Thursday, December 26, 2013

Pills Don't Save Lives - Psychiatrists Do

I am paraphrasing David Healy from a previous post and I am doing it here to emphasize - it's all about the side effects.  Healy's comment serves as a counterpoint to a highly successful multi-decade advertising campaign by pharmaceutical companies.  It began with the first National Depression Screening Day in 1991.  The emphasis  was on identifying and treating depression with antidepressants.  There was no real discussion of antidepressant side effects or the general problem of side effects with most medications.  Since then antidepressant treatment has been conceptualized as comprehensive treatment wrapped up in a pill or capsule.  That bias continues today as various political forces have shifted depression screening from an annual event to primary care clinics.  Some health care organizations and states consider depression screening and serial ratings of depression to be quality markers of health care services despite the fact that there are definite problems with that idea.  Unless there is a highly specific screening test any screening procedure has the potential to expose more people to the side effects of treatment.  There is no highly specific screening test for depression.

A second factor in considering side effects is the physician's role.  Doctors are trained to identify and treat conditions with surgery or medications.  Psychiatrists have additional training in psychotherapy. When you are in your training, the emphasis in on making the correct diagnosis and selecting the medication that will be the most useful.  Even though medical training is long, the longest you might follow any patient might be for a couple of years.  In medical practice you have the ability to see people for decades rather than months or years and how their medical treatment changes over those years.  You also observe first hand the long term toxicity of many medications when you might have only been exposed to that on a theoretical basis during training.  As a practicing physician you are expected to help people deal with the fact that they have side effects and the medications they are using may not be that useful.  In fact, in many cases they may not be beneficial or may be causing more harm than good.

All of that experience with side effects leads clinicians to develop new practices that they were never trained to do.  Very early in my career, I had the experience of treating a person who had been on an antidepressant for about 6 years.  She had headaches and depression and like many people with chronic depression she was in a stressful situation that she could not remove herself from.  She had chronic depression in the context of a chronic stressor that was not going away.  At some point her headaches resolved and her depression improved.  We decided to taper her off the antidepressant.  She came in 2 weeks later and said: "I feel much better.  All of the years that I was taking that medication I didn't realize it, but I felt like I had the flu.  That has now cleared up."  That early experience led me to modify the ways that I discuss medications with people.

I generally tell people that I don't expect anyone to "get used to" a medication.  I often tell them that people may get used to feeling ill rather than develop a tolerance to medication side effects.  I tell them that if they are experiencing any side effects at all to let me know about it and we will decide what to do about it at that time.  I let them know the range of experiences with medications and what they might expect.  As an example, I might say that "60-80% of people might take this medication and not notice that they are taking anything, but 5-10% of people might not tolerate it at all."  I let them know about all of the FDA contraindications, in some cases I review it with them many times.  I discuss the common side effects and usually provide them with the MedlinePlus handout on the medication.  I think it is more comprehensive than most handouts and it gives the FDA black box warnings (in a red box) on the front of every handout.  I talk with them about rare but potentially serious side effects like drug induced liver disease and arrhythmias and what to look for.  In the case of atypical antipsychotics, I discuss movement disorders and metabolic effects.  I demonstrate what the movements of tardive dyskinesia may look like.  I let people know if the medications they are taking are potentially addictive.  I the case of lithium, I let people know about the unique toxicities and the safest possible way they can take it.  In the case of antidepressants, I let people know that they may be difficult to stop due to discontinuation symptoms.

My side effect discussions with people have taught me valuable lessons.  There are people who are placebo responders and nocebo responders.  The nocebo responders develop problems taking any medication, even medications that are generally well tolerated at low doses.  Some of them are aware of the problem and decline any discussion of side effects.  They might say they don't want the MedlinePlus handout because: "If I read about any side effects I will probably get them."  They would rather be surprised.  Whenever I encounter that attitude, I respect their wishes but advise them to contact me if they have any side effects.  I also recall my Forensic Psychiatry lectures during residency.  The instructor advised us that we "could be sued" if our side effect discussions prevented a patient from taking a useful medication and there was an adverse outcome as a result.  I have realized over the years that basing your decisions on whether you could be sued is generally a bad idea because you can be sued for just about anything.  I think that people need to hear about what really happens with psychiatric medications and consider myself to be a good source of information.

I have also found that there is a hearty group of people who decide on their own that they will try to tolerate side effects and not let me know about it despite our discussion.  When I see them in the follow up appointment they will say: "Well you know doc, I had a pretty good headache the first three days on the medications, but I decided to keep taking it to see if it would go away and sure enough on day 4 the headache was gone."  They tell me that even though I advised them to not tolerate side effects and to call me if they had any side effects.  These patients are almost always men with a history of avoiding doctors and not taking care of themselves.  I guess their experience confirms that some people develop a tolerance to side effects but why would you want to?  I was at a large conference on the treatment of anxiety disorders and listened to a renowned psychopharmacologist talk about his technique for treating anxiety disorders with SSRI and SNRI type antidepressants.  His approach was to keep titrating the medication "to the point of toxicity" and then back off to the lower dose.  My experience has taught me that the best approach in non acute situations is to use the lowest possible dose.  That is usually the dose recommended for anxiety disorders and titrate it to the exact point where the symptoms are in remission.  I am never  compelled to increase a medication by a multiple based on the pill size or a drug level based on the aggregate experience of a cohort of people in a drug trial.

I obsess about the hypothetical.  Physicians in practice are aware of trends in the medications that are prescribed and psychiatry is no exception.  Drug interactions have been an area of focus in psychiatry since it was first learned that fluoxetine could inhibit the hepatic metabolism of tricyclic antidepressants and that could lead to antidepressant toxicity.  I treat people who are often on a mind boggling combination of medications for their chronic illnesses and psychiatric disorders.  I routinely run those lists through one or more computerized drug interaction software packages.  The software is inconsistent and I often have to look up the case report or study that suggest a specific interaction or problem.  I have to make the decision to accept or reject what the software is telling me.  The QTc interval or the interval on the electrocardiogram that corresponds with the total time of ventricular contraction and relaxation has been a major concern since the approval of ziprasidone.  It has been complicated lately by the FDA concern that citalopram may prolong the QTc interval in some people to a significant extent.  I screen people with electrocardiograms if it appears that their clinical status or total medication burden may lead to prolongation of the QTc interval.          

