Category: Policy

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Consult-Liaison Education Funding Medicine Policy Systems

The Value of Psychiatrists.

While slogging through a crappy first draft of a document about the value of psychiatrists in mental health and substance use disorder services, I did a literature search for supporting evidence.

I found nothing.[1. Physicians, as a population, don’t advocate for ourselves as much as we should because we’re “too busy taking care of patients”. This is true. However, our busy-ness creates a vacuum where non-physicians step in and make decisions for us. We then express resentment that we have to follow the edicts of people who have never done the work. If we did a better job of regulating and advocating for ourselves, we might not be in this position.]

“So how exactly are we helpful?” I mused out loud. Maybe we aren’t: There are groups out there who do not believe that psychiatrists can or do help anyone.

I am an N of 1. Therefore, this post is an anecdote, not evidence. Nonetheless:

Psychiatrists provide psychiatric services. These are increasingly limited to only medication management, which is unfortunate. Psychiatrists need psychotherapy skills—or, abilities to connect with people to build trusting and respectful relationships—to do effective medication management. I can write dozens of prescriptions and change doses as much as I want, but if the person I am working with doesn’t trust me, none of my tinkering matters.

When people think about medication management, they often think only of adding medications or exchanging one for another. Medication management also includes helping people come off of medications. This “deprescribing” also requires the use of psychotherapy skills: Some people feel great discomfort when coming off of medications. Sometimes the reasons are physiological; sometimes they’re psychological. Psychotherapeutic interventions and education are necessary in helping people cope with and overcome these discomforts.[2. For any psychiatrists out there: You could build an entire practice around “deprescribing”. This is one of the most common clinical requests I receive through my blog. I don’t have a private practice, so I turn all these people away. To be clear, deprescribing isn’t limited to private practices; I deprescribe in my clinical work in the jail.]

Psychiatrists often have the most clinical expertise. Most have had exposure to the spectrum of psychiatric services (in residency training) and thus have perspective about how systems work (or fail). Thus, psychiatrists can provide clinical consultation about specific patients and program design, implementation, and improvement. One example is the use of medication assisted treatment for substance use disorders. Certain programs or agencies may believe in abstinence only and will view medications as another misused substance. That perspective is not invalid, though giving people more options may help someone reach the goal of abstinence.

Psychiatrists can provide education to other staff to improve their clinical skills, which can elevate the quality of care clients receive across the agency. Psychiatrists can also provide leadership and influence the direction and ethos of a clinical service. For example, you can imagine how a psychiatrist might influence a service if he believes that the only way to help patients is to convince them to take psychotropic medications forever. A different psychiatrist who believes that employment or housing may be more effective than medication for some patients would provide a different influence.

Psychiatrists can triage patients who are in crisis. A roving psychiatrist on the streets or visiting people in their homes often can’t do things like draw blood, but they can assess people and circumstances to determine whether a visit to the emergency department can be avoided. Psychiatrists can also provide strong advocacy: Psychiatrists can work with law enforcement so that people who would be better served in a hospital actually go to the hospital, and not to jail. Similarly, if someone who has a significant psychiatric condition requires medical attention, psychiatrists can talk with hospital staff to advocate for this. Too many of us have stories about our patients who needed medical interventions, but others thought their symptoms were entirely due to psychiatric conditions.

Psychiatrists go through medical training and often have ongoing contact with other medical specialties. They are thus familiar with the practical realities of communication about and coordination of care for patients across systems. While overcoming the financial and policy hurdles to integrate care are important, the reason why integration matters (or, at least why I hope it matters) is to improve the experience for the patient. Administrators should consider the interaction and experience between the physician and the patient as paramount. The system should not sacrifice that relationship to make administration easier.

This is the message that all physicians, psychiatrists or otherwise, need to communicate to administrators. We don’t do ourselves any favors by assuming that people know what value we bring to patients or to the system. Sometimes it also helps to remind ourselves, too, so we can improve our work for the people we serve.

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Education Funding Policy Systems

Jail Costs versus Hospital Costs.

We received the State of Washington Voters’ Pamphlet in the mail today. One of the initiatives, I-1401, concerns “trafficking of animal species threatened with extinction”.

Have no fear: This post is unrelated to trafficking of animal species threatened with extinction.

The “Fiscal Impact Statement” includes a statement about jail costs (highlighted for emphasis):

jailcost

“No wonder why people with psychiatric conditions end up in jail!” I exclaimed. “It’s so much cheaper for them to be there!”

