pills, and cutting one’s wrists to draw blood, but not deeply enough to damage veins or arteries. Often the patient realizes later that suicide was not “really” the aim of the behavior. (Aim and intent become complex philosophical issues once the idea of a dynamic unconscious comes into play. Can one intend something without knowing it? Can intent be discerned by a therapist over the patient’s heartfelt disagreement?) Many patients in therapy eventually describe a very unpleasant, difficult-to-name emotional state that is relieved by these activities — especially painful, self-mutilating actions such as cutting or burning oneself. There is a sense of tension release. A communicative aspect is also often apparent, as in showing one’s anger or rage to important others, and eliciting an emotional reaction from them in return.
Parasuicide puts families and therapists, especially beginning therapists, in an uncomfortable position. These actions must be taken seriously, as failure to do so can make the person feel (further) abandoned and even angrier, leading to a spiral of increasingly self-destructive behavior. “Upping the ante” in this way can even lead to accidental death. For example, it is not widely appreciated that even modest overdoses of acetaminophen (Tylenol) can cause lethal liver failure. A seemingly minor overdose can unwittingly prove fatal. On the other hand, parasuicide looks manipulative. It is loudly claimed to be suicidal but isn’t “serious.” Families and therapists become angry themselves, potentially resulting in isolation, retaliation, and further harm to the patient. Patients brought to the emergency room after parasuicidal behavior challenge the on-call psychiatrist, often a resident, to walk a tightrope between dismissing the risk too casually, versus overreacting on the principle of “better safe than sorry.” Patients are sometimes hospitalized unnecessarily. A fascinating theoretical paper on psychiatric risk assessment can be found here.
To its credit, dialectical behavior therapy (DBT) tackles parasuicide head-on, as its top priority. This is wise not only from the perspective of patient safety, but also as a means to contain the anxiety of treatment providers. It is very difficult to work collaboratively with a patient who both scares and angers the therapist. While DBT addresses the problematic behavior itself, the manner in which a patient induces such negative feelings in the therapist is a direct focus of psychodynamic therapies. Transference-focused psychotherapy (TFT), another empirically validated treatment for BPD, was developed by Dr. Otto Kernberg and colleagues at Cornell, and pays particular attention to the communicative aspect of parasuicidal acts.
Parasuicide may look and feel manipulative to observers, but to the person with BPD it is a desperate attempt to secure relief from painful overwhelming feelings. It is both highly characteristic of the disorder, and one of its most challenging clinical features.
June 18th, 2009  Just as I was formulating a few thoughts on borderline personality disorder (BPD), I see the NY Times beat me to it. Jane E. Brody’s 6/15/09 “Personal Health” column, “An Emotional Hair Trigger, Often Misread,” provides an evocative description of this vexing disorder. Brody’s column seems informed largely by her consultant, Dr. Marsha M. Linehan, who devised the best known and best studied treatment for BPD, a combined individual and group therapy called Dialectical Behavior Therapy, or DBT. (Here are some links describing DBT: 1, 2, 3). Dr. Linehan also invited readers’ questions about BPD on a related NY Times blog, garnering over 200 comments. She began to answer some of those questions here.
In this post I’ll offer some of my own views on diagnosing borderline personality disorder, and in the next I’ll share some more reflections and thoughts on BPD.
The term “borderline” came from the impression of early clinicians that the disorder originates at the border of neurosis and psychosis: too severe to be the former, not severe enough to be the latter. Over the decades psychiatry has refined its understanding of this syndrome , yet much remains unclear. The May 2009 issue of the American Journal of Psychiatry was devoted in part to BPD. One article by psychiatric diagnostician John Gunderson MD reviews the history of the diagnosis and is well worth reading.
BPD is not as easily diagnosed as people, including many clinicians, think it is. Not all dramatic, irritable, self-destructive, and/or manipulative people have BPD. I currently see two patients in my practice who were referred to me by other well-trained psychiatrists as clearly having BPD. They don’t. One is a woman who suffered repeated childhood sexual abuse, leaving her full of mistrust, anxiety, and anger. She hardly discussed her traumatic past with her former psychiatrist of many years, who saw her weekly and maintained her on several antidepressant, tranquilizing, and sedating medications. I confess that I, too, thought she had BPD when we first met: She was overwhelmed by affect and seemed unable to sustain relationships. This has all changed with therapy. Now, about two and a half years later, she takes no psychiatric medications, has several important relationships, and usually can tolerate her own strong emotions. Either I cured her BPD (I don’t think so), or she never had it in the first place. My other patient has dramatic affective storms, identity diffusion, frequent limit-testing, “manipulative” suicidal threats, and so forth. But psychotherapy has revealed emotional conflicts, not borderline pathology, at the root of her distress. She too is improving.