In some cases a concern for the hypothetical requires some inductive reasoning.  Current textbooks, literature, and standard prescribing references create the illusion at times that everything is known about a medication, it is just a matter of finding it.  There are plenty of examples where that is not true or where there is a lot of uncertainty about when a medication can be safely and effectively prescribed.  To illustrate, consider a hypothetical situation of patient with bipolar disorder who may benefit from taking lithium.  For a time during my residency training the renal toxicity of lithium was openly debated.  Nephrologists at the time certainly believed it was nephrotoxic but there were large series of patients who were described with minimal signs of renal toxicity.  Clinical practice treating patients with severe bipolar disorder has lead me into situations where I have treated patients on, during and after dialysis and kidney transplantation.  The estimation of glomerular filtration rate (GFR) by 24 hour urine collections was also problematic.  That has been greatly improved by the practice of using calculated GFRs.   I have no doubt at all that taking lithium for a period of time can lead to renal failure in a portion of patients taking it.  Anyone prescribing lithium needs to be aware of this fact and take all measures necessary to minimize episodes of lithium toxicity and exposure to other nephrotoxins.  In some cases like NSAIDs, the toxins are well known.  In other cases like tenofovir, the interactions are not known and in fact you can scan an entire FDA approved package insert and might find no references to lithium.   Making that decision may take hours or a weekend of study to figure out the best course of action.

I hope that I have made the case for psychiatric medications needing a careful analysis of side effects before they can be initiated and continued.  The decision to take medications is a serious one.  In 29 years of practice I have not met a single person who told me that they liked to take medications.  The decision to take medications often comes down to having tried everything else and realizing that a major change is necessary to get back to where you want to be.  A recent reply to my previous blog post described medications as "tools" rather than a panacea and I think that until perfectly safe and effective medications are invented that is true.  Healy's point is that the advertising notion of "Take an antidepressant and get better" is false.  Psychiatrists are trained to help you navigate the complicated process of recovery from depression and side effects and the potential for side effects is generally the most complicated aspect.

George Dawson, MD, DFAPA

Additional Clinical Note 1:  Another blogger sent me an e-mail earlier this week asking me to send a list of psychiatrists who I thought were competent to taper people off of SSRI/SNRI type antidepressants.  The intention of the e-mail was to have a ready list of people who could help people with that particular problem.  I think that all psychiatric residents should be taught about medication discontinuation effects and how to resolve them, but apparently that is not the experience of some people who end up taking these medications.  As an instructor in a psychopharmacology course, I can verify that the residents I taught were all aware of this problem and how to deal with it.  They also had the very good back up reference of the ASCP psychopharmacology course PowerPoints and lecture materials on this problem.  I realize that this blog is not widely read, but I would appreciate any posts from instructors or professors about the issue of side effect recognition and treatment in general and SSRI discontinuation symptoms in particular and the approach to teaching these topics in your program.  I would also appreciate hearing your thoughts on this problem about SSRI/SNRI discontinuation symptoms and the variable experiences of people trying to get the problem diagnosed and treated.

Additional Clinical Note 2:  The processes that I am describing in the above post take time.  In many cases the equivalent amount of time required to do psychotherapy and longer.  I do have people telling me that their physicians (all types) seem to be poised over a prescription pad.  They tell me nobody has ever informed them of the risks or potential side effects of a medication.  I don't think the problem has been investigated and it would be difficult to do.  The idea that "medication management" in psychiatry, internal medicine or any other field is a brief uncomplicated encounter that takes little thinking on the part of a physician is largely an invention of business interests seeking to reimburse physicians at the lowest possible rate.  If you are a consumer of medical services, consider my approach in the above post and ask yourself if you have had the discussions that I describe.

Saturday, December 21, 2013

GSK Eliminates Appearance of Conflict of Interest - Who Is Next?

Glaxo Smith Kline came out with a major announcement a few days ago.   It will no longer pay doctors to promote its drugs and it will no longer tie the compensation of its sales force to the number of prescriptions written by doctors who have been detailed about those drugs.  These are both standard practices in the pharmaceutical industry and this is the first announcement of its kind within the industry.  GSK will continue to to provide "unsolicited independent educational grants" to educational institutions or medical societies.  Pharmaceutical reps will be paid on the basis of technical knowledge and customer service rather than sales.  GSK has been fined heavily lately about promoting off label use of its products and is currently under investigation in China.

My immediate reaction to the piece was "good riddance".  For the past decade there has been no bigger issue in psychiatry than the appearance of conflict of interest with the pharmaceutical industry.  Psychiatry has been targeted more than any other medical specialty by prominent politicians, the news media, and even by psychiatrists themselves.  There are endless blogs and opinion pieces about how the practice of psychiatry has been defined by this appearance of conflict of interest.  There are several blogs out there that have gained prominence by endlessly reviewing all of these details. It has affected the way the APA does business.  It has affected the way local district branches do business.  In the end the politicians are grandstanding on it, because the PPACA (Obamacare) will apparently list any physician receiving money from a pharmaceutical company.  That was suggested as a motivating factor in the NY Times article.  Those public lists have existed in some states like the one I have practiced in for years.

To me the arguments have always come down to advertising and ethics.  From an advertising perspective would we expect people to be affected by product advertising?  Of course we would.  The buying habits of the American population are shaped by advertising.  Selling products is more of a science than people think.  The American public can easily change its buying habits and can purchase products that are unnecessary and will be discarded after a brief period of time.  They can also be sold on products like junk food that are unhealthy but designed to be sold in large quantities.  Advertising would not seem to be the ideal basis for marketing drugs to physicians, but with many new products  physicians are now bypassed and the drug is sold directly to the consumer.  If the epidemiology  of a particular problem like "low-T" is known, direct-to-consumer marketing probably leads to many, many more physician visits than a physician suggesting to their patient that they probably have primary or hypogonadotropic hypogonadism.  All a patient has to do is go to the web site and take a non-specific checklist quiz on the features of "low-T" and be in their doctor's office to get the levels done within a week.  Things will probably go a lot smoother without a physician intermediary in the loop and I am sure that much physician behavior will be shaped by the onslaught of men coming in to be tested for "low-T".  I know for a fact that psychiatrists are approached for this problem because of the overlap between the syndrome and depression.