Information about hospital costs are public. This page shares inpatient hospital rates for people who have Medicaid insurance in August 2015. All the hospitals in Washington State are listed in the leftmost column. One of the columns has the title “Psych_ Per Diem”. That column tells you how much money each hospital is paid if a patient with Medicaid is admitted there for psychiatric reasons. First, you will note that hospitals are paid[1. Forgive the passive voice when I write “hospitals are paid”. In Washington, hospitals send bills for Medicaid patients to the state. The state pays the hospital bill. The state then turns around and sends a bill to the region that the patient “belongs” to. The region then pays that state bill. The region gets money to pay that bill from a mix of federal and state Medicaid dollars, which ultimately come from taxpayers. Confusing, right?] different amounts. That alone is fascinating—what accounts for that? who decides how much money each hospital will receive?

More to the point, it costs anywhere between $711.55 and $1788.93 per day for an adult with Medicaid to stay in a hospital. The average cost of incarceration in Washington is $88 per day. Thus, it is at least eight times cheaper for someone to stay in jail than in a psychiatric hospital.[2. This page shares inpatient hospital rates for people who don’t have any insurance. Note that the rates are lower compared to the Medicaid rates. They are nonetheless still much higher than the daily jail rate.]

On the one hand, the differences in cost aren’t surprising: Hospitals often have more staff, equipment, and services. On the other hand, we also know that jails are often the largest psychiatric hospitals in any given region. For example, in Seattle, the jail has about 120 psychiatric beds. The largest psychiatric hospital in Seattle has about 61 beds.

I really want to believe that no one intentionally designed the system this way. Surely no person or system could be so heinous and miserly to funnel people into jail instead of a psychiatric hospital. Right?

Right?

But, then the disgust kicks in: What if the costs were reversed? What if it cost $88 a day for someone to stay in a psychiatric hospital and $712 a day for someone to stay in a jail? Would we see as many people with psychiatric conditions in jail? Of course not.[3. To be clear, we should also help people stay out of psychiatric hospitals, too. Inpatient services should be available if people need them, but let’s focus on prevention and help people stay in their communities. Being in a hospital generally sucks.]

It shouldn’t be all about money, but when the cost differences are that big, money has undue weight. If we actually want to help people with psychiatric conditions, we must pay for services. Otherwise, we will only see more and more of them in jail.

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Consult-Liaison Education Medicine Observations Policy Systems

Buprenorphine and Other Controlled Substances.

I recently completed the buprenorphine waiver training. Buprenorphine, itself a partial opiate, is a medication that can be prescribed to patients who have opiate use disorders (e.g., taking Oxycontins or injecting heroin to get high). A physician must complete an eight-hour training and take an exam to become eligible to prescribe this medication. The physician must then apply for a specific “X license” through the DEA to prescribe it.

In some ways treatment of substance use disorders is the most evidence-based practice in psychiatry. When talking about opiate use disorders, for example, we can talk about specific mu-opioid receptors and their roles in pain and intoxication. We can discuss how drugs—both illicit and licit—work on these receptors and why certain medications can reduce or eliminate illegal drug use. This logic satisfies the analytical mind.

Since completing this training I have wondered: Why must one undergo a specific training and obtain a separate DEA license to prescribe buprenorphine?

With my current licenses I could prescribe all forms of pharmaceutical morphine (e.g., Oxycontin and Dilaudid), which can lead to severe physical and psychological dependence. Which could then result in the intervention of buprenorphine.

As a psychiatrist I would likely arouse the suspicions of the DEA if I prescribed opiate medications. That’s outside the scope of a psychiatrist’s practice.

However, it is not outside of the scope of a psychiatrist’s practice to prescribe benzodiazepines (e.g., Valium and Xanax), which are Schedule IV drugs (“a low potential for abuse relative to substances in Schedule III”).[1. You can learn more about controlled drug “schedules” on the DEA website.] I can also prescribe Schedule II drugs (“high potential for abuse which may lead to severe psychological or physical dependence”), such as Adderall and Ritalin. Physicians are not required to go through any special training or obtain separate licenses to prescribe those medications. Once I got my DEA license, I was free to prescribe these without anyone looking at me askance.

And, get this: buprenorphine is a schedule III drug!