I have no doubt that Dr. Linehan’s DBT helps a great many patients suffering from BPD. But I can’t help but worry about all those who do not really have BPD, and who could be helped in more fundamental ways by a nuanced understanding of their emotional dynamics. It is worth remembering that Dr. Linehan herself does not claim that improvement from DBT is diagnostic of any particular disorder. Who would not benefit by increased mindfulness, improved interpersonal effectiveness, and better emotion regulation and distress tolerance? (These are the four “modules” of DBT.) Perhaps some variant of these modules should be taught to all schoolchildren as a public health measure!
So there are people who “look” like they have BPD, but really have neurotic conflicts. Conversely, I have seen a number of patients who carry a diagnosis of bipolar disorder, usually qualified with terms like “atypical” or “rapid cycling,” who really have BPD. The world of psychiatry is divided into those who believe bipolar disorder is under-diagnosed, and those who believe it is over-diagnosed. (The same is true of ADHD and other popular [trendy?] diagnoses.) I happen to believe it is over-diagnosed. Rapid-cycling bipolar is defined as four or more extreme mood states per year. These would be moods that last at least a week or two, usually considerably longer. Dramatic mood swings that occur hour to hour, or day to day, are most likely something else: a personality disorder, an organic brain condition, a drug or alcohol addiction. It’s a waste and a risk to take unneeded bipolar medication for years and years, surely worse than undergoing DBT for a mistaken BPD diagnosis. Worst of all, I suppose, is to be given both diagnoses, bipolar and BPD, when neither is correct. I am very wary when patients tell me they have both disorders. While not impossible, it far more likely points to sloppy diagnosis than to a particularly unlucky patient.
The term “borderline” has seeped into public consciousness just enough to make it a powerful putdown, or pseudo-explanation to account for a socially difficult or antagonistic person. Moreover, the DSM-IV does a poor job with personality disorders, perhaps because it aims to be atheoretical, whereas personality assessment relies inherently on a theory of mind. I believe a psychodynamic framework is required to understand BPD, even if effective interventions need not themselves be psychodynamic.
More reflections to follow in the next post.
June 7th, 2009 I moved the website and blog to new web space this past week, and converted the blog from Blogger to WordPress. This makes it easier for me to write, edit, and manage the blog, although there were some trade-offs in making this transition. The biggest is that pre-existing links were broken. So if you have a blog or website of your own, and have linked to anything in Reidbord’s Reflections, those links are now broken. I apologize for this, and hope you may find it worth your while to re-link.
WordPress offers a wide variety of “themes” to change the look of blogs without altering their contents. I will be experimenting with different themes, simple ones I expect, until I find the most suitable one. As with all else here, I welcome your feedback and suggestions. Thanks for reading.
May 13th, 2009  Yesterday I evaluated a new patient, a young woman who wondered whether medication might ease her depression. She was in therapy elsewhere, and although seeing me was her idea, she was apprehensive about adding an antidepressant. I did end up recommending one, at which point she asked: “Aren’t antidepressants just a crutch?”
I relish this question. It is asked in anxiety, hesitation, and doubt, yet carries within it its own hopeful answer.
“Why yes,” I answered with a smile. “Antidepressants are exactly that, just a crutch.” I pointed out that antidepressants, and all psychiatric medications, are symptomatic treatments. Despite pharmacologic hand-waving about how they supposedly work, the truth is that no one really knows. We do know that antidepressants relieve mood symptoms, in the same way we knew aspirin relieved headaches long before we knew how. Likewise, an actual crutch relieves pressure on a healing foot or ankle without our necessarily knowing the cause or exact nature of the injury.
Like a crutch, an antidepressant provides relatively quick relief without addressing the underlying problem. There is nothing wrong with that. Relief is good, that’s what crutches are for — that, and helping to prevent further injury while the part is healing. The danger is in mistaking this for treatment of the underlying problem. A crutch alone can’t treat a fractured leg bone or a foot infection, and an antidepressant can’t repair the family dynamics or interpersonal losses (or genetic vulnerabilities) that result in depression. Fortunately, crutches are added to treatments, such as casts and antibiotics, that do remedy the underlying problem. And my patient was in psychotherapy to address the underlying problems that led to depressive symptoms. (While we cannot as yet offer definitive treatment for bad genes, that too will come eventually.)