Part of the advertising argument has always been that there are unconscious factors in play.  Really?  That is the basis for all advertising in general.  The main difference has been that pharmaceutical representatives have been schooled on the relationship aspects of the sale.  They have been taught that basically if a physician likes them or feels indebted to them for free food, trinkets like poor quality pens that never seem to write very well, a round of golf, or tickets to the Lakers game that they may be more likely to prescribe their product.  Most physicians were apparently naive enough to not realize that there was a huge marketing database out there that tracked their prescription writing to see if they were writing the required number of prescriptions for that product.  In the real heyday of marketing bonuses to physicians, companies would pay for travel to important meetings.

While the people focused on the advertising influence kept chipping away mostly at psychiatrists, they seemed to ignore two important developments that made detailing or selling to individual physicians much less relevant.  The first was restricted formularies.  I was on the Pharmacy and Therapeutics Committee (P&T) of one of the largest health plans in the state and an affiliated hospital for a total of 10 years.  During that time, the predominant factor in the decision about whether to put a drug on a formulary that would make it available to prescribing physicians was the cost.  There were very few instances where a drug was so unique that it was made available even if it was very expensive.  In those cases a drug might be available for an incurable illness that had a negligible benefit but it was included basically for public relations.  One of the other overriding themes of the P & T Committee was that all drugs in a particular class (like antidepressants) were equivalent and therefore the least expensive drug in the class could be substituted for anything else.  This potentially led to a lot of unnecessary chaos when medications fell out of favor due to pricing and patients needed to be shifted en masse to the least expensive drug.  It gave hospitals and health plans leverage in dealing with pharmaceutical companies, but in some cases the deals were complex.  As an example, in order to get a new blockbuster drug at a good price, the health plan would need to accept the same company's generic in a different class that had been removed because it was considered too expensive.  Over a decade ago, business entrepreneurs decided that there was money to be made rationing medications to health plan enrollees and now a lot of that is done by pharmaceutical benefit managers (PBMs).  PBMs are currently a multibillion dollar industry.

The second important development was generic drugs.  Practically all of the blockbuster psychiatric medications of the past two decades are now generic drugs.  Many generic drugs are easily affordable even as direct out of pocket purchases.  At that point they are no longer actively marketed by the pharmaceutical company that held the exclusive patents.  They are more likely to be the preferred drugs of PBMs and health plan formularies.  They are in that role because of a scientific approximation.  That approximation is that all drugs in a certain class, like antidepressants that have the same purported mechanism of action are equivalent and one can be substituted for another.  That is clearly false but it allows the health plan to to provide you with the least expensive medication or charge you a hefty copay for one that is not.  It also seems to not consider after market information that can even affect generic drugs.  The best example I can think of there is the FDA warnings on citalopram.  I would guess that despite the warnings, it remains a preferred drug by most health plans.  Health plans in general seem to be geared up to prescribe antidepressants at higher and higher rates.  I would take it a step further and venture a guess that most health plans have not taken a look at the data in their systems on whether or not they have observed problems related to the FDA warning on citalopram.

The ethical argument goes something like this.  Physicians should have the best interests of their patients in mind and an advertising based conflict-of-interest to prescribe a certain drug creates an ethical concern.  On the face of it, it seems like a straightforward argument.  But there are several problems with it.  For example, what is the direct evidence that this occurs - if any?  Is it really believable that a physician would prescribe a decidedly suboptimal medication to a patient based on schmoozing with a pharmaceutical representative?  There are often other factors in play.  It is common to treat people with chronic illnesses who have suboptimal response to the current therapy and who are looking for the "next biggest thing" to try.  A physician who has been detailed on the "next biggest thing" is likely to prescribe it if asked.  There is a similar dynamic with the issue of overprescribing in general.  If a patient persists in their request for an opioid, an antibiotic, a stimulant or any other drug are they likely to get it?  The recent declaration that the CDC initiative to decrease antibiotic prescribing has failed would suggest that they will.  Finally there is the dynamic of "see the doctor and leave with a pill."  There are any number of scenarios where medications are used in medical practice and other options are not even discussed.  The psychiatric cases are highlighted but it happens as frequently in cases of mild diabetes mellitus, back pain, chronic pain of various causes, hypercholesterolemia, mild hypertension and others.  Many people have described this as "the doctor was poised over his prescription pad" but the healthcare industry is set up to see people in brief medication focused visits and physician reimbursement is tied to it.   There are also patient related factors and a recent Tom Hanks interview is illustrative.  He was on a late night talk show discussing his recent diagnosis of diabetes mellitus and he said his physician told him that if he could get back to his high school body weight he probably would not have it.  His reply was: "Well I'm going to have Type II diabetes."

The ethical arguments, especially the ones I have seen constructed by physicians also ignore the general case of conflicts of interest at the professional level.  Practically every major university department allows its faculty to supplement their salaries by consulting in private industry.  In many cases that is a major source of additional income.  In some cases those professionals are involved in setting standards and their approach is much different than the wall that is currently being constructed between the medical profession and the pharmaceutical industry.  As an example, academic and industry professionals within the engineering profession are often on committees responsible for setting standards that govern all of the products within that industry.  Their approach is to include as many industry professionals as necessary rather than suggesting the academics can set the standards themselves.  Considering that pharmaceutical companies employ some of the top scientists in the world it would seem that medicine has a lot to lose if it goes along with the prevailing assumption.  The prevailing assumption is that physicians are powerless to stop prescribing expensive medications that are of questionable benefit for their patients based solely on advertising and no scientific merit.

I applaud the GSK decision even though the above cited factors would suggest that for most physicians it has only historical relevance.  I would encourage all of Big Pharma to adopt the same policies toward physicians.  But this doesn't really go far enough and it is basically a token gesture at this point.  To really make a difference I would suggest that they stop giving money to politicians.  GSK spent $1.9 million on candidates and $4.9 million in lobbying last year.  All of that money was directed at a few politicians.  It is a part of a massive industry wide contribution to politicians.  What do you think buys more influence, giving free pizza and pens to doctors or giving thousands to tens of thousands of dollars to politicians?