The training offered the Harrison Narcotics Tax Act of 1914 as one reason behind the training requirement: This law suggests physicians can prescribe opiates as part of “normal” treatment, but not for treatment for addiction. Addiction was not considered a disease in 1914. Thus, if addiction is not a disease, no intervention is indicated.

That explanation, however, doesn’t make sense. There is growing consensus that substance use disorders are diseases. Nothing, other than my good judgment, prevents me from cranking out prescriptions for stimulants and benzodiazepines. Use of either medication can lead to addiction. What makes opiates so special?

The consequences of the buprenorphine training are not slight: The eight-hour training alone likely deters some physicians from pursuing it. The extra licensure is also an obstacle, as well as the consequences of using the license: No one wants regular, but unannounced, DEA audits (which, just to be clear, doesn’t happen with when one prescribes benzodiazepines or stimulants). No one is eager to maintain the documentation that is required when one prescribes buprenorphine.

It just makes me wonder what the actual story is….

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Medicine Observations Policy Reflection Systems

On “Mental Illness”.

I’ve been invited to speak to a group of attorneys who work at the interface of psychiatry and the law. The topic of my talk? “Psychiatry 101.”

A psychiatrist who gave this talk to a similar group a few years ago advised me: “You should assume that lawyers are laymen. It’s surprising how little they know, given the work that they do.”

This teaching opportunity to teach has given me pause: What is mental illness?

Most of my work has been with people with few resources (no home, no job, etc.) or with people who are experiencing symptoms that cause significant distress (they won’t eat because they think all food is composed of their internal organs; they often try to kill themselves due to hearing voices telling them to do so; etc.). Most people would agree that these individuals have “mental illnesses”, whether “caused” by their circumstances (imagine people trying to set you on fire or rape you because you are sleeping outside) or by apparent biological events (imagine a freshman in college with an unremarkable history who, over the course of months, begins to believe that the government inserted a chip into his brain).

I have also worked in settings where:

  • a wealthy man’s wife felt overwhelmed with anxiety about which of their three homes they should remodel first
  • a aerospace engineer with no symptoms wanted to try an antidepressant because his girlfriend started taking one and she now seemed to have greater clarity of mind; “maybe that will happen to me, too”
  • a college student felt depressed because his parents wanted him to pursue a professional degree, but he didn’t want to do that

Do those individuals have mental illnesses? Does psychological suffering equate to mental illness? Even if they are able to get on with the necessary details and difficulties of life?[1. Do not misunderstand: People with means can and do have mental illnesses. Take the software developer who was certain that public surfaces were contaminated with exotic diseases; he couldn’t get himself to go to work or spend time with friends due to fears that he would get sick and die. Or the accountant who, if she doesn’t sleep enough, would believe that she is the mother of God; she went to hospitals insisting that she was in labor with Jesus when, in fact, she was not pregnant.]

My mind then spins to recent events, such as the Germanwings place crash. Many people have argued that, because the co-pilot killed people, he was mentally ill. He apparently had a diagnosis of depression, but I agree with Dr. Anne Skomorowsky that a diagnosis of depression alone does not explain why he committed mass murder.

But if he was mentally ill, what diagnosis would best describe his condition? What do we call it when people kill other people? Is that behavior alone sufficient to say that someone is mentally ill? If so, what do we make of:

  • soldiers killing other people during war
  • gang members who, without provocation, shoot police officers or other gang members
  • suicide bombers
  • parents who kill their newborn infants because the babies aren’t the parents’ desired sex

Does a person’s intentions affect the definition of “mental illness”? (How good are we at reading the minds of others? We often assume intention when observing behavior. And those assumptions can be way off.) Does the situational context also affect what a “mental illness” is? (When in Rome, do you do as the Romans do? What if you don’t know what Romans do?)

People have surmised that people who kill other people may have conditions such as antisocial or narcissistic personality disorder. However, these designations are still problematic: Not everyone with those personality disorders kill people.

Perhaps this is why I prefer to work with people who demonstrate behaviors that undoubtedly impair their function.[2. It is easier for me to work with people who demonstrate clear evidence of “impairment in function”. Part of this is due to the greater ease and clarity in diagnosis: If someone’s symptoms are within the spectrum of normal human experience, then diagnosis is unnecessary. Part of this is also due to treatment: Some interventions in psychiatry—specifically medications—are not benign. Furthermore, it is unclear how some—many?—psychotropic medications work. We first must do no harm.] I am reluctant to describe most people as “mentally ill” because some behaviors that people find bizarre have helped the person cope with their circumstances. The people who always wear masks or scream on the street? Those behaviors may have somehow protected them in the past—even if it means that the general public derides them for being “weird”. It seems unfair to say someone is “ill” when what they have done before in the past has given them some degree of protection. (To be clear, I don’t necessarily apply this formulation to people who have committed murder. For example, I can’t think of how flying a plane into a mountain could ever be an adaptive coping skill.)