The old concern of psychoanalysts that mere symptom relief would lead to “symptom substitution” and a more difficult analysis has not been borne out. On the contrary, combinations of psychotherapy and medication appear in studies to work better for depression than either type of treatment alone.
I assured my patient that the antidepressant I was suggesting was indeed a crutch: a temporary means to relieve her suffering while her mind is healing. It would also help minimize further psychic injury from poor sleep, social withdrawal, undue pessimism, and perhaps suicidal urges. Like a crutch, when she is feeling better she will stop using it, secure in the knowledge it is available again if it is ever needed.
May 6th, 2009  Last weekend I attended the annual one-day conference for providers of continuing medical education (CME) in California. Presented in Sacramento this year by the Institute for Medical Quality (IMQ), a division of the California Medical Association, there were talks on documentation requirements and updated accreditation criteria. There was praise and support for the majority of those attending, the office staff who organize much of the CME offered in the state.
I was there as chair of my hospital’s CME Committee, a position I’ve held since January. While my primary concern is commercial bias in CME, the conference highlighted two other areas of potential controversy I thought I’d share here as well.
Regarding industry bias, there is good news and bad news. The good is that overt bias is explicitly and increasingly monitored. There are regulations at both state and national levels to maintain a wall of separation between industry funding sources and the content of CME presentations. Physician audiences evaluate each CME offering and are asked whether any bias was present. Thanks to media attention and official pronouncements, the issue is now on everyone’s mind. At last it seems reasonable to hope that bald-faced marketing pitches in the guise of balanced CME are on their way out, at least in academic settings.
The bad news is that CME is not provided only in academic settings. “Medical education communication companies” (MECCs) are private entities that host about 40% of all CME accredited by ACCME, using funds mostly from drug companies. As described in the PharmaLive blog, “Most MECCs were simply spun off from advertising and marketing agencies doing business with pharmaceutical companies.” Psychiatrist-blogger Daniel Carlat calls this arrangement “money laundering”; the fairness of this characterization hinges on whether the MECC itself allows its funding to influence its message. While I imagine MECCs run the gamut from earnest educators to crass money launderers, I confess to some cynicism after having experienced first-hand a public relations firm showcasing a Wyeth drug pitch in the guise of a public education event.
More subtle biases continue to slip under the radar as well. New products are welcome topics for CME, while older products, perhaps equally effective, are not. Prescription medications heavily advertised to the public — all new, relatively expensive, and not available generically — require CME introductions, so that doctors have an intelligent response when patients obey the advertising pitch and “ask their doctor” about them. Since physicians themselves seek education about new products, truly unbiased CME at this level seems an ideal not easily reached in real life.
Another topic discussed at the IMQ conference was a 2006 California law that requires all CME in the state to include “cultural and linguistic competency” (CLC) as part of the presentation. This CLC requirement aims to incorporate information regarding “health disparities” in all ongoing medical education. The basic idea is that language, economic, and cultural barriers have health consequences, and that it ought to be part of every California doctor’s training to know about them, and how they apply in every clinical situation. I’m sure the legislation was well-intended, and I agree CLC warrants special focus in medical education.
The problem is force-fitting CLC into every CME presentation. Many CME speakers have an area of research or clinical expertise, which is why they were chosen to speak in the first place. Most are not experts on CLC issues, but in deference to state law they need to cover (or pay lip-service to) this anyway. Instead of making speakers talk about something they lack expertise in, a better alternative would be to require a certain number of CME hours specifically devoted to CLC for annual re-licensing. Then CLC could be presented by CLC experts, and be given the attention and focus it deserves.
Perhaps the most interesting thing I experienced at the IMQ conference was the way “improving patient care” constituted the unquestionable goal of CME. Certainly it is a hard rationale to argue with. After all, medical practice as a whole is aimed toward patient care. It also lends itself to empirical validation: Did physician practices change, and ideally did patient outcomes improve, as a result of a given educational experience? I do agree that the goal of the great majority of CME should be to improve patient care.
However, physicians are not mere technicians. I have attended CME talks on psychiatric practices in other countries. I would be hard pressed to say how this changes my care of patients here, but it still seems valuable for me to know. I have attended CME on standards of care in medical areas other than psychiatry, areas I will never practice myself. I can easily imagine valuable CME that reviews public perceptions of controversial area of medicine both psychiatric and non-psychiatric, cosmetic surgery for instance, that would have no effect on patient care per se. Each of these examples rounds out the education of physician-learners in important but intangible ways. Unless the profession and the public are content with medical “training” as opposed to education, the focus of CME should in my opinion span a somewhat wider domain.