George Dawson, MD, DFAPA

Katie Thomas.  Glaxo Says It Will Stop Paying Doctors To Promote Drugs.  New York Times December 16, 2013.

Wednesday, December 18, 2013

Elimination of Homosexuality from the DSM - An Old But Important Story

I follow Michael Blumenfield's blog Psychiatry Talk and his most recent post reminds us that homosexuality was eliminated as a diagnostic category from the DSM 40 years ago.  Incredibly he interviewed the President of the American Psychiatric Association at the time of this decision and has these interviews posted on his blog.  Many years ago, I encountered a piece done on This American Life that documented another side to the process.  In that discussion Robert Spitzer one of the main architects of the DSM was directly influenced by his attendance at a parallel meeting of gay and lesbian psychiatrists - informally self titled the GAYPA.  He was apparently struck by the fact that homosexuality did not confer any disability in terms of psychiatric careers or social functioning and advocated for eliminating it from the DSM.

Dr. Freedman's interview (especially recording 2 and 3) starts to talk about the issues raised by the Committee for Concerned Psychiatry.(paragraph 4).  The major issues of the day were opposing the Vietnam War and homosexuality as a disease.  Dr. Freedman accepted their offer to be a petition candidate to oppose the "old boy's club" approach to APA presidency.  He describes the 1972 APA Annual Meeting in Dallas where a  gay APA member gave a talk wearing a disguise about how the DSM definition had harmed him.  He received a standing ovation.

Dr. Freedman refers to Spitzer as the Chair of a Task Force to look into homosexuality.  He prepared a document that supported dropping homosexuality as a diagnosis.  At the same time the APA Board and members were strongly in favor of it.  It was debated in committees on nomenclature, research and reference committees in a process similar to the recent DSM-5 process.  The evidence to maintain the homosexuality was found to be unscientific, based on highly selected samples and it was rejected.  The decision was front page news in both the New York Times and Washington Post.  On December 16, 1999 the Washington Post selected the APA decision as one of the "stories of the century."

There was not complete consensus and two psychoanalysts insisted on a referendum at the next election and their petition was defeated by a margin of 2:1.  Dr. Freedman provided this information because of criticism that the APA Board and not the membership favored the elimination of homosexuality.  He points out in retrospect that there were other issues that he was focused on at the time including the theft of psychoanalytic records during the Watergate scandal and the reaction to that incident.  He also raised the issue of psychiatric abuse in the Soviet Union and interview detainees who had been inappropriately placed in psychiatric hospitals.  The APA contingent refused to travel to the USSR unless they would have access to patients in psychiatric hospitals and could interview them.  The Soviets sandbagged the process by presenting cases of severe chronic mental illness and not allowing interviews.  

The 81 Words piece is given primarily by Alix Spiegel, the granddaughter of John Spiegel a past President of the APA.  At the time of this decision he was President Elect of the APA.  She waxes rhetorical at times about psychiatry but I won't dwell on those details.  They are minor in comparison with a well researched human interest story about the parallel stories that factored into this decision. She also discusses a parallel story within her family based on the occurrences at the time.

At the time that Dr. Spitzer decided to eliminate homosexuality as a diagnostic category he was probably early in his career in terms of designing diagnostic criteria and extending the DSM technology. He has described that process as basically reviewing literature, talking with experts and trying to type up a notecard with the criteria for that disorder. The MPR piece described his process with regard to the homosexuality question as more complex. He first met with a gay activist and wanted to understand that viewpoint. Several months later he arranged for three gay activists to present their case to the DSM nomenclature committee. A forum was organized at the 1973 APA Convention in Honolulu with an open debate between the analysts supporting homosexuality as a diagnosis, a faction of psychiatrists who did not, and Ronald Gold, the gay activist who befriended Spitzer. The event that led to the redraft that evening was Spitzer's attendance at the GAYPA party later that evening. After stating that he did not know any gay psychiatrists, he saw many notable psychiatrists at that meeting and went back to his hotel and redrafted the DSM criteria.

I have an interest in flagging these resources for future reference.  Listen to the This American Life piece and the interviews by Dr. Blumenfield.  This is a compelling story and clearly a decision that the APA and its membership got right.  A common criticism of psychiatry is that it is unscientific or pseudoscientific and yet one of the main points in this historic decision was the rejection of psychoanalytic research that was considered unscientific.  Dr. Freedman's commentary points out that the decision went through a process that seems to be very similar to the current DSM-5 process.  Contrary to the flurry of criticisms of the DSM-5 before the recent release, this decision was precedent setting.  It preceded most state laws regulating gay marriage by nearly 40 years.  It was hailed as recently as 1999 as being a story of the century.  And yet the press image of the DSM process suggested that the organization was socially inept and could not be trusted with similar decisions without close monitoring by non-medical organizations.

If anything this decision combined with precedent setting decisions on confidentiality, commenting on public figures, and banning psychiatry from participating in torture and capital punishment suggests that psychiatry should be one of the first professional organizations consulted.  Anyone reading this blog gets the message that the APA is far from perfect, but at times they get it very right.  This is a forty year decision that has stood the test of time and is also a good example of activism within the organization as a driving force.  Activism and political tension within the organization can be as important as the science behind the position.

George Dawson, MD, DFAPA

1.  This American Life.  81 Words.  January 18, 2002.  The NPR story of how the American Psychiatric Association decided that homosexuality was no longer a mental illness.

2.  Michael Blumenfield, MD. 40th Anniversary of "Homosexuality" Being Removed from DSM.

3.  DSM-II Change - The actual DSM-II change involved the category "Sexual Deviations".  The introductory paragraph was 81 words long and "302. Homosexuality" was removed from the list.  It begins with the sentences:

"This category is for individuals whose sexual interests are directed primarily toward objects other than people of the opposite sex, toward sexual acts not usually associated with coitus, or toward coitus performed under bizarre circumstances as in....."

Sunday, December 15, 2013

A Gun In The Snow

A colleague of mine was out for a walk today.  It is a brisk winter day in Minnesota.  There is about 6 - 8 inches of snow cover.  He was walking across the street and found this handgun laying there.

