{"id":535,"date":"2012-02-17T23:37:31","date_gmt":"2012-02-18T07:37:31","guid":{"rendered":"http:\/\/blog.stevenreidbordmd.com\/?p=535"},"modified":"2012-06-04T08:43:51","modified_gmt":"2012-06-04T15:43:51","slug":"the-commodification-of-psychiatry","status":"publish","type":"post","link":"http:\/\/blog.stevenreidbordmd.com\/?p=535","title":{"rendered":"The commodification of psychiatry"},"content":{"rendered":"

\"\"Several recent articles<\/a>, blogs<\/a>, and even my participation in HealthTap<\/a> (discussed in my last two<\/a> posts<\/a>) have led me to think about how psychiatry, and mental health treatment generally, are increasingly viewed as commodities. \u00a0In the language of economics, a commodity is a\u00a0physical good, such as food, grain, or metal, which is interchangeable with any other\u00a0product\u00a0of the\u00a0same\u00a0type. \u00a0Commodities are carefully specified, e.g., “Wheat, No.1 Hard Red Winter, ordinary protein, FOB Gulf of Mexico,” but the supplier is immaterial. \u00a0Everything one needs to know about a commodity is in the specification. \u00a0Based on that alone, a smart buyer seeks the lowest price.<\/p>\n

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. \u00a0A New York Times<\/em> profile<\/a> of one such high-volume practice generated notoriety<\/a> for this approach, well deserved in my view<\/a>. \u00a0Even the profiled doctor had reservations, but succumbed to the lure of higher income as compared to the traditional model of one patient per hour.<\/p>\n

Although psychiatric medication management can be done well, the “med check” is often<\/a> critiqued<\/a> as<\/a> an<\/a> assembly<\/a>–line<\/a> approach that treats collections of symptoms, not people. \u00a0The assembly-line metaphor highlights the commodification of both parties. \u00a0On an assembly-line, each “part” moving down the line can be treated as any other. Likewise,\u00a0each worker is interchangeable with any other having the same qualifications. \u00a0In commodity psychiatry, any fully specified “Major depression, single episode, moderate severity” can be treated as any other. \u00a0Mental health workers of a given specification (psychiatrist, nurse, counselor) are interchangeable as well. \u00a0The only thing left is to let the marketplace (or government) set the price of this commodity transaction.<\/p>\n

While commodity treatment is easiest to recognize in the stereotypical “med check,” it is rampant in the rest of the field as well. \u00a0Suicidal patients should immediately be sent to the ER, yes? \u00a0Because all patients who declare themselves suicidal are the same, just like “Wheat, No.1 Hard Red Winter, ordinary protein, FOB Gulf of Mexico.” \u00a0Well, no. \u00a0In 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. \u00a0I 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!” \u00a0Nonetheless, I can’t recall the last time I hospitalized anyone for suicide risk, and I’ve never had a patient die by suicide. \u00a0Why? \u00a0Because it means<\/em> something when someone threatens suicide, and that meaning varies from person to person. \u00a0“Suicidality” isn’t a commodity specification, and it should not be treated as such.<\/p>\n

Nor is psychotherapy immune from commodification. \u00a0“You have social anxiety? \u00a0We offer a 16 session cognitive-behavioral treatment for that.” As though people who are anxious in social situations are interchangeable \u2014 and as though any practitioner who conducts a brand-name 16 session intervention is the same as any other who offers that brand. \u00a0The specification is all that matters, the supplier is immaterial. \u00a0Perhaps the ultimate example of therapy as commodity is when there is no therapist at all, as in this recent article<\/a> about a smartphone app designed to decrease social anxiety. \u00a0Here, 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.<\/p>\n

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<\/em> has symptoms, it only matters what the symptoms are. \u00a0Likewise, 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. \u00a0It 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.<\/p>\n

To be sure, there are areas of medicine well-served by rote protocol. \u00a0Thankfully, no one stops to “customize” CPR during a cardiac arrest. \u00a0But in most health care scenarios, treating patients as commodities is dubious. \u00a0And in the subtle realm of emotional health it’s tragic. \u00a0As I wrote in my post<\/a> 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. \u00a0For 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. \u00a0But if we stop there, at the nomothetic level of knowledge, we are treating the bipolar disorder, not the patient. \u00a0The “supplier,” the person suffering the disorder, is immaterial. \u00a0We are doing commodity psychiatry.<\/p>\n

The alternative is not to abandon the hard-won knowledge of western medicine and nomothetic research. \u00a0It is to acknowledge that every person sharing a diagnostic category is unique \u2014 that no individual experiences major depression or bipolar disorder in quite the same way as anyone else. \u00a0Understanding and enhancing each patient’s unique experiential reality is the essence of psychiatric practice, and mental health care generally. \u00a0Since these nuanced goals cannot be accomplished without considering the “supplier” \u2014 the person with the disorder, as well as the person offering care \u2014 the commodity model will forever shortchange psychiatrists and their patients.<\/p>\n","protected":false},"excerpt":{"rendered":"

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 […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[4,34,7,51],"tags":[48,46],"class_list":["post-535","post","type-post","status-publish","format-standard","hentry","category-current-events","category-human-nature","category-psychiatric-diagnosis","category-psychiatry-in-general","tag-commodity","tag-nomothetic-vs-idiographic","odd"],"aioseo_notices":[],"_links":{"self":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/535","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=535"}],"version-history":[{"count":7,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/535\/revisions"}],"predecessor-version":[{"id":591,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/535\/revisions\/591"}],"wp:attachment":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=535"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=535"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=535"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}