Ironically, the IMQ conference itself awarded me 5.5 hours of CME credit for attending, and yet nothing presented will “improve patient care” in any direct sense. It was still valuable, and I am glad I attended.
April 11th, 2009  What could be worse than Bristol-Myers Squibb marketing its powerful and risky antipsychotic Abilify for simple depression, when there are so many effective and safer alternatives? How about AstraZeneca marketing its equally powerful and risky antipsychotic Seroquel for depression and generalized anxiety? A few days ago the FDA heard arguments from the company to do just that; lengthy background material as well as evaluations by FDA staffers are available here.
The issue is the same whether the drug is Abilify, Seroquel, or any of the other newer, patent-protected antipsychotics that are sure to follow in their footsteps. Even if Seroquel treats depression or anxiety better than placebo:
(1) there are already a great many approved medications for these indications,
(2) the existing alternatives are generally safer and much less expensive, and yet
(3) intense marketing directed to professionals and consumers will lead to widespread, unwarranted prescribing of the product.
Here are the words of one FDA scientist reviewing AstraZeneca’s claims that Seroquel is safe and effective for major depressive disorder (MDD):
[T]he safety profile we are seeing in the MDD population is not different from the profile we have already observed in other populations. However, it is of some concern that approving these claims will likely greatly expand the use of this product. Thus, we need to think carefully about the risks and benefits of such expanded use, particularly with regard to longer-term risks which are not yet fully established.
Unfortunately, the comments of other FDA reviewers did not express this concern.
FDA approval of antipsychotics for non-psychotic conditions is hardly a new practice. The typical antipsychotic Stelazine (trifluoperazine) was FDA approved for non-psychotic anxiety decades ago. This 1973 journal ad shows, in addition to the awkward sexism of the era, the same lopsided presentation we see now: modest benefits overshadowing serious risks. Of course, trifluoperazine has been available generically and inexpensively for years; there is no economic incentive to promote this particular agent anymore. In contrast, there is great economic incentive for the makers of Abilify, Seroquel, and similar products to tap expanded markets.
One argument offered in favor of approving atypical antipsychotics for depression goes like this: Even with 25 approved medications already out there (accurate figure), it’s a net benefit to have a 26th that might help the occasional patient. Why not leave the weighing of risks and benefits in the hands of the doctor, as long as the drug does what it claims?
This highlights a central question: What does FDA approval mean? Physicians are already free to prescribe “off-label,” and to weigh risks and benefits on a case by case basis. For example, the FDA has not approved the use of atypical antipsychotics as sleeping aids, yet according to some reports, over half of all Seroquel is prescribed for sleep and other non-approved uses. FDA approval must mean more than “doctors have the right to prescribe it,” since we already do. The public reasonably assumes that FDA approval adds an endorsement, something like “it’s usually a good idea for doctors to prescribe it for this particular indication.” The latter is a complex judgment that weighs risks as well as benefits, and that takes existing alternatives into account. In my view it is hard to justify stamping such an imprimatur on the use of powerful antipsychotics for common, relatively minor problems that already have good treatments. FDA approval gives a drug maker permission to market its product for the approved use. Antipsychotics are already being (mis)used in various ways even without such marketing. The wheels of commerce hardly need to be greased by a federal agency charged with public safety.
I haven’t said much about the generalized anxiety indication, but this could be a huge public health misstep if approved. In the 1960s the tranquilizer Valium was the most prescribed drug in the US. It was generally effective and well tolerated. Its major drawback was addiction and withdrawal effects, shortcomings shared by its contemporary successors such as Ativan, Xanax, and Klonopin. If the FDA approves Seroquel for anxiety, the aggressive marketing campaign for Seroquel will strongly emphasize its lack of addiction or withdrawal effects, issues that many physicians are wary of, and somewhat sensitive about. In an effort to sidestep the real (but manageable) problem of addiction, patients will receive Seroquel instead, even though it carries far more serious medical risks and is hugely more expensive (especially the time-release version AstraZeneca is promoting, the rationale for which is dubious at best). Seroquel could become the new “Mother’s Little Helper” — resulting in a bumper crop of obese, diabetic mothers (and fathers).
Interesting additional discussion on Seroquel and its new proposed indications can be found here.
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