He took a picture of the gun and called the police to pick it up.  They were there in 20 minutes.

My views on violence and gun violence are fairly well known. My recent position has been that arguing with gun advocates and the pro-gun lobby in Congress is futile.  But when I saw this posted on Facebook with the accompanying story I couldn't help but think: "Guns are so common they are falling on the ground like wallets."  Only a fool believes that this level of gun availability does not result in death and injury of all kinds including accidents, suicides, and homicides.  Only a fool believes that with this level of gun availability it is possible to prevent guns from ending up in the hands of people who are not competent to use them.  I live in a state that passed a concealed carry law that  is basically the right to carry a concealed firearm.  It passed a few years ago by tacking it on to unrelated legislation.  The gun and holster look like a common one that is sold to those who complete a brief concealed carry course.  The main argument of the concealed carry contingent was that they were supermen of sorts.  There was literally nothing that would compromise their judgment if they were carrying a handgun.  Since then there have been a number of incidents involving concealed carry owners showing that in fact problems happen.  In the most notable incident a concealed carry owner opened fire on an undercover police officer.  I think it is safe to assume that there are probably at least as many lapses of judgment involving concealed weapons as there are driving automobiles.  The main difference is that people spend more time driving.  The reporting of these incidents is not transparent and that is typical of much gun legislation.

On a worldwide basis, small arms fire is a leading cause of death and disability.  I had the opportunity to see how some of that was transacted when I lived in Africa for two years.  In travelling as little as 100 miles there were frequent roadblocks at times.  The intent of the roadblocks was not clear but each roadblock was manned by police or paramilitary personnel and everybody was heavily armed.  The American friend that I most frequently traveled with told me about a time he got out of his car to ask if there was a problem.  One of the police officers pushed the barrel of a machine gun into his chest and prodded him back to his car.  He previously served in a country where a fellow volunteer accidentally drove through a police checkpoint because there was nobody around.  It appeared to be abandoned.  He made it a short distance before he was shot through the head by soldiers out of sight up on a hill.

In the US, besides the obvious problems with the legal availability of firearms there is also the issue of the black market and stolen firearms.  Since 1994 an average of 232,000 firearms are stolen every year and 80% of those are not recovered.  Stolen guns account for 10-15% of the guns used in crimes.  The majority of guns used in crimes are purchased by proxy or so-called straw purchase sales including other tactics like diversion of guns to criminals by licensed gun dealers.  There are several common sense changes that can occur in firearm policy that might make a difference in the sheer number of firearms in the general population and their availability to criminals.

This week marked another school shooting.  It marked the anniversary of the Sandy Hook Elementary School shootings.  In practically every school shooting easy access to firearms is a major part of the problem.  There are clear models for what happens to firearm deaths when some restrictions are placed on their access.  Fareed Zakaria has a new feature Global Lessons on Guns on his Sunday news program GPS.  Last Sunday he reviewed gun policies in Japan.  Getting a license to have a firearm in Japan is very difficult.  The authorities need advance information on where it will be stored and they need a detailed floor plan of the residence where it will be stored.  In a country of 130 million people there were a total of 4 firearm homicides last year.  By contrast, in the United States with a current census of 317 million people, there were 31,672 firearm related deaths (see Table 1-1 and 1-2).  The example from Japan is also interesting because it looks at the issue of violent video games.  They are played at a higher rate in Japan than the U.S. and it obviously had no impact in the context of extremely limited gun availability.

Even though I think there are better approaches for psychiatry to focus on than strictly gun policy and confrontations with a pro-gun lobby we need a basic level of awareness that current gun laws in the US are probably not what the Framers of the Constitution intended.  I think they would be as shocked as anyone if they found a gun in the street.  They would be equally shocked to find out that 7 times as many Americans die every year as a result of firearms than died in the Revolutionary War.  (see Table 1)

George Dawson, MD, DFAPA

Sunday, December 8, 2013

The Spine In Psychiatric Practice

I am not talking about the spine as a metaphor, I am talking about the real spine.  I am also not going to discuss some alternate therapies affecting the spine, I am going to refer to it only in the context of actual medical practice.  Maybe it was my interest in chronic pain and neurosurgery that led me to the observations, but many years ago I started to notice the high number of patients who were seeing me and had associated spine problems either associated with their psychiatric disorder or making it worse. As far as I can tell, this problem is really not well addressed in the psychiatric literature.

The spectrum of spinal disorder presentations varied from undiagnosed, to incorrectly diagnosed, to diagnosed and treated many times.  There is also the issue of how normal imaging studies vary greatly with age and eventually produce radiology reports that sound pathological but do not necessarily explain the observed pain or disability.  The usual psychiatric diagnoses included depression, anxiety, insomnia, and chronic pain.  The correct diagnoses were most often only possible by a detailed discussion of the problem.  In many cases the patients I was seeing had never actually seen a physician for back pain.  Let me illustrate with a couple of examples (none of these vignettes represent actual patients).

Patient A is a 35 year old woman being seen for depression.  She is in a stressful work situation because she is expected to be physically vigorous and move many 40 pound boxes of paper per day, but she is limited by neck pain and muscle atrophy in the left arm.  She injured her neck at a different job 5 years earlier lifting a heavy piece of equipment down from a shelf.  She felt immediate neck pain and over the next several weeks had muscle twitching in her left arm.  She did not have health insurance from her employer and was never assessed for the injury.  She has had daily pain since the injury and on days where she has more physical activity, she has more pain and more depression.  She is interested in treating the depression.

Patient B is a 50 year old man being seen for depression and insomnia.  He has a 5 year history of taking zolpidem for insomnia.  He is referred by his primary care physician because he has had to increase the dose of zolpidem to 20 mg/day because of worsening insomnia.  The patient gives a history of no longer being able to sleep on his right side because he has neck pain with radiation to the shoulder that resolves when he changes his sleeping position.  He has seen the Silenor and Lunesta commercials and is interested in changing his sleep medication.

Patient C is a 60 year old woman with a history of multiple upper and lower back procedures including fusions, discectomies, and foraminotomies.  She has also had surgical complications including infections and a cerebrospinal fluid leak.  She is taking oxycodone 40 mg QID with addition 5-10 mg prn doses of oxycodone.  She is also taking lorazepam 1 mg TID for anxiety and drinks wine on a daily basis.  She is referred for treatment of depression and chronic pain.