Words matter. I’m not sure that I have more clarity yet about what I should teach, though it is clear that I should focus on how I phrase the information I present.

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Education Funding Homelessness Observations Policy Systems

Asylums are not the Answer.

The New York Times recently featured an op-ed from a psychiatrist, Dr. Montross, who argues for the return of the asylum.

I understand her frustrations: I have worked with homeless individuals in both New York and Seattle who, if they were in psychiatric institutions, would not have had to worry as much about their safety, getting food, or sleeping at night. Many of the patients I now see in jail should undoubtedly be in a psychiatric institution (though not necessarily for a long period of time).

However, I disagree with her assertion that we should return to the era of the asylum.

President Kennedy signed the Community Mental Health Act into law in 1963. The goal of this legislation was to move people out of long-term psychiatric institutions, such as state hospitals, and help them integrate into the community by enrolling them in outpatient services. This is what “deinstitutionalization” refers to.

The Community Mental Health Act, however, only provided funds for the construction of the community mental health centers. The law made no provisions to fund the services that would occur in these buildings.

What we see now—the “transinstitutionalization” of people with severe psychiatric conditions into homelessness and jails—is a consequence of this lack of funding and support for patient care services.

Think of it this way: A city wants to improve its public transportation system. The city passes a law that provides funds to buy a lot of buses. However, the law provides no money to hire and retain bus drivers. There is also no money to hire and retain mechanics for bus maintenance.

The people of the city are frustrated: “Our public transportation system sucks! The city should build a subway system!”

The bus system never got a fair chance.

We also moved away from asylum care for good reasons: Conditions in psychiatric institutions were often terrible. It was not uncommon for state psychiatric hospitals to have insufficient staff for the number of patients in the institution. In Alabama in 1970, one psychiatric institution had one physician for every 350 patients, one nurse for every 250 patients and one psychiatrist for every 1,700 patients.

Dr. Montross herself notes (emphases mine):

But as a result, my patients with chronic psychotic illnesses cycle between emergency hospitalizations and inadequate outpatient care. They are treated by community mental health centers whose overburdened psychiatrists may see even the sickest patients for only 20 minutes every three months.[2. Unfortunately, 20-minute appointments every three months for the sickest patients is also a common occurrence here in Washington.]

If that is the quality and quantity of care “the sickest patients” in outpatient settings receive, then of course “many patients struggle with homelessness” and “many are incarcerated.”

Dr. Montross calls for “modern” asylums, though it is unclear to me what incentives government has at this time to build and support institutions that “would be nothing like the one in ‘One Flew Over the Cuckoo’s Nest'”. Asylums from years past did not receive sufficient funding to provide adequate care. Current outpatient centers often do not receive enough funding to provide adequate care. (How much longer must we wait before this changes?)

To be clear, I do believe there is a role for asylums in patient care. There is a small segment of the population with severe symptoms who would benefit from care in an institution. I’m talking about people who keep trying to jump off of buildings because they believe they can fly. Or people who cannot stop smashing their heads against the wall because they are trying to dislodge the computer chip they believe is in their heads. Or the people who eat their own feces and literally cannot use words to explain why.[1. As I have noted before: If you do not believe that these scenarios actually happen, I encourage you to volunteer at your local emergency department.] These individuals can and do recover; they are not necessarily destined to spend the rest of their lives in an asylum.

We also now have interventions such as assertive community treatment, assisted outpatient treatment[3. Assisted outpatient treatment is controversial, though preliminary data support its use. You can read an admittedly biased summary about it here.], and supportive housing/housing first. There is evidence that these intensive outpatient services keep people in the community and out of psychiatric institutions. What would happen if government and communities supported these interventions?

Modern psychiatric services—in an asylum or elsewhere—will not be modern at all if there are not enough staff to provide care for patients. It also will not be modern if the staff do not receive ongoing training and supervision for the care they provide. It cannot be modern if administrators do not understand the work and are unwilling to provide financial, technical, and emotional support to the front-line staff.

We must get away from the idea that where people receive services is more important than the quality of those services.