These three descriptions of patients highlight a number of problems unique to psychiatric practice.  Psychiatrists often see people with degenerative or traumatic changes to their spine that have never been assessed by a physician.  We also see patients who have had intensive surgical treatment and who have been treated in pain clinics for a long time before anyone thought to refer them to a psychiatrist.  In both cases an antidepressant seems to be a proxy for a psychiatric evaluation or an interview that seeks to determine if the spinal problem is a cause of depression, insomnia, or anxiety.  That type of evaluation is fairly straightforward but it does require time and the ability to do a medical and neurological review of systems and recognize common patterns of spinal syndromes.  The risks are minimal and the potential rewards are great for the patient.  I have had people ask me why I was asking them so many "medical" questions or report that their primary care physician wanted to know the same thing.   But I have also had people tell me that they were glad to know that they really had chronic pain from a fixable spinal problem rather than chronic insomnia and a need to take sleep medication forever.

This issue also highlights the issue of a physical exam in psychiatric practice.  When is it necessary and in what context can it be done?  In my first job I recall asking the clinic administrator whether she would provide a room and basic equipment for a physical exam.  She said that she would but in the three years I worked there it never happened.  If there is no adequate place to examine a patient I don't think an examination should be done.  There is also the question of the emotional relationship with the patient.  Many people seeing psychiatrists consider them to be their primary physician and have had many intense discussions with them over the years.  Psychiatrists should be aware of this emotional context and the meaning of any physical touch that occurs in that context and keep the assessment at the verbal level.  Referral to a physician who you know does a thorough neurological and spine exam is indicated for most cases, but in many cases you are seeing people referred from these physicians and it has already been done.  What about imaging studies?  My rule of thumb is to do them only if the patient has been physically examined.  I have physically examined people only in acute care settings and ordered imaging studies (CT and MRI) in that context.

On the positive side a lot can be done within the constraints outlined above, first and foremost is a detailed evaluation of the problem.  How is it that insomnia from neck pain can be treated for years as primary insomnia without any attention being paid to the cervical spine pain as being the likely source of that insomnia?  The only explanation I can come up with is a cursory evaluation of the pain.  Borrowing a page from Engel any psychiatric evaluation of a person with depression or anxiety, insomnia, and pain needs to be as comprehensive as possible.  The evolution of those problems since childhood and the relationship to physical and psychological trauma as well as other major life events needs to be detailed.  Assessing the patient for any possible addictions is another requirement.  A description of the pain and associated neurological symptoms is critical.  I like to review old records, imaging reports and the images themselves if possible.  There are a few of the highlights of what is necessary to come up with a psychiatric plan of care for people with spinal problems.  In many cases, a psychiatrist is the only person addressing their pain, even though they have a known diagnosis of degenerative disk disease and chronic back pain.  It is very useful to have referral patterns and treatment plans established to be able to offer treatment of the pain or associated spinal problem in addition to addressing the identified psychiatric syndrome.

The ability to help this group of patients also has training implications.  You don't learn about the spine, neurosurgery or neurology doing psychiatry rotations in medical school.  I was fortunate enough to have intensive exposure to these areas and to excellent clinicians.  I was also fortunate to work in a multispecialty clinic for 23 years where I had the benefit of discussing these cases with specialists from all fields.  I was also able to walk down to Radiology and discuss films with an excellent neuroradiologist.  The training suggested by Insel with a clinical neuroscience in psychiatry, neurology, and neurosurgery would enhance the evaluation of these problems. 

It pays to focus on both the central and peripheral nervous system when indicated.

George Dawson, MD, DFAPA

Friday, December 6, 2013

MCAT Hyperbole

The Medical Education issue of JAMA came out today with two articles discussing the new and improved Medical College Admission Test (MCAT).  I read both articles and they reminded me of the new and improved MCAT that I took back in the day when I applied to medical school.  I think that we were about two years into the new and improved version then.  I could not tell the difference between physicians selected on the basis of the old version, the new version or no versions of the MCAT.  I am sure that many of the professors that I identified with had never taken an MCAT.  Many were not trained in the United States.  Good doctors are good doctors and the idea that a multiple choice test will pick them seems about as likely as making accurate diagnoses of depression using a multiple choice questionnaire.

At the time I took the exam, there were all sorts of ideas about how you could select a "good" doctor.  They were in a trend where science was being deemphasized.  Somebody had the idea that you had to be "well rounded" with a liberal arts education.  Pure science majors might be frowned upon.  As a Biology/Chemistry major - did I stand a chance?  They had just phased out the General Knowledge section of the MCAT.  The rumor was it discriminated against students born and raised in rural areas with no access to museums, art, and theater.  As a Jack Pine Savage (I like the loose definition of a native from the natural range of Pinus banksiana) - I probably dodged a bullet there.  Critical thinking was emphasized.  It always is in these tests.  I took the GRE and they said the same thing.  It seemed like the critical phase of the admissions process was the interview.  I was interviewed by a Cardiologist who wanted to know if I was "aggressive" enough.  I did not know what he meant and stammered for quite a while.  Then he learned I was in the Peace Corps and said: "Anyone sitting in the bush for two years is aggressive enough for me."  He gave me a favorable rating.

The new MCAT promises to pick doctors of the future better.  It is described as being the product of a survey of 2700 shareholders.  It is supposed to be designed to test the competencies suggested in two reports - The Scientific Foundations for Future Physicians and Behavioral and Social Science Foundations for Future Physicians.  In the current JAMA article one of the authors defines 4 signals that the new MCAT sends for the future of medicine as summarized in the Table below (per reference 2):

Signals Sent by the MCAT Revision
Focus on foundational competencies required of future physicians rather than specific undergrad courses.
Candidates must be able to learn and think like scientists.
Behavior interacts with biology.
Critical thinking will be emphasized with a balanced testing between natural sciences and social/behavioral sciences.

None of these ideas seems revolutionary to me.  Looking at the second signal:  "Candidates must be able to learn and think like scientists."  I can think of no better way to do that than take a senior level chemistry or physics course from an interesting professor.  For me it was Physical Chemistry, the dreaded course of Chem majors.  You either were or you were not a Chem major based on whether or not you passed PChem.  It was the most mentally strenuous course I have ever taken and there certainly were no medical school courses that came close.  I can still recall studying thermodynamics and learning how Maxwell and Gibbs thought about things.  Our professor even digressed to talk about how long it took Linus Pauling to learn thermodynamics.  I still have thermodynamics swirling in the background whenever I see crystals dissolving in a solution, whenever I have to bring my car battery in the house to warm it up, and whenever I am thinking about complicated pharmacodynamic interactions.  Keep in mind that at the time I took the MCAT, science majors were out of favor.  The thinking at the time was that you would develop critical thinking from a liberal arts education with only the core science course (general chemistry, organic chemistry, quantitative analysis, and physics) being specified.  Unless you are Gauss, I think that generally involves some level of advanced training beyond what are generally the rote courses.

What actually happened to the cohort of physicians trained under the previous iterations of MCAT?  I am thoroughly biased by my undergrad training and always like to hear about other undergrad chem majors.  In the department where I previously worked there were two and they are excellent psychiatrists.  There are chem majors in every medical and surgical speciality and they are excellent physicians even if they did not have the same amount of humanities courses.  At the same time I have encountered excellent physicians from practically every undergraduate major ranging from music performance to applied mathematics.  The only logical conclusion is that the undergraduate medical education system can turn any reasonably bright group of people into physicians irrespective of their undergraduate majors or MCAT results.  It seems to me that some of these documents emphasize the MCAT as the limiting factor when there is no evidence to suggest that is true.  How can it be considered a signal when the signals are the same ones that have been important since formal education of physicians began?

The real area where physicians are produced is in medical school and if you want physicians to think like scientists that is also the logical place where it happens.  Recalling my biochemistry course in medical school - there was practically no memorization.  We had a seminar group (in addition to lectures) where ten of us were expected to discuss state-of-the-art biochemistry experiments at the time and on an ongoing basis.  Volumes of these papers were assigned - each emphasizing a specific concept.  We had to know the experimental methods and the limitations.  We were also expected to have a subscription to the New England Journal of Medicine and discuss any relevant research there.  The exams were essays about these experiments and methods.  They were 7 points apiece and you had to get a 6 or a 7 on each exam to pass.  There was an undercurrent of dissatisfaction by many with the typical complaint being that we would go into the board exams at a disadvantage because we were not memorizing metabolic pathways. 

During the clinical years, the formative process was seeing and identifying with professors who were excellent clinicians and scholars.  They did not have to be scientists in the Kandel sense of the word, but they needed to be scholarly, well-read, and experts in their field.  For me the most engaging process was being on a team with one or two of these folks, senior residents and me as the medical student. That dynamic learning environment was absolutely the best way to acquire the skills, attitudes, and knowledge base requires to be a physician.

So where does that leave me with regard to the messages of the main article and the opinion piece?  I think the science aspect of the MCAT is overemphasized but not for the reason that Cohen suggests in the editorial.  I have always believed that physicians should think like scientists and we are ethically obliged to provide scientifically based treatment.  The problem is that physicians are currently practicing in an unscientific environment.  Any scientist would be appalled at the number of pseudoscientific guidelines and quality markers that physicians have to adhere to.  They range from the purely financially based to management decisions negating any critical analysis that a physician may come up with.  The wringing of science out of medicine is a direct result of the political theory that funding private businesses to ration health care is an effective way to reduce health care inflation and it certainly is not.  I don't think it is honest to build medicine up as an intellectual endeavor when physicians will be routinely second guessed by administrators who often have only business training.  We need to tell the people who are truly interested in science to go into science and engineering and avoid medicine.  And if that is really true why are we interested in physicians thinking like scientists at all?   

Cohen's editorial has two issues that I would like to comment on.  The first has to do with what he describes as "skills previous generations of physicians had scant use for" among them "how to use resources parsimoniously".  As a member of the medical specialty that has been viciously rationed over the past three decades to the point where there are marginal resources to treat the most ill patients, I say it is time to get rid of the "cost effectiveness" argument.  It has been the battle cry of the managed care industry and you only have to look as far as your nearest emergency department to see the result.  Pricing is the largest single economic problem in American medicine and the best way to address it is to get the prices on par with other efficient health care systems (like Japan) and to suggest that managed care companies owning the means of production (MRI scanners, cardiology clinics, hospitals, etc) is a massive conflict of interest resulting in prices that are much higher than they are anywhere else in the world.

The second issue is Cohen's multidisciplinary team concept.  His view is that physicians need to "demonstrate antihierarchical teamwork".  His ideal team of the future eschews individual accountability and ability to function as a leader but also as an equally valuable member.  Like most other areas of medicine, psychiatric expertise and experience in this area is ignored.  I had a multidisciplinary team that met on a daily basis for 23 years.  We met during a time when the dark forces within managed care were telling us we didn't need to meet and we met during a time when they wanted us to meet so that they could put case managers on the team and tell us what to do.  Apart from the expected negative influences of managed care, teams depend on a number of practical issues including the number of full time employees and who is present when patients are admitted, discharged, and when their family members show up.  In those 23 years there were no other team members present for the time that I was present and I viewed it as my job to communicate what happened to everyone else.  The other practical matter and a significant cost factor that Cohen may wish to compensate for by parsimonious use of resources is defensive medicine and all that entails.

In conclusion,  I don't have a favorable view of either of these articles for the previously stated reasons.  The  best way to assure that future physicians have what it takes is to make sure that they have a practice environment that is intellectually and professionally stimulating.  Can you really expect that medicine can continue to attract high quality candidates from all undergraduate majors if the practice environment remains stagnant or deteriorates further?  You can't expect to have people thinking like scientists when they are managed like production workers by people with no knowledge of medicine or science.  At the very best, you will end up with highly frustrated overtrained professionals or at the worst a much wider range of skills than currently exists in the field.  By that I mean the spread of applicant qualifications will increase and the brightest people will go to any school that can get them placed outside of the current managed care environment as the health care system evolves into two tiers of care.

When that day comes, the nature of and scores on the MCAT will be meaningless.

George Dawson, MD, DFAPA

1: Cohen JJ. Will changes in the MCAT and USMLE ensure that future physicians have what it takes? JAMA. 2013 Dec 4;310(21):2253-4. doi: 10.1001/jama.2013.283389. PubMed PMID: 24302085.

2: Kirch DG, Mitchell K, Ast C. The new 2015 MCAT: testing competencies. JAMA.  2013 Dec 4;310(21):2243-4. doi: 10.1001/jama.2013.282093. PubMed PMID: 24302080.

Wednesday, December 4, 2013

My First Flu Shot









George Dawson, MD, DFAPA

Tuesday, December 3, 2013

The Selling of Medical Marijuana

I have been thinking about how to approach this topic for a while.  My experience is not the experience of most people because as a psychiatrist I am seeing some of the worst possible outcomes.  That usually involves psychotic symptoms, depression, severe anxiety and panic, paranoia or some combination of all of these symptoms.  I have seen a much larger group of people who stopped on their own, usually after getting paranoid or experiencing a panic attack.  A lot of people cannot stop smoking even when they have a clear medical problem.  In some cases they are using marijuana or some cannabinoid product for a specific medical problem despite the fact that they are not getting relief and I would not expect them to.  These folks are typically heavy smokers (blunts, spliffs, vaporizers) but like all pharmacologically active compounds the dose response curve is highly variable.  

The  epidemiology of major symptoms caused by cannabis use has become a lot clearer in the past 10 years.  Thirty years ago there was an isolated study showing that army conscripts who were marijuana smokers were more likely to develop schizophrenia.  There was also a prominent researcher at the time suggesting that populations where there were high levels of cannabis use did not have higher rates of psychosis.  But those populations did not have high quality epidemiological data.  The latest studies show significant increases in the likelihood of schizophrenia and mood disorders.  I think that this probably happens in a minority of people and probably those consuming the most THC.  There is a lot of discussion about the differences in THC content of marijuana in the 1970s relative to what it is now, but not much reliable data to back that up.  Since THC is a pharmacologically active molecule with known pharmacokinetic properties it is always a question of dose as well as potency.  Multiple doses will eventually get you to the same levels of fewer doses of a more potent product.  he need to avoid positive urine toxicologies for THC also drives the market in synthetic cannabinoids, since the word on the street is that taking these drugs does not result in a positive toxicology screen and jeopardize employment.

A recent public opinion poll shows (click  to enlarge).  The recent trend to legalize comes in the context of an increasing trend about using marijuana and other controlled substances for legitimate medical purposes and media portrayals of marijuana as a source of employment, entertainment, and alternative medicine.

There is not the same level of skepticism about marijuana as there is about psychiatric medications.  In that case, the drugs are approved as safe and efficacious by regulatory bodies.  There is no evidence that they cause problems at anywhere near the level of marijuana and yet the latter is generally given a bye in the media.  Incredibly, many states get around the legalization of a scheduled drug by making it a "medically necessary" substance.  In spite of the fact that cannabis has been around for over 850 years and tens of thousands newer medications were invented and used successfully, the myth that cannabinoids are necessary as a medication has been promulgated in an apparent effort to increase the legalization of this substance.  The Obama administration has taken a public stand on the medical marijuana issue saying that the state statutes stand, but that they will engage in a selective prosecution that targets organized and violent crime, especially if that crime involves children or increased access to firearms.

I think that medical marijuana is generally a concept that has little to do with medicine and more to do with the legalization of marijuana.  It would become much more obvious if there were exposes in the press about how prescriptions for medical marijuana actually work.  What has to be said in the interview to get the prescriptions and what are the incentives of these prescribers?  We have had a fairly constant barrage of criticism of psychiatrists prescribing non-addicting drugs to patients for legitimate FDA approved indications that are in aggregate safer than cannabinoids.  Where are the questions about an industry that is selling a potentially addictive drug that has no clear medical indication and the potential conflict of interest of the prescribers?  I certainly have no problem continuing to advise all my patients with, anxiety, mood, addictive, and psychotic disorders that they need to not use marijuana at all, despite the fact that they are getting advice that marijuana is good for anxiety, depression, and insomnia.  I also have no problem telling anyone who might want a medical marijuana prescription that medical marijuana is a political term that has nothing to do with the practice of medicine and as such - I am not a "prescriber".

The other physician dimension to this issue is overprescribing.  The current epidemic of prescription opioid use and resulting accidental overdose deaths is a good example.  Unlike marijuana, the opioids have clear indications for use and contraindications.  In aggregate, marijuana probably has a wider safety margin, but the prescribing dynamic is similar to opioids and antibiotics.  The physician is confronted with a highly motivated patient who wants to leave the office with a prescription and physicians have have varying levels of motivation and skill to deny a wanted but unnecessary prescription.

I have no problem with any state declaring marijuana or any cannabinoids legal for its residents to line up and purchase.  Although marijuana promoters always give the message that it is safer than alcohol, it has the same general parameters  of use and no real medical indication.  I do have a problem with involving medicine in an experiment to legitimize it for just about anything.  I also think that physicians should know better.  We ran similar experiments for drugs with clear medical indications like opioids in the past century and they did not turn out well.

George Dawson, MD, DFAPA

American Society of Addiction Medicine (ASAM):  ASAM Medical Marijuana Task Force White Paper.

Joseph Lee, MD on Marijuana Legalization and the Impact on Children and Adolescents.

Dr. Oz addendum:

An example about the type of information the public gets from the media can't get any better than this Dr. Oz episode "Is Weed Addictive?" on December 4, 2913.  The full details are not really provided at this time.  I saw a debate and one of the participants was Pamela Riggs, MD who provided standard information on the addictive properties of marijuana.

Dr. Oz posts additional comments on his blog and seems to confuse the issues of addiction, legalization, and medical use.  After talking how it is going to be widely available he concludes:

"As the trend towards legalizing this drug continues, we need to be aware of its risks and teach our children its proper place, which is in the pharmacy, not in the kitchen cabinet and certainly not in the school locker."

So it will be more widely legalized as a pharmaceutical that people will use that way?

I will post additional details of this broadcast as they become available.